Severe neck pain, evaluate for disc herniation. Additional history, patient had recent trauma following which she developed neck pain. Craniovertebral junction appears within normal limits. The cervical vertebral bodies are appropriate in height. There is mild anterolisthesis of C2 on C3 and C3 on C4 as well as mild reversal of cervical lordosis. Bone marrow signal is benign. Motion artifact somewhat limits assessment. There is however no gross cord signal abnormality.Degenerative changes are seen in the cervical spine as described below:C2-3: No significant compromise to the spinal canal or right neural foramen. There is mild left neural foraminal narrowing related to facet arthropathy.C3-4: There is moderate right and mild to moderate left neural foraminal stenosis related to prominent bilateral facet arthropathy. No significant spinal canal stenosis.C4-5: Disc osteophyte complex with uncovertebral hypertrophy and facet arthropathy, particularly on the left. There is is mild to moderate spinal canal stenosis. There is moderate bilateral neural foraminal stenosis, worse on the left, with also edema surrounding the left facet joint. There is also mild edema involving the bone marrow of the facets on the left.C5-6: Small disc defect complex and ligamentum flavum thickening contribute to mild to moderate spinal canal stenosis. There is moderate left-sided neural foraminal stenosis and mild to moderate on the right related to uncovertebral hypertrophy and facet arthropathy.C6-7: Small disc osteophyte complex and bilateral uncovertebral hypertrophy. There is partial effacement of the left ventral aspect of the thecal sac but otherwise no significant spinal canal stenosis. There is moderate left-sided neural foraminal stenosis and to a milder degree on the right.C7-T1: No significant compromise to the spinal canal or neural foramina. Left-sided perineural cysts incidentally noted. There is facet arthropathy, particularly on the left.Facet arthropathy on the left at the T1-T2 level is also noted and contributes to mild to moderate left T1-T2 neural foraminal stenosis.The vertebral artery flow voids appear to be intact. There is edema involving the left paraspinous muscular at the left C4-C5 level and extending more inferiorly into the lower cervical spine. Mild edema involving the right lower cervical paraspinous musculature is also noted.
1. Multilevel degenerative changes in the cervical spine with mild to moderate spinal canal stenosis at C4-C5 and C5-C6 levels. There is also multilevel neural foraminal stenoses, which are detailed above.2. There is edema involving the left paraspinous musculature, relatively greatest at the left C4-C5 level with extension more inferiorly. There is also suggestion of mild soft tissue edema in the right lower cervical paraspinous muscle structure. These findings are nonspecific and may be related to recent trauma or inflammation related to facet arthropathy, with infection not entirely excluded. Post gadolinium sequences with axial and postgadolinium T1 fat-sat images is suggested if there is suspicion for infection.Dr. Ali discussed findings with the treating nurse practitioner at the time of this report.