ke/hs/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyza Trilmn / F / 54 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O neckpain with giddiness and gait ataxia.
C/O radicular pain to BLE.

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 beaking of the cerebellar tonsils and the tip is seen to lie 6.0 mms below the level of the foramen magnum. The posterior fossa appears to be smaller than normal and the clivus is placed horizontally. There is mild fullness of the fourth ventricle.

There is straightening of the cervical spine with loss of water content of the cervical intervertebral discs.

There are small posterior disc herniations at the C5-C6 and C6-C7 levels with peridiscal osteophytes and anterior indentation of the thecal sac. Small posterior disc bulges are noted at the C3-C4 and C4-C5 levels.

A right paracentral disc protrusion with peridiscal osteophytes is seen at the C7-D1 level.

The C4-C5 facet joints bilaterally shows degenerative changes.


The cervical vertebrae show fatty marrow changes. The 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.

Incidental note is made of prominence of the cerebellar folia.

IMPRESSION :

1. Chiari malformation.

2. Small posterior disc herniations at the C5-C6 and C6-C7 levels with peridiscal osteophytes.

3. Facetal arthropathy at the C4-C5 level.