Name of the Patient : Abc Xyzl Sonalmn / M / 38 yrs.
Referred by : Dr. Abc Xyzzare.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neckpain with pain radiating to both shoulders and paresthesias in all four extremities.
C/O gait ataxia.
M.R.I of the cervical spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and Fast Scan (T2 *) axial images.
There is a large posterior disc extrusion with posterior peridiscal osteophytes at the C5-C6 level causing anterior compression of the spinal cord and bilateral neural foraminal narrowing. The extruded disc portion is seen to lie in the posterior epidural space on the right side of the C6 vertebral body with impingement of the right C6 nerve root.
The spinal cord shows a hyperintense signal on the T2 Weighted images at the C5-C6 level suggestive of cord edema/ischemia.
A right postero-lateral disc herniation with peridiscal osteophytes is seen at the C6-C7 level with right antero-lateral indentation of the cord and right neural foraminal narrowing. There is indentation upon the right C7 nerve root. Mild left neural foraminal narrowing is also noted at this level.
There is a small postero-central disc herniation at the C4-C5 level with anterior indentation of the thecal sac.
The left C3-C4 joint of Luschka shows degenerative changes with left neural foraminal narrowing.
Facetal hypertrophy is noted on the left side over the C2-C3 to C5-C6 levels.
The cervical intervertebral discs show loss of water content.
The cervical vertebral bodies show normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
The dorso-lumbar spine was screened with 4 mm thick T2 Weighted sagittal images and shows posterior disc herniations at the L3-L4 and L4-L5 levels.
1. A large posterior disc extrusion with posterior peridiscal osteophytes at the C5-C6 level with the extruded disc portion lying in the posterior epidural space on the right side at the C6 vertebral level with impingement of the right C6 nerve root.
2. Cord edema/ischemia at the C5-C6 level.
3. A right postero-lateral disc herniation with peridiscal osteophytes at the C6-C7 level with indentation upon the right C7 nerve root.
4. A small postero-central disc protrusion at the C4-C5 level.