ke/sb/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzn Kumblmn / M / 50 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE:

C/O weakness of the RUE since 15 days.
C/O fasciculations.
EMG s/o anterior horn cell disease.

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 a left paracentral disc herniation at the C5-C6 level with antero-lateral indentation of the cord and left neural foraminal narrowing. There is indentation upon the left C6 nerve root.

A small right postero-lateral disc herniation is seen at the C3-C4 level with antero-lateral indentation of the thecal sac and slight right neural foraminal narrowing.

Diffuse posterior disc herniations are noted at the C4-C5 and C6-C7 levels and a focal right paracentral disc herniation is noted at the C2-C3 level. The cervical intervertebral discs show loss of water content,

Posterior peridiscal osteophytes are noted at the C3-C4, C4-C5 and C5-C6 levels.


The C3-C4, C4-C5 and C5-C6 facet joints appear slightly hypertrophied.

Diffuse fatty changes are noted in the cervical vertebrae.

The joints of Luschka at the C3-C4 and C4-C5 levels on the right show degenerative changes.

The visualized pre and paravertebral soft tissues are unremarkable.

The cervical spinal cord shows normal signal intensity.

The atlanto-axial region and the cervico-medullary junction are unremarkable.

IMPRESSION :

1. A left paracentral disc herniation at the C5-C6 level with indentation upon the left C6 nerve root.

2. A small right postero-lateral disc herniation at the C3-C4 level.

3. Diffuse posterior disc herniations at the C4-C5 and C6-C7 levels and a focal right paracentral disc herniation at the C2-C3 level.

4. Posterior peridiscal osteophytes at the C3-C4, C4-C5 and C5-C6 levels.

5. Degenerative changes of the C3-C4, C4-C5 and C5-C6 facet joints and of the right sided joints of Luschka at the C3-C4 and C4-C5 levels.