hs/ke
Date : 00.00.00

Name of the Patient : Abc Xyzlmn / M / 48 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE:

Alleged H/O fall with injury to neck 1 month back with inability to lift the RUE and paresthesias since then.
C/O mild pain in the neck.

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.

4 mm thick T1 Weighted and T2 Weighted (with fat saturation) coronal images.

OBSERVATION :

There is forward translation of the C5 vertebra over the C6 vertebra. There appears to be diastasis of the right C5-C6 facet joint.

A large posterior disc extrusion with peridiscal osteophytes is seen to indent the cord at the C5-C6 level. A disc portion is seen to lie in the anterior epidural space at the C6 and C5 (more to the right) levels. Also seen is a right postero-lateral disc herniation narrowing the right neural foramen at the C5-C6 level.

There is a small postero-central disc herniation at the C6-C7 level and left paracentral disc herniation at the C2-C3 level. Posterior disc bulges are noted at the C3-C4 and C4-C5 levels.


Hyperintense signal on the T2 Weighted images (hyperintense to muscle but hypointense to fat on the T1 Weighted images) is seen in the right paravertebral soft tissues at the C5 and C6 levels and in the right C5-C6 neural foramen. This may represent soft tissue edema/haemorrhage.

The right joint of Luschka at the C4-C5 level shows degenerative changes with right neural foraminal narrowing.

The cervical intervertebral discs show loss of water content.

Small posterior disc herniations are noted at the C2-C3, C3-C4, C4-C5 and C6-C7 levels.

The cervical vertebral bodies show normal signal intensity. The remaining joints of Luschka are unremarkable.

The cervical spinal cord shows normal signal intensity.

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

IMPRESSION :

The MRI features are suggestive of :

1. A large posterior disc extrusion with peridiscal osteophytes at the C5-C6 level with a disc portion lying within the anterior epidural space at the C6 and C5 (more to the right) levels.
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2. A right postero-lateral disc herniation at the C5-C6 level.

3. Forward translation of the C5 vertebra over the C6 vertebra.

4. Probable soft tissue edema/haemorrhage in the right paravertebral soft tissues at the C5 and C6 levels.

5. A small postero-central disc herniation at the C6-C7 level.

6. A small left paracentral disc herniation at the C2-C3 level.