hs/bv/nl/rg.
Date : 00.00.00
Name of the Patient : Abc Xyzath V. Jlmn / M / 16 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
Alleged H/O neck injury with quadriplegia 3 years back. Recovered partially.
Now C/O inability to lift the RUE.
EXAMINATION :
M.R.I of the cervical spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and Fast Scan (T2 *) axial images.
OBSERVATION :
There is fusion of the C5 and C6 vertebral bodies and posterior elements. There is a decrease in the antero-posterior dimensions of these vertebral bodies and these most likely represents a congenital fusion of the C5 and C6 vertebrae. There is a slight decrease in the height of the C4 vertebral body. The posterior elements (lamina and spinous processes) of the upper cervical vertebrae appear defecient (it is difficult to identify at which vertebral levels. Please correlate with plain films).
The cervical and visualized upper dorsal spinal cord appears to be smaller in calibre than normal. There is evidence of a well-defined area which is near isointense to CSF on all the pulse sequences within the cord at the C3/C4 levels. Also seen are areas of hypointensity on the T1 Weighted images which turn hyperintense on the T2 Weighted images, superior and inferior to this lesion.
A posterior disc bulge is noted at the C4-C5 level. The left C4-C5 facet joint shows degenerative changes.
..2/.
The C2-C3, C3-C4 and C4-C5 intervertebral discs show loss of water content.
There is no significant change in the atlanto-dens interval on the flexion and extension images.
The cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
IMPRESSION :
1. Congenital block C5/C6 vertebra.
2. Slight thinning of the cervical and visualized upper dorsal spinal cord with myelomalacic changes at the C3/C4 vertebral levels.