sb/bv/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyz Melmn / F / 34 yrs.
Referred by : Dr. Abc Xyz.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE:
C/O neck pain radiating to the RUE with paresthesias since 6 months.
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 and loss of water content of all the cervical intervertebral discs.
There is a fairly large, right postero-lateral disc herniation with peridiscal osteophytes at the C6-C7 level with right neural foraminal narrowing and indentation on the spinal cord and traversing right C7 nerve root.
Minimal posterior disc bulges with peridiscal osteophytes are noted at the C3-C4 and C4-C5 levels.
Degenerative changes of the right sided joint of Luschka at the C5-C6 level is noted.
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.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
IMPRESSION :
A fairly large, right postero-lateral disc herniation with peridiscal osteophytes at the C6-C7 level with right neural foraminal narrowing and indentation on the spinal cord and traversing right C7 nerve root.