hs/sb/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Molmn / M / 50 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O neckpain with tingling in the LUE and gait imbalance.

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 :

A posterior disc herniation with peridiscal osteophytes, more to the right of the midline is seen to indent the cord at the C4-C5 level.

A posterior disc herniation with peridiscal osteophytes, more to the left of the midline is seen to indent the cord at the C5-C6 level.

A postero-central disc herniation with peridiscal osteophytes is seen to indent the cord at the C3-C4 level.

Posterior disc bulges are noted at the C2-C3 and C6-C7 levels.

Anterior disc herniations with peridiscal osteophytes are noted at the C3-C4, C4-C5 and C5-C6 levels.

The C5-C6 facet joints show hypertrophic degenerative changes. Degenerative changes of the joints of Luschka at the C4-C5 and C5-C6 levels, bilaterally is also noted.

The cervical intervertebral discs show loss of water content.

The upper cervical vertebral bodies show areas of fatty replacement of normal marrow.

The rest of the cervical vertebral bodies show normal signal intensity. The remaining 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.

The brain was screened with 5 mm thick T2 Weighted axial images and shows small areas of hyperintensity within the white matter in the left frontal lobe and these may be ischemic in etiology.

IMPRESSION :

The MRI features are suggestive of :

1. A posterior disc herniation with peridiscal osteophytes, more to the right of the midline indenting the cord at the C4-C5 level.

2. A posterior disc herniation with peridiscal osteophytes, more to the left of the midline indenting the cord at the C5-C6 level.

3. A postero-central disc herniation with peridiscal osteophytes indenting the cord at the C3-C4 level.

4. Hypertrophic facetal arthropathy at the C5-C6 level with degenerative changes of the joints of Luschka at the C4-C5 and C5-C6 levels.

5. A tight canal over the C3-C4 to the C5-C6 level.