51 years Male (DOB:9/14/1965)Reason: compare to image in epic. Unknown lesion 3 month follow up History: lesion in cervical spinePROVIDER/ATTENDING NAME: BEN-ZION ROITBERG BEN-ZION ROITBERG The cervical vertebral bodies are appropriate in overall alignment and height. The C1 vertebral body appears to be fused to the skull base. The posterior arch of C1 is not readily identifiedPatient status post laminectomies from C3 through C6. There is redemonstration of an enhancing lesion present within the spinal cord at the C4 vertebral body level measuring 6 x 4 x 6 mm in size which measured 6 x 6 x 9 mm. There is redemonstration of associated T2 signal hyperintensity within the spinal cord extending from the C2-3 down to the C4 vertebral level. This T2 signal hyperintensity has regressed since the prior exam.There is redemonstration of low-lying cerebellar tonsils which extend approximately 20 mm below the level of the foramen magnum. It have a pointed appearance and have not changed substantially since prior exam.At C2-3 there is no significant compromise to the spinal canal. There is a disc bulge present at level associated with some uncovertebral osteophytes and narrowing of the neural foraminal encroachment of left-sided exiting nerve roots..At C3-4 there is no significant compromise to the spinal canal. There is a disc bulge present this level associated with uncovertebral osteophytes and narrowing of the neural foramina bilaterally and encroachment of the exiting nerve roots.At C4-5 there is no significant compromise to the spinal canal or neural foramina. There is a disc bulge at this level. There are some right-sided uncovertebral osteophytes at this level.At C5-6 there is no significant compromise to the spinal canal. There is a disc bulge at this level associated with uncovertebral osteophytes bilaterally worse on the right side. There is encroachment of the right exiting nerve roots within the neural foramen.At C6-7 there is no significant compromise to the spinal canal. There are endplate and uncovertebral osteophytes present this level associated with encroachment of the exiting nerve roots within the neural foramina 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.An enhancing lesion within the cervical spinal cord is slightly smaller on the current exam compared to the prior exam. Since the prior exam there has been some regression of associated cord edema.2.Chiari I malformation.3.Multilevel degenerative changes present in the cervical spine with encroachment of exiting nerve roots within the neural foramina bilaterally at C6-7, on the right-sided C6, bilaterally at C3-4 and on the left side at C2-3.4.Congenital malformation of the C1 vertebra with fusion to the occiput and absence of the posterior arch.