ke/bv
Date : 00.00.00

Name of the Patient : Abc Xyzm R. Rohlmn / M / 60 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE :

C/O progressive gait imbalance with inability to walk since 6-7 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 slight retroplacement of the C5 over the C6 vertebra.

There is a posterior disc herniation at the C5-C6 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing, right more than left. A large posterior peridiscal osteophyte is seen at this level.

A postero-central disc herniation is seen at the C4-C5 level with anterior indentation of the cord. The joint of Luschka on the right side show slight degenerative changes at this level with right neural foraminal narrowing.

Posterior peridiscal osteophytes are also noted at this level.

Small posterior disc bulges are noted at the C2-C3 and C3-C4 levels.

The cervical intervertebral discs show loss of water content.

Mild ligamentum flavum hypertrophy is noted at the C4-C5 and C5-C6 levels.

The C5-C6 intervertebral disc shows hypointense areas on all the pulse sequences suggestive of calcification/vacuum phenomena.
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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 reveals normal signal intensity.

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

The brain was screened with 5 mm thick T2 Weighted axial images which shows hyperintense areas in the periatrial deep white matter, suggestive of areas of ischemic changes. A lacunar infarct is noted in the right lentiform nucleus with mild age related cerebral atrophy. Note is made of right maxillary sinusitis.

IMPRESSION :

1. A posterior disc herniation with a large posterior peridiscal osteophyte
at the C5-C6 level.

2. A postero-central disc herniation with small posterior peridiscal osteophytes at the C4-C5 level.