sb/hs/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzhdas Pithlmn / M / 72 yrs.
Referred by : Dr. Abc Xyzah / Dr. Abc Xyztrak.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O weakness and wasting of BUE with fasciculations.

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 slight retroplacement of the C3 over the C4 and C4 over the C5 vertebrae.

Posteriorly herniated discs with posterior peridiscal osteophytes are noted at the C4-C5, C5-C6 and C6-C7 levels, indenting the cervical spinal cord anteriorly. A smaller, postero-central disc herniation with peridiscal osteophytes is noted at the C3-C4 level.

A postero-central protruded disc is noted at the C2-C3 level.

The cervical spinal cord over the C4 to C6 vertebral levels appears atrophied and shows a hyperintense signal on the T2 Weighted images at the C4-C5 and C5-C6 levels which may suggest cord ischemia/myelomalacia.

Ligamentum flavum hypertrophy is noted at the C4-C5 and C5-C6 levels. Facetal hypertrophy is noted at the C3-C4 and C4-C5 levels bilaterally.


The joints of Luschka at the C6-C7 level bilaterally show degenerative changes.

Fatty marrow changes are noted in the C2 and C3 vertebral bodies and a hemangioma with fat content is noted in the C7 vertebral body.

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

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

IMPRESSION :

1. Slight retroplacement of the C3 over the C4 and C4 over the C5 vertebrae.

2. Posteriorly herniated discs with posterior peridiscal osteophytes at the C4-C5, C5-C6 and C6-C7 levels, indenting the cervical spinal cord anteriorly.

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

4. A postero-central protruded disc at the C2-C3 level.

5. Atrophy of the cervical spinal cord over the C4 to C6 vertebral levels with altered signal at the C4-C5 and C5-C6 levels which may suggest cord isclmn / Myelomalacia.

6. Ligamentum flavum hypertrophy at the C4-C5 and C5-C6 levels with facetal hypertrophy at the C3-C4 and C4-C5 bilaterally.

7. Cervical canal stenosis at the C4-C5, C5-C6 and C6-C7 levels.