71 years Male (DOB:11/24/1944)Reason: 71 y/o male with worsening pain History: neck painPROVIDER/ATTENDING NAME: SERVICES ANCILLARY SERVICES ANCILLARY The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology. There is hypertrophy of the posterior longitudinal ligament predominantly along the upper cervical spine extending from C2 down to C4.At C2-3 there is no significant compromise to the spinal canal or neural foramina.At C3-4 there is loss of disc space height, disc desiccation, diffuse disc bulge as well as some endplate uncovertebral osteophytes and some hypertrophy of posterior longitudinal ligament. There is also some hypertrophy of the ligamentum flavum at this level. There is narrowing of the spinal canal and some atrophy of the spinal cord associated with signal change at this level. There is only mild narrowing of the right neural foramen at this level. There is moderate encroachment of the left-sided exiting nerve roots at this level.At C4-5 there is no significant compromise to the spinal canal. There is some disc desiccation and some hypertrophy of the posterior longitudinal ligament. There is a disc bulge at this level with narrowing of the neural foramina bilaterally. There are some encroachment of the left-sided exiting nerve roots within the neural foramen.At C5-6 there is no significant compromise to the spinal canal . There is some loss of disc space height, desiccation and uncovertebral osteophyte formation at this level as well as a disc bulge and narrowing of the neural foramina bilaterally with encroachment of the exiting nerve roots.At C6-7 there is loss of disc space height, disc desiccation as well as endplate uncovertebral osteophyte formation and narrowing of the neural foramina bilaterally but worse on the left side compared to the right. There is hypertrophy of the ligamentum flavum at this level and partial effacement of spinal fluid ventral and posterior the spinal cord. Overall there is a moderate degree of spinal stenosis 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.
1.There are multilevel degenerative changes present in the cervical spine without moderate spinal stenosis at C6-7 as a result of degenerative changes and an neural foramina encroachment of exiting nerve roots predominantly on the left-sided C6-7, C4-5 and C3-4 and bilaterally at C5-6.2.There are some spinal cord myelomalacia present at the C3-4 level where there is narrowing of the spinal canal and spinal stenosis.3.There is hypertrophy of the posterior longitudinal ligament predominantly along the upper cervical spine. This contributes to narrowing of the spinal canal especially at the C3-4 level.