Female, 54 years old, with unstable gait and brisk deep tendon reflexes, history of cervical laminectomy. Cervical:Evidence of anterior instrumented spinal fusion are seen from C5 through C7, similar to the prior examination. At least some degree of osseous fusion is evident across the disc space at C5-6 with only questionable fusion across C6-7.Spinal alignment is within normal limits. Apart from operative changes, the morphology and signal characteristics of the vertebral bodies are within normal limits. No pathologic marrow enhancement is seen.The spinal cord demonstrates normal signal intensity and morphology throughout. No pathologic spinal cord or leptomeningeal enhancement is seen.Incidental note is made of at least two nodules within the left thyroid gland.C2-3: Mild facet hypertrophy. No significant spinal canal or foraminal stenosis. No interval changes.C3-4: Mild left facet hypertrophy. No significant spinal canal or foraminal stenosis. No interval changes.C4-5: Mild facet hypertrophy. No significant spinal canal or foraminal stenosis. No interval changes.C5-6: Mild facet hypertrophy. Fusion across the disc space. No significant spinal canal or foraminal stenosis. No interval changes.C6-7: Mild facet hypertrophy. No significant spinal canal or foraminal stenosis. No interval changes.C7-T1: Mild facet hypertrophy. No significant spinal canal or foraminal stenosis. No interval changes.Thoracic:Alignment is grossly anatomic. Vertebral body morphology is within normal limits. Signal characteristics suggesting a benign hemangioma are evident within the T7 vertebral body. No concerning marrow space signal abnormality or enhancement is seen.The visualized spinal cord demonstrates normal signal and morphology throughout. No pathologic cord or leptomeningeal enhancement is seen.A small left paracentral disc protrusion is evident at T8-9 which may have slightly increased in size from the prior examination. No other significant disc bulges or disc herniations are seen. The spinal canal and neural foramina are not significantly compromised at any level.
1.Redemonstration of findings related to anterior instrumented fusion from C5 through C7.2.Relatively mild degenerative findings are seen as described by level above.3.No areas of significant spinal canal or foraminal stenosis are detected in either the cervical or thoracic spine.4.No enhancing spinal lesions are demonstrated.