66 years Male (DOB: 7/6/1949)Reason: trauma while lifting suitcase 4 weeks ago. Persistent pain in C3-C5. No radiation, on right side. Weakness and increased reflexes in biceps. History: trauma while lifting suitcase 4 weeks ago. Persistent pain in C3-C5. No radiation, on right side. Weakness and increased reflexes in biceps.PROVIDER/ATTENDING NAME: MARK SIEGLER MARK SIEGLER The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology.At C2-3 there is no significant compromise to the spinal canal or neural foramina. There is a mild disc bulge and disc desiccation at this level.At C3-4 there is no significant compromise to the spinal canal or neural foramina. There is some left-sided facet hypertrophy at this level.At C4-5 there is no significant compromise to the spinal canal. There are right-sided uncovertebral osteophytes present at this level associated with disc material which is associated with encroachment of the right-sided exiting nerve roots.At C5-6 there is no significant compromise to the spinal canal. There are endplate and uncovertebral osteophytes present this level associated with narrowing of the neural foramina. There is mild encroachment of exiting nerve roots within the neural foramina at this level which is somewhat worse on the right compared to the left side. There is disc desiccation at this level.At C6-7 there is no significant compromise to the spinal canal. There is some loss of disc space height, disc bulge and endplate and uncovertebral osteophyte formation associated with narrowing of the neural foramina and some encroachment of exiting nerve roots bilaterally.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 degenerative changes present in the cervical spine mainly in the form of endplate and uncovertebral osteophyte formation. This associated with encroachment of right-sided exiting nerve roots at C4-5 and and bilateral exiting nerve roots at C6-7.2.No intrinsic spinal cord lesion is appreciated. There is no cervical spinal canal stenosis appreciated.