50 years Male (DOB:11/15/1965)Reason: evaluate neck pain History: neck painPROVIDER/ATTENDING NAME: ANDREA H. SHASHOUA ANDREA H. SHASHOUA Cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology. The patient is status post anterior fusion at C6-7. There is osseous bridging at the disc space.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 . There is a disc bulge present at this level associated with narrowing of the neural foramina bilaterally with encroachment of exiting nerve roots which appears be slightly worse in the right when compared to the left side. This was also present on the prior exam.At C5-6 there is a disc bulge present this level associated with endplate and uncovertebral osteophytes and encroachment of the neural foramina bilaterally. There is effacement of spinal fluid ventral and posterior the spinal cord at this level and overall a mild degree of spinal stenosis. This has progressed since the prior exam from 2012.At C6-7 there is no significant compromise to the spinal canal or neural foramina.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.Lumbar spine:Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall alignment and height. The conus medullaris on sagittal imaging is grossly intact.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is loss of disc space height and disc desiccation at this level associated with a disc bulge.At L4-5 there is no significant compromise to spinal canal or neural foramina. There is loss of disc space height and disc desiccation at this level associated with a disc bulge. There is a Schmorl's node at this level.At L3-4 there is no significant compromise to spinal canal or neural foramina.At L2-3 there is no significant compromise to spinal canal or neural foramina.At L1-2 there is no significant compromise to spinal canal or neural foramina.
1.There are degenerative changes present in the cervical spine which appear to progress since the prior exam. There is now a mild degree of spinal stenosis at C5-6. There is moderate encroachment of the exiting nerve roots bilaterally at C5-6 and C4-5 related to uncovertebral osteophytes.2.There is some mild degenerative changes present in the lower lumbar spine without significant compromise to the spinal canal or exiting nerve roots