ke/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzr Almn / M / 35 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O weakness of BUE (left more than right) and BLE with dragging of the LLE since 6 months.
Alleged H/O vehicular accident 2 years back with loss of consciousness for an hour.

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 partial occipitalization of the atlas.

The tip of the odontoid process is seen to lie at the level of the foramen magnum. There is atlanto-dens subluxation with the atlanto-dens interval measuring approximately 5 mms. The postero-superior aspect of the odontoid process is seen to compress upon the cervico-medullary junction which shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images and is isointense to cord on the T1 Weighted images. This would represent cord edema/gliosis. The clivus is placed more horizontally as compared to normal.

Posterior disc herniations are noted at the C2-C3, C4-C5 and C5-C6 levels with anterior indentation of the thecal sac.

The cervical intervertebral discs show loss of water content.
..2/.







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

The brain was screened with 5 mm thick T2 Weighted axial images and shows mild fullness of both the lateral ventricles and inflammatory changes in the maxillary sinuses bilaterally (right more than left) and sphenoid sinus.

IMPRESSION :

1. Partial occipitalization of the atlas with the tip of the odontoid process seen to lie at the level of the foramen magnum with atlanto-axial dislocation and atlanto-dens subluxation with atlanto-dens interval measuring 5 mms.

2. Altered signal at the cervico-medullary junction
represents cord edema/gliosis.