hs/bv
Date: 00.00.00
Name of the Patient : Abc Xyznath Chaudlmn / M / 42 yrs.
Referred by : Dr. Abc Xyzlwalkar.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE:
C/O neckpain with occasional weakness of the LUE since 1 year.
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 :
Diffuse areas of hypointensity on the T1 Weighted images which turn mildly hyperintense on the T2 Weighted and Fast Scan (T2 *) images are seen to involve the C4 vertebral body (more to the right) and the left lateral mass of the C1 and C2 vertebrae. There is mild extension of this pathologic process into the left pre and paravertebral soft tissues at the C1/C2 levels. Suspicious involvement of the periodontoid tissues is noted.
A postero-central disc protrusion with peridiscal osteophytes, more to the right of the midline is seen to indent the thecal sac at the C3-C4 level.
The cervical intervertebral discs show loss of water content.
- 2 - Scan - 00005
The cervical vertebral bodies show normal signal intensity. The joints of Luschka are unremarkable.
The cervical spinal cord shows normal signal intensity.
Small subcentimetre lymph nodes are identified deep to the sternomastoid muscles bilaterally.
The cervico-medullary junction is unremarkable.
IMPRESSION :
The MRI features are suggestive of a pathologic process involving the C4 vertebral body (more to the right) and the left lateral mass of the C1 and C2 vertebrae. The differential diagnosis may include :
1. Infective processes like tuberculosis (more likely).
2. Neoplastic processes like secondaries or small cell tumors (less likely).