61 years Male (DOB:11/24/1954)Reason: MS or Cx disk History: R leg weak x 9 mo; bladder insensitive; new loss of vibration in LLEPROVIDER/ATTENDING NAME: ANTHONY T REDER ANTHONY T REDER MRI brain:There is redemonstration of periventricular and subcortical white matter lesions which are high signal on FLAIR and T2 MRI sequences and low signal on T1. Some are perpendicularly oriented to the lateral ventricles. These were also present on the previous exam and have not changed significantly.The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal 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 demonstrate minor opacities. 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. There are T2 hyperintense foci present throughout the cervical spinal cord. This includes the C2 level in the left posterior lateral and right lateral aspect, the C1 level posteriorly the C5 level posteriorly and to the right of midline, the C6 level at the left posterior lateral aspect and the C7 level on the right side.At C2-3 there is no significant compromise to the spinal canal. There is a left lateral recess disc protrusion at this level with some mild encroachment of left-sided exiting nerve rootsAt C3-4 there is no significant compromise to the spinal canal. There is a left lateral recess disc protrusion present associated with uncovertebral osteophyte which encroaches on the left-sided exiting nerve roots and left hemicord.At C4-5 there is no significant compromise to the spinal canal or neural foramina. There is a disc bulge and disc desiccation at this level.At C5-6 there is no significant compromise to the spinal canal . There are bilateral uncovertebral osteophytes more on the right than the left side associated with disc material and encroachment of the right-sided exiting nerve roots.At C6-7 there is no significant compromise to the spinal canal or neural foramina. There are endplate and uncovertebral osteophytes at this level with some narrowing of the 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.
1.There are multiple lesions redemonstrated within the brain parenchyma which are compatible with patient's diagnosis of multiple sclerosis. There are unchanged prior exam.2.There are multiple lesions identified in the cervical spinal cord compatible with demyelination.3.There are multilevel degenerative changes present in the cervical spine with encroachment of the right-sided exiting nerve roots at C5-6 and left-sided exiting nerve roots and hemicord at C3-4