Abnormal reflex Other specified personal history presenting hazards to health(V15.89)Clinical question: r/o intracranial lesionsSigns and Symptoms: umnl on rightWeakness of right leg MRI brain:The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal enhancing mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.Normal vascular flow voids are present in the distal carotid and vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries as well as the internal cerebral veins and superior sagittal sinus.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. The cervical spinal cord has normal signal characteristics and overall morphology. No abnormal enhancing lesions are identified in the cervical spine.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 or neural foramina.At C5-6 there is a right paramedian broad based disk protrusion associated with mild posterior ligamentous hypertrophy, endplate and uncovertebral osteophytes and effacement of CSF ventral and posterior to the spinal cord. There is encroachment of the right sided exiting nerve roots at this level. Overall there is mild to moderate spinal stenosis at this level.At C6-7 there is no significant compromise to the spinal canal . There is encroachment of the left sided exiting nerve roots at this level due to osteophytes and disk material.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 is mild to moderate spinal stenosis at C5-62.There is encroachment of left sided exiting nerve roots at C6-7 and right sided exiting nerve roots at C5-6.3.There is no evidence for acute ischemic cerebral infarction and no evidence for intracranial mass.