58 years Female (DOB:4/12/1958)Reason: Left arm radicular pain with history of cervical fusion in 2002 History: AbovePROVIDER/ATTENDING NAME: THOMAS J. KELLY THOMAS J. KELLY The cervical vertebral bodies are appropriate in overall alignment and height. The patient status post anterior fusion from C3 through C6. There is also osseous bridging across the C6-7 disc space. The cervical spinal cord has normal signal characteristics and overall morphology. No abnormal enhancing lesions are identified in the cervical spine.At C2-3 there is no significant compromise to the spinal canal or neural foramina.At C3-4 there is no significant compromise to the spinal canal or neural foramina.At C4-5 there is no significant compromise to the spinal canal or neural foramina.At C5-6 there is no significant compromise to the spinal canal or neural foramina.At C6-7 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with ligamentum flavum hypertrophy. There is effacement of spinal fluid ventral and posterior the spinal cord and overall a moderate degree of spinal stenosis at this level. There is also narrowing of the neural foramina bilaterally at this level with encroachment of exiting nerve roots. There is facet hypertrophy at this level.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.
The patient is status post anterior fusion from C3 through C7. There is a moderate degree of spinal stenosis present at C7-T1 associated with encroachment of exiting nerve roots within the neural foramina at C7-T1.