ke/sb/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyz Mlmn / M / 30 yrs.
Referred by : Dr. Abc Xyzkil.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neck pain radiating to the RUE with numbness on the tip of fingers of the right hand since 3 days.
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 right paracentral disc herniation with posterior peridiscal osteophytes 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. A sequestered disc fragment is noted in the right lateral recess of C6 (scans 103.6, 104.15, 103.15).
A small postero-central disc herniation is seen at the C4-C5 level with anterior indentation of the thecal sac. 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.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
IMPRESSION :
The MRI features are suggestive of :
1. A right paracentral disc herniation with posterior peridiscal osteophytes at the C5-C6 level with a sequestered disc fragment in the right lateral recess of C6.
2. A small postero-central disc herniation at the C4-C5 level.