HIV on HAART with bilateral sensory disturbances in the hands and feet. Brain: There is no evidence of intracranial hemorrhage, mass, or acute infarct. The brain parenchyma and pituitary gland appear unremarkable. There is no abnormal intracranial enhancement. There is prominence of the retrocerebellar cerebrospinal fluid spaces. The ventricles and basal cisterns are otherwise normal in size and configuration. There is no midline shift or herniation. The major cerebral flow voids are intact. The orbits, skull, paranasal sinuses, and scalp soft tissues are grossly unremarkable.Cervical Spine: There is a large central disc extrusion that compresses the spinal cord at the C5-6 level. There is patchy high T2 signal and punctate enhancement within the spinal cord at this level. There is also a smaller central disc protrusion at the C4-5 level that slightly indents the spinal cord. The vertebral column alignment is within normal limits. The vertebral body and disc space heights are preserved. The vertebral bone marrow signal is unremarkable. The paravertebral soft tissues are unremarkable.
1. A large disc extrusion compresses the spinal cord at the C5-6 level with associated spinal cord edema. A disc smaller central disc protrusion at the C4-5 level also slightly indents the spinal cord. 2. No evidence of intracranial hemorrhage, mass, or acute infarct. Discussed with Dr. Weyer at 3 PM on 3/12/16.