74 years Male (DOB:6/5/1942)Reason: Hx multiple myeloma. Hx cardioembolic stroke. Now on anticoagulation. History: gait deterioration.PROVIDER/ATTENDING NAME: RIMAS V. LUKAS RIMAS V. LUKAS MRI brain:The CSF spaces are appropriate for the patient's stated age with no midline shift. There is a mild to moderate degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images. These have not changed since since the prior exam.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. No abnormal enhancing lesions are identified in the cervical spine. There is heterogeneous marrow replacement present at C2 associated with a 15 x 10 mm sagittal dimension focus of enhancement. This was also present on the previous exam where it measured similar dimensions.There is redemonstration of punctate foci of signal hyperintensity within the cervical spinal cord at the C5 vertebral level.At C2-3 there is no significant compromise to the spinal canal or neural foramina.At C3-4 there is encroachment of the exiting nerve roots at this level due to endplate osteophytes. There is a disc bulge at this level.At C4-5 there is encroachment of the left neural foramen due to some osteophytes and disc material. There is a small central disc protrusion present this level which effaces spinal fluid ventral to the spinal cord.At C5-6 there is encroachment of the neural foramina bilaterally due to uncovertebral and endplate osteophytes as well as some disc material. This affects the right side more than the left. There is also effacement of spinal fluid ventral and posterior the spinal cord at this level with overall a moderate degree of spinal stenosis.At C6-7 there is a diffuse disc bulge present at this level associated with endplate osteophytes as well as some ligamentum flavum hypertrophy. Overall there is mild spinal stenosis present in encroachment of exiting nerve root neural foramina bilaterallyAt 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 degenerative changes present in the cervical spine worse at C5-6 and C6-7 where there is moderate spinal stenosis and bilateral encroachment of exiting nerve roots at C5-6 and mild to moderate spinal stenosis and mild to moderate encroachment of exiting nerve roots at C6-7. Additionally there is encroachment of exiting nerve roots bilaterally at C3-4 and on the left-sided C4-5. This is stable when compared to the prior exam from 8/24/2016.2.There is a C2 vertebral body lesion present which is stable when compared to the prior exam from 8/24/2016. The patient is known to have multiple myeloma.3.Punctate lesion in the cervical spinal cord at the C5 level is present which could represent a small focus of myelomalacia.