Posttraumatic left hand paresthesia. History of spinal fusion. Patient demonstrates evidence of previous C3-C5 anterior fusion and C3-C7 laminoplasties. The vertebral body osseous fusion is solid. The thecal sac is decompressed at the operated levels. The soft tissue on the laminoplasty bed is enhancing but does not impinge on the thecal sac. The spinal cord is notable for focal T2 hyperintense focus involving the cord bilaterally at the upper C5 vertebral level. It is associated with mild cord thinning. This is may be related to prior compressive myelopathy. The spinal cord otherwise shows no significant signal or morphologic abnormality (down to T4-T5 level). The included lower brainstem/cerebellum also shows no abnormality.Cervical alignment is notable for straightening which is expected given the multilevel fusion. There is mild, symmetric height loss at the C6 vertebral body but without associated edema or retropulsion. This is probably chronic. The other included vertebral bodies (down to T4) are normal. There is no suspicious marrow abnormality. Mild ossification along the posterior longitudinal ligament better seen on CT.C2-C3: There is no spinal canal or foraminal stenosis.C3-C4: There is mild left uncovertebral proliferative change causing minimal left foraminal stenosis. There is no spinal canal or right foraminal stenosis.C4-C5: There is mild uncovertebral proliferative change causing mild left and minimal right foraminal stenosis. There is no spinal canal stenosis.C5-C6: Uncovertebral and facet proliferative change are associated with moderate biforaminal narrowing. There is no spinal canal stenosis.C6-C7: Uncovertebral and facet proliferative change are associated with moderate left and minimal right foraminal narrowing. There is no spinal canal stenosis.C7 T1: There is mild left foraminal narrowing by proliferative facet/endplate disease. There is no spinal canal narrowing.
1.Prior C3-C5 solid osseous anterior fusion and C3-C7 laminoplasties with well-decompressed thecal sac. 2.Focal cord signal abnormality at C5 level is consistent with myelomalacia. No evidence of cord edema or traumatic contusion. No findings to suggest ligamentous injury. No epidural hematoma. 3.Degenerative changes with foraminal narrowing, moderate bilateral at C5-C6 and on the left at C6-C7.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.