Male, 58 years old, with severe pain in the mid cervical region of the neck and between the shoulder blades after trauma on 02/19/16. Please evaluate soft tissues for muscle or ligament tear. Please evaluate cervical and thoracic spine for nerve entrapment. Cervical:Anterior fusion instruments are in place spanning from C3 to C4. An interbody fusion device has also been placed within the C3-4 disc space. Sagittal spinal alignment is within normal limits. Vertebral body heights are preserved. No evidence of marrow replacement or significant marrow edema is detected. No pathologic marrow enhancement is seen. No evidence of soft tissue edema or ligamentous injury is seen.The visualized spinal cord shows normal signal intensity and morphology throughout. No epidural abnormalities are suspected. No pathologic intraspinal enhancement is seen.C2-3: No spinal canal stenosis or neuroforaminal narrowing. C3-4: The disc space has been surgically obliterated. No significant spinal canal or foraminal stenosis is seen, an improvement from the preoperative examination of 10/14/14. C4-5: Mild facet arthropathy. Mild left uncovertebral hypertrophy. No spinal canal stenosis. Moderate left foraminal narrowing. No interval changes.C5-6: Mild facet arthropathy. Minimal posterior disc-osteophyte complex formation and uncovertebral hypertrophy asymmetric towards the left. Minimal effacement of the left ventral thecal sac. No significant generalized spinal canal stenosis. Severe left foraminal narrowing. No interval changes. C6-7: Facet arthropathy. Minimal posterior disc-osteophyte complex formation. No spinal canal stenosis. Moderate left foraminal narrowing. No interval changes. C7-T1: Facet arthropathy. Ligamentum flavum thickening. Mild posterior disc-osteophyte complex formation with slight effacement of ventral thecal sac. No significant generalized spinal canal stenosis. Moderate left foraminal narrowing. No interval changes. Thoracic:Sagittal alignment is within normal limits. Vertebral body heights are preserved allowing for one or two scattered Schmorl's nodes. No evidence of marrow replacement or edema is seen. No pathologic marrow enhancement is observed. There is no evidence of paraspinal soft tissue edema or of ligamentous injury.Visualized spinal cord shows normal signal intensity and morphology throughout. No epidural abnormalities are suspected. No pathologic intraspinal enhancement is seen.The intervertebral discs demonstrate preservation of height. No significant bulging or herniation is seen. No spinal canal or foraminal stenosis is detected.A hepatic cyst is partially visualized.
1.No evidence of any paraspinal soft tissue edema or ligamentous injury is seen in the cervical or thoracic spine.2.In the cervical spine, there is evidence of anterior and interbody fusion at C3 and C4. This intervention has relieved the spinal canal and foraminal stenoses seen at this level on the preoperative examination.3.Elsewhere in the cervical spine, no definite high-grade spinal canal stenosis is seen. However, significant left-sided foraminal narrowing is demonstrated at most levels, particularly at C5-6 where the stenosis is severe. These findings have not significantly changed over the prior exams.4.In the thoracic spine, there are no areas of spinal canal stenosis, foraminal narrowing or other abnormal findings to account for the patient's symptoms.