hs/ke/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyzv Galmn / M / 76 yrs.
Referred by : Dr. Abc Xyzmania.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O backache with weakness of BLE since October 0000.
H/O decompressive upper cervical laminectomy on 00.00.00. Also H/O spinal surgery in the neck region (details not available).
For follow up.
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 normal cervical lordosis. There is evidence of laminectomy of the C2, C3 and C4 vertebrae with post-operative changes in the posterior soft tissues over these levels.
There appears to be congenital fusion of the C6 and C7 vertebrae.
There is ossification of the posterior longitudinal ligament at the C2 and C3 vertebral levels with resultant indentation upon the cord.
Posterior disc herniations with peridiscal osteophytes are noted at the C3-C4, C4-C5 and C5-C6 levels. There is bilateral neural foraminal narrowing at these levels. The facet joints at these levels show degenerative changes.
Posterior peridiscal osteophytes are noted at the C2-C3 level.
The spinal cord over the C1 to C5 vertebral levels shows a hyperintense signal on the T2 Weighted images and this would represent cord edema/ischemia/gliosis. The spinal canal over these levels is seen to be tight.
Anterior disc herniations with peridiscal osteophytes are seen at the C4-C5, C5-C6 and C7-D1 levels.
The cervical intervertebral discs show loss of water content. The cervical vertebral bodies show areas of fatty replacement of normal marrow.
The visualized pre and paravertebral soft tissues are unremarkable.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
IMPRESSION :
The MRI features are suggestive of :
1. Ossification of the posterior longitudinal ligament at the C2 and C3 vertebral levels.
2. Posterior disc herniations with peridiscal osteophytes at the C3-C4, C4-C5 and C5-C6 levels.
3. Facetal arthropathy at the C3-C4, C4-C5 and C5-C6 levels.
4. Posterior peridiscal osteophytes at the C2-C3 level.
5. Cord signal alteration over the C1 to C5 vertebral levels represents cord edema/ischemia/gliosis.