ke/bv
Date : 00.00.00
Name of the Patient : Abc XyzShlmn / M / 62 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE:
C/O wasting of the LLE since 2 years.
C/O radicular pain to the RUE with weak grip.
C/O tingling in the LLE.
H/O being hit by a bull 5 years back.
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 normal cervical lordosis.
The cervical intervertebral discs show loss of water content.
There is a small posterior disc herniation with peridiscal osteophytes with anterior indentation of the thecal sac at the C5-C6 level. The joint of Luschka on the right side at this level shows slight degenerative changes.
Small posterior disc bulge is seen at the C4-C5 level.
There are posterior peridiscal osteophytes at the C3-C4 and C6-C7 levels.
The cervical vertebral bodies show normal signal intensity. The rest of the joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The cervical spinal cord shows normal signal intensity and normal contour.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
The right vertebral artery appears hypoplastic and may be a normal variant.
The dorsal spine was screened with 5 mm thick T2 Weighted sagittal images which shows no significant feature of note.
The lumbar spine was screened with 5 mm thick T1 Weighted sagittal images which shows posterior disc herniations at the L3-L4, L4-L5 and L5-S1 levels.
IMPRESSION :
1. A small posterior disc herniation with peridiscal osteophytes at the C5-C6 level with right neural
foraminal narrowing.
2. Posterior peridiscal osteophytes at the C3-C4 and C6-C7 levels.