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sb/ke/nl/nl
Date : 00.00.00

Name of the Patient : Abc XyzK. Thlmn / M / 28 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O numbness in BLE and occasional tingling since 2 1/2 months.

EXAMINATION :

M.R.I of the cervical spine was performed using the following parameters :

5 mm thick T1 Weighted and T2 Weighted sagittal images.

5 mm thick T1 Weighted and Fast Scan (T2 *) axial images.

OBSERVATION :

There is loss of water content of the cervical intervertebral discs.

There are posteriorly herniated disc with fairly large posterior peridiscal osteophytes, more to the left of the midline, at the C3-C4 and C4-C5 levels, with cord compression and left neural foraminal narrowing. The cervical spinal cord at the C4-C5 level shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images suggesting cord edema/ischemia.

A fairly large, postero-central disc herniation with peridiscal osteophyte is noted at the C5-C6 level with cord compression. The cervical spinal cord at this level shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images suggesting cord edema/ischemia.





Small postero-central protruded disc with peridiscal osteophyte is noted at the C6-C7 level.

The facet joints at the C4-C5 level appears slightly hypertrophied. The left sided joints of Luschka at the C3-C4 and C4-C5 levels show degenerative changes.

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.

IMPRESSION :

1. Posteriorly herniated discs with fairly large posterior peridiscal osteophytes, more to the left of the midline, at the C3-C4 and C4-C5 levels, with cord compression and left neural foraminal narrowing.

2. A fairly large, postero-central disc herniation with peridiscal osteophyte at the C5-C6 level with cord compression.

3. Altered cord signal at the C4-C5 and C5-C6 levels suggests cord edema/ischemia.

4. Small postero-central protruded disc with peridiscal osteophyte at the C6-C7 level.

5. Hypertrophy of the facet joints at the C4-C5 level degenerative changes of the left sided joints of Luschka at the C3-C4 and C4-C5 levels.


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    • Interventional Pain Procedure Templates
    • The Ultimate Guide to Rapid Reporting for FRCR 2B
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