Ssb.ke.nl.rg.can No : 00007 Date : 00.00.00

Name of the Patient : Abc Xyz Kilmn / M / 21 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O headaches with neckpain and vomiting since 00.00.00.
H/O right sided pleural effusion. Received AKT.
(? spinal surgery for tumor, surgical details not available).

EXAMINATION :

M.R.I of the cervical spine was performed using the following parameters :

5 mm thick T1 Weighted and T2 Weighted sagittal images.

5 mm thick T1 Weighted and Fast Scan (T2 *) axial images.

4 mm thick T2 Weighted (with fat saturation) coronal images.

OBSERVATION :

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

Small posterior disc bulges are noted at the C3-C4, C4-C5 and C5-C6 levels.

Degenerative changes of the joints of Luschka are noted at the C3-C4, C4-C5 and C5-C6 levels, bilaterally.

The cervical vertebral bodies and the remaining intervertebral discs show normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
Scan-00007


The cervical spinal cord reveals normal signal intensity.

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

A hyperintense signal on all the pulse sequences is noted in the right internal jugular vein, which appears slightly dilated at the base of the neck.

Incidentally noted is a large, right sided pleural effusion.

An intermediate signal intensity lesion is seen on the T1 Weighted images in the right neural foramen at the D3-D4 level which is seen to turn hyperintense on the T2 Weighted images and would require further evaluation.

IMPRESSION :

1. Small posterior disc bulges at the C3-C4, C4-C5 and C5-C6 levels.

2. Degenerative changes of the joints of Luschka at the C3-C4, C4-C5 and C5-C6 levels, bilaterally.

3. A large, right sided pleural effusion.

4. H/O surgery for spinal tumor 4 years back of which details are not available).