55-year-old female with left-sided neck pain with radicular pain down the left upper extremity. There are scattered patchy non-expansile T2/STIR spinal cord signal abnormalities located at the upper C2 level, centrally at the lower C2 level, posteriorly at the upper C3 level, along the right lateral aspect of the spinal cord at the C3-4 level and within the right lateral aspect of the spinal cord at C5 level.Similarly, there are at least two small focal T2/STIR lesions in the deep white matter of the left cerebellum and a single focus of signal abnormality in the left medial dorsal lower medulla.The cervical spine alignment is maintained. The cervical vertebral bodies are appropriate in height. There is mild loss of disc height at the C4-5 and C5-6 levels. The bone marrow signal is within normal limits. Degenerative changes are seen in the cervical spine as described below:C2-3: No significant disc disease or compromise to the spinal canal or neural foramina.C3-4: Trace diffuse disc osteophyte complex with mild uncovertebral hypertrophy which causes mild bilateral neuroforaminal narrowing. No spinal canal stenosis.C4-5: Small diffuse disc osteophyte complex with mild uncovertebral hypertrophy which causes moderate bilateral neuroforaminal narrowing. There is minimal spinal canal stenosis. C5-6: Trace disc osteophyte complex and mild bilateral neuroforaminal narrowing. No spinal canal stenosis.C6-7: Small disc osteophyte complex with mild to moderate bilateral neuroforaminal stenosis and minimal spinal canal stenosis.C7-T1: No significant compromise to the spinal canal or neural foramina.At the T1-T2 and T2-T3 levels, there is minimal disc disease but no significant neuroforaminal or spinal canal stenosis.The vertebral artery flow voids appear to be intact. The paraspinous soft tissue structures appear within normal limits. There is partially visualized mucosal thickening involving the left maxillary sinus and an air-fluid level within the right maxillary sinus which could indicate sinusitis.
1.Scattered patchy areas of T2/STIR signal abnormality in the posterior fossa and cervical spinal cord which are suspicious for a demyelinating process. MRI Brain with and without contrast is recommended for further evaluation.2.Mild spondylotic changes of the cervical spine with at most moderate bilateral neuroforaminal narrowing and minimal spinal canal stenosis at the C4-5 level.3.Maxillary sinus mucosal thickening with a air-fluid level within the right maxillary sinus which could indicate sinusitis. Please correlate clinically.