sb/hs/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyz Khailmn / M / 48 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
C/O neck pain and tingling in the RUE and RLE since 5-6 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 water content of the cervical intervertebral discs.
There is a left postero-lateral disc herniation with peridiscal osteophytes at the C4-C5 level with left neural foraminal narrowing.
Small postero-central protruded discs are noted at the C2-C3 and C3-C4 levels. Posterior disc bulges with small peridiscal osteophytes are noted at the C5-C6 and C6-C7 levels.
Degenerative changes of the joints of Luschka are noted at the C6-C7 level, bilaterally.
The upper cervical vertebral bodies show spotty fatty marrow changes.
Scan-00001
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.
IMPRESSION :
1. A left postero-lateral disc herniation with peridiscal osteophytes at the C4-C5 level.
2. Small postero-central protruded discs at the C2-C3 and C3-C4 levels.
3. Degenerative changes of the joints of Luschka at the C6-C7 level, bilaterally.