ke/sb/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyzshore Pabrlmn / M / 36 yrs.
Referred by : Dr. Abc Xyzar.
Examination : M.R.I. of the Cervico-dorsal Spine.
CLINICAL PROFILE :
C/O neckpain and neck stiffness with inability to move the neck to the right and bend forwards since 3-4 months.
C/O radicular pain with paresthesias in the RUE.
H/O lifting heavy weights.
EXAMINATION :
M.R.I of the cervico-dorsal spine was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and T2 Weighted axial images.
OBSERVATION :
There is a right postero-lateral disc herniation at the C5-C6 level with antero-lateral indentation of the cord and right neural foraminal narrowing. There is indentation upon the right C6 nerve root.
Small right paracentral disc herniation is noted at the C3-C4 level.
Small postero-central disc protrusions are seen at the C4-C5 and C6-C7 levels. The cervical and visualized upper dorsal intervertebral discs show loss of water content.
The visualized cervico-dorsal vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The visualized cervico-dorsal spinal cord reveals normal signal intensity.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
IMPRESSION :
1. A right postero-lateral disc herniation at the C5-C6 level with indentation upon the right C6 nerve root.
2. Small postero-central disc protrusions at the C4-C5 and C6-C7 levels.
3. Small, right paracentral disc herniation at the C3-C4 level.