52 years Female (DOB:11/25/1963)Reason: recurrent stenosis History: right arm pain numbnessPROVIDER/ATTENDING NAME: BEN-ZION ROITBERG BEN-ZION ROITBERG The patient status post anterior corpectomy and fusion, including bone graft with anterior side plate and screw device spanning from C3 through C5 is present. The patient is also status post anterior fusion at C5-6. There is osseous bridging essentially extending from C3 down to C5. There is no evidence of hardware loosening. No fractures are identified in the cervical spine. The patient status post laminectomies at C2, C3, 4 and C5.At C2-3 there is calcification along the posterior longitudinal ligament extending from the body of C3 superiorly, to the level of C2. There is associated effacement of the spinal fluid ventral to the cord, which at least produces moderate spinal stenosis. This lesion has not progressed significantly since the 2014 exam. There is no significant compromise to neural foramina evidentAt 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 endplate osteophyte formation as well as small uncovertebral osteophyte formation associated with disc material and narrowing of the cervical spinal canal. There is effacement of spinal fluid ventral and posterior the spinal cord with mild flattening of the spinal cord at this level resulting in moderate degree of spinal stenosis. There is narrowing of the neural foramina bilaterally with mild to moderate encroachment of the exiting nerve roots within the neural foramina with greater encroachment on the right versus the left side.At C7-T1 there is endplate osteophyte formation associated with some ossification along the posterior longitudinal ligament. There is partial effacement of spinal fluid ventral to the spinal cord at this levelThere is a small syrinx present at the T2-3 level.
1.There are degenerative changes present cervical spine worse at C6-7 where there is moderate spinal stenosis and mild to moderate encroachment of the exiting nerve roots within the neural foramina bilaterally but worse on the right side relative to the left.2.There is osteophyte formation present at C2-3 with some narrowing of the spinal canal without significant compromise to the spinal cord.3.Status post anterior cervical fusion from C3 through C6 with corpectomy at C3-C5 and laminectomies from C3 through C5.4.Small syrinx at T2-3.