Mechanical fall, outside hospital CT/MRI head with concern for bleed/lesion. Per chart, history of cavernous malformations. Patient is status post ground-level fall, tenderness to palpation along the cervical spine. Partially imaged is a T1 and T2 hyperintense mass with rim of susceptibility involving the right aspect of the pons compatible with history of cavernous malformation and seen on prior CT from 2012. Examination of the spine is mildly motion degraded. Craniovertebral junction appears within normal limits. The cervical vertebral bodies are appropriate in height. Alignment is maintained. Bone marrow signal is grossly benign. There is a T1 and T2 hyperintense lesion involving the C7 vertebral body which may represent sclerotic lesion such as bone island and can be correlated with outside CT.The cervical spinal cord has normal signal characteristics. Degenerative changes are seen in the cervical spine, worst at the C4-C5 level where there is severe loss of disc height and mild nonspecific T2 hyperintensity within the disc space. Individual levels as below:C2-3: No significant compromise to the spinal canal or neural foramina.C3-4: No significant compromise to the spinal canal or neural foramina.C4-5: Disc osteophyte complex and ligamentum flavum thickening. There is moderate spinal canal stenosis including mild deformity of the cord. There is bilateral uncovertebral hypertrophy with moderate to severe left and mild to moderate right neural foraminal stenosis.C5-6: Small disc osteophyte complex and ligamentum flavum thickening. There is mild narrowing of the spinal canal. Uncovertebral hypertrophy is associated with moderate bilateral neural foraminal stenosis. C6-7: Minimal disc bulge and ligamentum flavum thickening. There is minimal narrowing of the spinal canal. There is mild narrowing of the bilateral neural foramina.C7-T1: No significant compromise to the spinal canal or neural foramina.Ligamentous structures appear intact. The vertebral artery flow voids appear to be intact. Paraspinous soft tissue structures appear within normal limits.
1. No evidence of traumatic injury to the cervical spine. Specifically, no cord signal abnormality, hematoma within the spinal canal, or evidence of ligamentous injury,2. Multilevel degenerative changes changes, worst at the C4-C5 level, where there is moderate spinal canal stenosis. There is also significant neural foraminal stenoses at the left C4-C5 and bilateral C5-C6 levels.3. Large right pontine cavernous malformation is partially imaged and also evident on prior CT from 8/18/2012.4. T1 and T2 hypointense focus involving the C7 vertebral body may represent a sclerotic focus such as bone island and can be correlated with prior outside CT cervical spine.