sb/hs
Date : 00.00.00

Name of the Patient : Abc Xyzlmn / M / 57 yrs.
Referred by : Dr. Abc Xyzlkaka.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O gait imbalance since 10 days with paresthesias in the LUE and BLE.

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.

OBSERVATION :

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

A postero-central protruded disc is noted at the C2-C3 level and a small postero-central disc herniation at the C3-C4 level.

A small, posterior disc herniation with peridiscal osteophytes is noted at the C4-C5 level with indentation upon the cord at this level.

A fairly large, posteriorly extruded disc with peridiscal osteophytes is noted at the C5-C6 level with cord compression. The cervical spinal cord at this level shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images suggesting cord edema/ishcemia. There is bilateral neural foraminal narrowing at this level.
Scan - 00003

A posterior and left postero-lateral disc herniation with peridiscal osteophytes is also noted at the C6-C7 level with left neural foraminal narrowing. Mild ligamentum flavum hypertrophy is noted at the C6-C7 level.

Degenerative changes of the joints of the Luschka on the left is noted at the C3-C4 and C4-C5 levels, with left neural foraminal narrowing. The facet joints at the C5-C6 and C6-C7 levels bilaterally and on the left side at the C3-C4 and C4-C5 levels shows hypertrophic degenerative changes.

The C3 to C5 vertebral bodies show spotty fatty marrow changes.

The visualized pre and paravertebral soft tissues are unremarkable.

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

IMPRESSION :

1. A fairly large, posteriorly extruded disc with peridiscal osteophytes at the C5-C6 level with canal stenosis, cord compression and cord signal alteration at this level suggests cord edema/ischemia.

2. A posterior and left postero-lateral disc herniation with peridiscal osteophytes at the C6-C7 level.

3. A small, postero-central disc herniation at the C3-C4 level.

4. Degenerative changes of the joints of the Luschka on the left at the C3-C4 and C4-C5 levels.

5 Hypertrophic facetal arthropathy bilaterally at the C5-C6 and C6-C7 levels and on the left side at the C3-C4 and C4-C5 levels.