49 years Male (DOB: 12/20/1966)Reason: please compare to prior History: progressionPROVIDER NAME: JACQUELINE T BERNARD MRI brain:The CSF spaces are appropriate for the patient's stated age with no midline shift. There is redemonstration of multiple periventricular and subcortical white matter lesions many of which are perpendicularly oriented to the lateral ventricles. Additional lesions are present in the internal capsules bilaterally which are also unchanged.No abnormal enhancing mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.The visualized portions of the paranasal sinuses are clear. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.MRI cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. . No abnormal enhancing lesions are identified in the cervical spine.There is a high signal focus present within the cervical spinal cord at the C3 vertebral body level measuring 6 x 12 mm sagittal dimensions which is eccentric to the right hemicord. There is a 34 mm in length T2 hyperintense lesion within the cervical spinal cord extending from the C4 level to the C6 level which is eccentric to the left hemicord. There is a T2 hyperintense lesion within the cervical spinal cord at the C2 vertebral body level involving the right hemicord. Overall the cervical spinal cord is small. These lesions were also present on the prior exam from 5/22/2012At C2-3 there is no significant compromise to the spinal canal or neural foramina. There is disc desiccation at this level.At C3-4 there is no significant compromise to the spinal canal. There is disc desiccation present at this level. There is a left lateral recess disc protrusion present at this level which is associated with uncovertebral osteophytes and encroachment of the left-sided exiting nerve roots. This has not significantly progressed since the prior exam.At C4-5 there is no significant compromise to the spinal canal. There is disc desiccation at this level associated with diffuse disc bulge and endplate and uncovertebral osteophytes with narrowing of the neural foramina bilaterally and encroachment of the left-sided exiting nerve roots. This has not significantly progressed since the prior exam.At C5-6 there is loss of disc space height, disc desiccation, diffuse disc bulge and endplate uncovertebral osteophytes associated with ligamentum flavum hypertrophy. There is effacement of spinal fluid ventral and posterior the spinal cord and encroachment of the exiting nerve roots within the right neural foramen at this level. Overall there is mild to moderate spinal stenosis at this level. This has not significantly progressed since the prior exam.At C6-7 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with endplate and uncovertebral osteophytes. There is some narrowing of the neural foramina but no significant optimized to the exiting nerve roots. There is partial effacement of spinal fluid ventral and posterior the spinal cord. Overall there is a mild degree of spinal stenosis at this level. This has not significantly progressed since the prior exam.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 multiple lesions within the cervical spinal cord which are compatible with demyelinating disorder. These were also present on the prior exam from 5/22/2012 and have not changed significantly.2.There are multilevel degenerative changes present in the cervical spine which appear to be worse at C5-6 where there is mild to moderate spinal stenosis and encroachment of right-sided exiting nerve roots. There is some encroachment of exiting nerve roots at other levels as well. These findings are stable compared to the prior exam.3.There are multiple white matter lesions scattered within the brain parenchyma which are stable compared to prior exam 5/22/2012 which support the patient's clinical diagnosis of multiple sclerosis.