sb/ke/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzra D. Klmn / M / 27 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

Known C/O tuberculosis involving the left atlanto-occipital joint with enlarged lymphnodes in the cervical region. Detected in February 0000. On AKT since then.
For follow-up.

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 still seen an ill-defined, hypointense signal on the T1 Weighted images in the left occipital condyle and the left lateral mass of C1. This lesion is predominantly hypointense on the T2 Weighted images with subtle hyperintense areas. Minimal left paravertebral soft tissue lesion is noted around the left atlanto-occipital joint.

There is loss of water content of the cervical intervertebral discs.

Posterior disc bulge with posterior peridiscal osteophytes is noted at the C3-C4 level.

The rest of the cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized prevertebral soft tissues are unremarkable.

The cervical spinal cord reveals normal signal intensity.
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The cervico-medullary junction is unremarkable.

Small, subcentimeter lymphnodes are noted deep to the sternocleidomastoid muscles bilaterally.

IMPRESSION :

As compared to the previous MRI dated 00.00.00 (scan no.00003), there is significant resolution of the left paravertebral soft tissue lesion. Signal change in the left occipital condyle and left lateral mass of C1 may suggest sclerosis, the sequelae of healing of the previous infective lesion. There is reduction in the size of the cervical lymphnodes.