ke/sb/rg.
Name of the Patient : Abc Xyz. Fernalmn / M / 53 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
Alleged H/O train accident at 10.30 am on 00.00.0000 with quadriparesis and bladder involvement since then.
EXAMINATION :
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.
OBSERVATION :
There is a large postero-central disc herniation with peridiscal osteophytes at the C3-C4 level with anterior compression of the spinal cord. The spinal cord over the C2-C3 to the C4-C5 level shows a hyperintense signal on the T2 Weighted and Gradient images, centrally, which is isointense to hypointense to normal cord on the T1 Weighted images. This would represent cord edema/contusion in the given clinical setting. Ligamentum flavum hypertrophy is also noted at the C3-C4 level.
A postero-central disc herniation is seen at the C5-C6 level with anterior compression of the cord. A small posterior disc bulge is noted at the C4-C5 level.
The cervical intervertebral discs show loss of water content.
Avulsion of the antero-inferior margin of C3 body is noted with suspicious fracture of the spinous process of C4 vertebra.
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- 2 - Scan-00000
Hyperintense signal is seen in the prevertebral soft tissue extending from the level of the clivus upto the C5 level on the T2 Weighted and Fast Scan (T2 *) images suggesting edema/contusion/hematoma.
Fatty changes are noted in the cervical bodies except C6 vertebral body.
Degenerative changes of joints Luschka at C5-C6, bilaterally and at the C4-C5 level on the left is noted. Facetal hypertrophy is noted at the C5-C6 level on the left.
The visualized paravertebral soft tissues are unremarkable.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
IMPRESSION :
1. A large postero-central disc herniation with peridiscal osteophytes at the C3-C4 level with slight ligamentum flavum hypertrophy at that level.
2. Altered signal of the spinal cord over the C2-C3 to the C4-C5 level would represent cord edema/contusion, in the given clinical setting.
3. A postero-central disc herniation at the C5-C6 level.
4. Altered signal in the prevertebral soft tissues extending from the level of the clivus upto the C5 level suggests edema/contusion/hematoma.
5. Avulsion of the antero-inferior margin of C3 body with suspicious fracture of the C4 spinous process.
6. Degenerative changes of joints Luschka at C5-C6, bilaterally and at the C4-C5 level on the left with facetal hypertrophy at the C5-C6 level on the left.