65 years Female (DOB:12/5/1950)Reason: hx cervical fusion. eval for stenosis above/below or abnormality History: neck spasms, shooting neck pain to occiputPROVIDER/ATTENDING NAME: EDWIN RAMOS EDWIN RAMOS The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology. No abnormal enhancing lesions are identified in the cervical spine. The patient status post anterior fusion from C4 through C7 using anterior plate and screws. This partially obscures visualization from C4 through C7 especially the neural foramina.At C2-3 there is no significant compromise to the spinal canal or neural foramina.At C3-4 there is a disc bulge present associated with some endplate and uncovertebral osteophytes and effacement of spinal fluid anterior and posterior the spinal cord. There is narrowing of the neural foramina bilaterally with encroachment of the exiting nerve roots bilaterally within the neural foramina at this level.At C4-5 there is no significant compromise to the spinal canal .At C5-6 there is no significant compromise to the spinal canal .At C6-7 there is no significant compromise to the spinal canal .At C7-T1 there is no significant compromise to the spinal canal or neural foramina.Some T2 signal hyperintensity is present within the brainstem on T2 imaging. The right vertebral artery flow voids very small and not readily perceptible distally. There is also on MRI internal auditory canals from 4/11/2016 which also demonstrates loss of the vertebral artery flow-void proximal to the right posterior inferior cerebellar artery origin.
1.Status post cervical spine anterior fusion from C4 through C7. There is a mild to moderate degree of spinal stenosis present at C3-4 associated with encroachment of the exiting nerve roots within the neural foramina bilaterally at this level.2.Findings are suspicious for occlusive disease involving the right vertebral artery. If clinically appropriate additional imaging of the right vertebral artery may be of benefit. Please note that there is a prior MRI of the internal auditory canals which also demonstrates right vertebral artery occlusive disease3.There are T2 signal changes within the brainstem which are suspected to be vascular related.