Date : 00.00.00

Name of the Patient : Abc XyzJ. Salulmn / M / 38 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O pain in the cervical and dorsal regions radiating to both the shoulders and paresthesias in BUE and BLE with gait imbalance since 1 1/2 months.
H/O fall 7-8 years back.

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 large postero-central disc herniation at the C3-C4 level with anterior compression of the spinal cord. A small portion of the disc is seen to lie posterior to the C4 vertebral body. The cord at this level shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images (isointense to normal cord on the T1 Weighted images) suggestive of cord edema/ischemia.

A right postero-lateral disc herniation is seen at the C4-C5 level with antero-lateral compression of the cord which also shows hyperintense signal on the Fast Scan (T2 *) images suggestive of cord edema/ischemia.

A postero-central disc herniation is seen at the C2-C3 level and small posterior disc herniations are noted at the C5-C6 and C6-C7 levels with anterior indentation of the thecal sac. The cervical intervertebral discs show loss of water content.

Posterior peridiscal osteophytes are noted over the C2-C3 to C6-C7 levels.

The cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
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The atlanto-axial region and the cervico-medullary junction are unremarkable.

Incidental note is made of a well-defined oval shaped lesion measuring approximately 1.0 x 0.8 cms in the right lobe of the thyroid gland on the T1 Weighted images and is seen to remain so on the T2 Weighted and Fast Scan (T2 *) images. This may represent a complicated cyst with probable high protein content.

Facetal hypertrophy is noted at the D3-D4 and D4-D5 levels.

IMPRESSION :

1. A large postero-central disc herniation at the C3-C4 level with a small portion of the disc lying posterior to the C4 vertebral body. Cord signal alteration at this level suggests cord edema/ischemia.

2. A right postero-lateral disc herniation at the C4-C5 level with cord compression and cord signal alteration at this level suggesting cord edema/ischemia.

3. A postero-central disc herniation at the C2-C3 level and small posterior disc herniations at the C5-C6 and C6-C7 levels.

4. Posterior peridiscal osteophytes over the C2-C3 to C6-C7 levels.