Diagnosis: Other cervical disc displacement, unspecified cervical regionClinical question: herniated disk The cervical vertebral bodies are appropriate in overall alignment and height. Since the prior exam the patient is undergone anterior fusion at C4-5. A previously noted disc extrusion at C4-5 has been removed.At C2-3 there is no significant compromise to the spinal canal or neural foramina.At C3-4 there is a diffuse disc bulge associated with posterior ligamentum flavum hypertrophy as well as uncovertebral osteophytes. There is effacement of spinal fluid ventral and posterior the spinal cord at this level associated with mild flattening the spinal cord. Compared to the previous exam this has not progressed significantly. There is spinal stenosis of a moderate degree present at this level. There is mild encroachment of the exiting nerve roots within the neural foramina at this level.At C4-5 there is no significant compromise to the spinal canal. The patient is status post anterior fusion at this level and removal of disc protrusion. There is mild encroachment of the left-sided exiting nerve roots within the neural foramen at this level. There is subtle cord signal hyperintensity present this level which was also present on the preoperative exam.At C5-6 there is no significant compromise to the spinal canal. There is a mild disc bulge present at this level associated with some mild ligamentum flavum hypertrophy. There is mild encroachment of left-sided exiting nerve roots related to a small disc protrusion and some uncovertebral osteophytes.At C6-7 there is no significant compromise to the spinal canal or neural foramina. There is a mild disc bulge present at this level associated with some mild ligamentum flavum hypertrophy.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.
1.There is moderate spinal stenosis and mild encroachment of exiting nerve roots present at C3-4 related to a degenerative changes which has not progressed since the prior exam.2.Status post anterior fusion at C4-5 with alleviation of spinal stenosis due to a large disc extrusion.3.There is encroachment of left-sided exiting nerve roots at C4-5 related to disc disease and uncovertebral osteophytes.4.There is mild encroachment of left-sided exiting nerve roots at C5-6 due to degenerative changes.