ke/sb
Date : 00.00.00
Name of the Patient : Abc Xyzlal K. lmn / M / 69 yrs.
Referred by : Dr. Abc Xyzah / Dr. Abc Xyzykar.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE:
C/O gradual, progressive weakness of BLE with bladder involvement since 15 days.
H/O laminectomy done over L1 to L5 levels on 00.00.00.
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 are posterior disc herniations at the C3-C4, C4-C5 and the C5-C6 levels with compression of the cord and canal stenosis. The spinal cord at these levels shows a hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images suggestive of cord edema/ischemia. Posterior peridiscal osteophytes are also noted at these levels.
Small posterior disc protrusions are noted at the C2-C3 and C6-C7 levels. The cervical intervertebral discs show loss of water content.
Fatty changes are noted in the upper cervical vertebrae.
The rest of the cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The facet joints at the C3-C4, C4-C5 and C5-C6 levels appear hypertrophied.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
The left lobe of the thyroid appears prominent and would required further evaluation.
Incidentally noted is a diffuse hyperintense signal in the which needs further evaluation.
IMPRESSION :
1. Posterior disc herniations with posterior peridiscal osteophytes at the C3-C4, C4-C5 and the C5-C6 levels with cord compression and canal stenosis at these levels. Altered signal of the cord at these levels suggests cord edema/ischemia.
2. Small posterior disc protrusions at the C2-C3 and C6-C7 levels.