ke/bv
Date : 00.00.00
Name of the Patient : Abc XyzLaklmn / F / 71 yrs.
Referred by : Dr. Abc Xyzah / Dr. Abc Xyzmpat.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE:
H/O fall and injury to the back on 00.00.00.
C/O no control over bladder/bowel since 10-15 days.
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 a small posterior disc bulge at the C4-C5 level. Mild ligamentum flavum hypertrophy is identified at the C5 vertebral level.
The cervical intervertebral discs show loss of water content.
The cervical vertebral bodies show spotty fatty changes suggesting osteoporosis. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The cervical spinal cord shows normal signal intensity.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
Scan-00006
The dorsal spine was screened with 5 mm thick T2 Weighted sagittal images which does not reveal any diagnostic feature of note. The visualized brainstem is unremarkable.
The lumbar spine was screened with 5 mm thick T1 Weighted sagittal images which shows fracture of the S2 and S3 vertebral bodies with a intermediate soft tissue lesion (probably a hematoma) located anterior to the S2 and S3 sacral segments.
IMPRESSION :
No significant abnormality is detected within the cervical spine on this study.
Fracture of the S2 and S3 vertebral bodies with a probable hematoma anteriorly at this level.