sb/hs/nl/rg
Date : 00.00.00

Name of the Patient : Abc Xyzuleman Ghalmn / M / 38 yrs.
Referred by : Dr. Abc XyzParekh.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O neckpain radiating to all four extremities with paresthesias.
H/O anterior microdiscectomy of C4/C5 done in March 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 loss of water content of the cervical intervertebral discs. The C4-C5 intervertebral disc is not identified, the result of previous discectomy. The C4 and C5 vertebral bodies appar to be fused. The upper cervical vertebral bodies show spotty fatty marrow changes.

A postero-central disc herniation with peridiscal osteophyte is noted at the C3-C4 level, slightly more to the left of the midline with cord compression.

A posterior peridiscal osteophyte is noted at the C4-C5 disc level, indenting the dural theca anteriorly.

A left paracentral disc herniation with peridiscal osteophyte is noted at the C5-C6 level with left neural foraminal narrowing and probable indentation on the left C6 nerve root.

A small posterior peridiscal osteophyte is noted at the C6-C7 level.
..2/.






The facet joints at the C4-C5 and C5-C6 levels appear slightly hypertrophied.

The rest of the visualized cervical and upper dorsal vertebrae show a hypointense signal as compared to normal marrow on the T1 Weighted images, which remains isointense to normal marrow on the T2 Weighted images.

The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.

The cervical spinal cord at the C4-C5 disc level shows a hyperintense signal on the T2 Weighted images which may represent cord edema/gliosis.

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

IMPRESSION :

1. Post-operative status.

2. A postero-central disc herniation with peridiscal osteophyte at the C3-C4 level, slightly more to the left of the midline with cord compression.

3. A posterior peridiscal osteophyte at the C4-C5 disc level.

4. A left paracentral disc herniation with peridiscal osteophyte at the C5-C6 level with probable indentation on the left C6 nerve root.

5. A small posterior peridiscal osteophyte at the C6-C7 level.

6. Slight facetal hypertrophy at the C4-C5 and C5-C6 levels.
..3/.






- 3 - Scan-00004


7. Altered marrow signal in the visualized upper dorsal and lower cervical vertebrae suggests a preponderance of hematopoeitic marrow.

8. Cord signal alteration at the C4-C5 disc level may represent cord edema/gliosis.