hs/ke/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyz. Srivalmn / M / 33 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neckpain radiating to BUE (occasionally) with paresthesias in the LUE since November 0000.
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 postero-central disc protrusion with small peridiscal osteophytes indenting the thecal sac at the C5-C6 level. The left facet joint at this level shows mild degenerative change.
A posterior disc bulge with small peridiscal osteophytes is noted at the C6-C7 level. A mild posterior disc bulge is noted at the C4-C5 level.
The cervical intervertebral discs show loss of water content.
The cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The cervical spinal cord reveals normal signal intensity.
- 2 - scan-00002
The atlanto-axial region and the cervico-medullary junction are unremarkable.
The dorsal spine was screened with 4 mm thick T2 Weighted sagittal images and shows mild degenerative changes. Small posterior disc herniations are noted at the D2-D3, D3-D4, D8-D9 and D9-D10 levels.
IMPRESSION :
The MRI features are suggestive of :
1. A postero-central disc protrusion with small peridiscal osteophytes at the C5-C6 level.
2. A posterior disc bulge with small peridiscal osteophytes at the C6-C7 level.
3. Mild facetal arthropathy on the left side at the C5-C6 level.
As compared to the previous MRI dated 00.00.00, there is no significant change noted.