Diagnosis: Unspecified abnormalities of gait and mobilityClinical question: gait disorder, falls. Assess for cervical lesion.Signs and Symptoms: Unsteady gait Cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology.No abnormal enhancing lesions are appreciated in the cervical spine. Overall there is no significant change since the prior exam from 1/20/2010At C2-3 there is no significant compromise to the spinal canal or neural foramina. There is bilateral facet hypertrophy right more than left this level.At C3-4 there is no significant compromise to the spinal canal . There are small uncovertebral osteophytes present in bilateral facet hypertrophy at this level. There is a mild disc bulge present at this level. There is encroachment of the exiting nerve roots within the neural foramina bilaterally (right worse than left) at this level as a result of facet hypertrophy and uncovertebral osteophyte formation.At C4-5 there is no significant compromise to the spinal canal . There are small uncovertebral osteophytes present in bilateral facet hypertrophy at this level. There is encroachment of the exiting nerve roots within the neural foramina bilaterally (right worse than left) at this level as a result of facet hypertrophy and uncovertebral osteophyte formation.At C5-6 there is no significant compromise to the spinal canal . There are small uncovertebral osteophytes on the right side present and bilateral facet hypertrophy (right worse than left) at this level. There is mild encroachment of the exiting nerve roots within the right neural foramen at this level as a result of facet hypertrophy and uncovertebral osteophyte formation.At C6-7 there is no significant compromise to the spinal canal or neural foramina. There is bilateral facet hypertrophy present at this level. There is a couple millimeters anterior subluxation of C6 on C7.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.MRI thoracic spine:The thoracic vertebral bodies are appropriate in the overall alignment and height. The thoracic spinal cord has normal signal characteristics and overall morphology. There is no compromise of thoracic spinal canal or exiting nerve roots. No abnormal enhancing lesions are appreciated in the thoracic spine.
1.There are multilevel degenerative changes present in the cervical spine with some encroachment of the right-sided exiting nerve roots at C3-4 and C4-5 and narrowing of neural foramina elsewhere. These findings have not changed substantially since 2010 exam. There is no evidence for cervical spinal cord compromise.2.There is no compromise of thoracic spinal cord or exiting nerve roots appreciated.