sb/ke/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyzlallmn / M / 36 yrs.
Referred by : Dr. Abc Xyzndhi / Dr. Abc Xyzpta.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neck pain radiating to the LUE since 4 months.
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 normal cervical lordosis and loss of water content of the cervical intervertebral discs.
There is a postero-central and left postero-lateral disc herniation with peridiscal osteophytes at the C6-C7 level with left neural foraminal narrowing.
A small postero-central disc herniation with peridiscal osteophytes is noted at the C4-C5 level, indenting the cervical spinal cord anteriorly.
Small postero-central disc herniation is noted at the C5-C6 level.
Small postero-central protruded disc is seen at the C3-C4 level.
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 cervical spinal cord reveals normal signal intensity.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
IMPRESSION :
1. A postero-central and left postero-lateral disc herniation with peridiscal osteophytes at the C6-C7 level with left neural foraminal narrowing.
2. A small postero-central disc herniation with peridiscal osteophytes at the C4-C5 level, indenting the cervical spinal cord anteriorly.
3. Small postero-central disc herniation at the C5-C6 level.