71 years Male (DOB:10/20/1944)Reason: eval for nerve impingement. Pt with lateral soft tissue like neck mass and now with radiating pain of neck, shoulder, arm History: R neck, shoulder, and arm painPROVIDER/ATTENDING NAME: DIANE B CHANEY DIANE B CHANEY 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 identified in the cervical spine. There is multilevel disc desiccation present.At C2-3 there is no significant compromise to the spinal canal or neural foramina. There is mild loss of disc space height and the disc bulge at this level.At C3-4 there is no significant compromise to the spinal canal or neural foramina. There is mild loss of disc space height and the disc bulge at this level.At C4-5 there is no significant compromise to the spinal canal or neural foramina. There is mild loss of disc space height and the disc bulge at this level.At C5-6 there is a broad-based right lateral recess disc protrusion present at this level which encroaches on the right-sided exiting nerve roots. There is narrowing of the spinal canal present with mild spinal stenosis.At C6-7 there is a diffuse disc bulge present at this level associated with endplate and uncovertebral osteophytes and some narrowing of the neural foramina bilaterally with encroachment of the left-sided exiting nerve roots. There is partial effacement of spinal fluid ventral and posterior the spinal cord. Overall there is mild spinal stenosis at this level. There is endplate reactive change present at this level. This endplate reactive change has high signal on T1 and heterogeneous signal on T2 STIR..At C7-T1 there is no significant compromise to the spinal canal. There is mild disc bulge at this level associated with endplate and uncovertebral osteophytes and narrowing of the neural foramina bilaterally. There is some mild encroachment of the exiting nerve roots within the neural foramina bilaterally at this level.The vertebral artery flow voids appear to be intact.
1.There are multilevel degenerative changes present in the cervical spine with narrowing of the spinal canal in the lower cervical spine. There is moderate encroachment of the right-sided exiting nerve roots at C5-6 as a result of a disc protrusion and some osteophytes. There are lesser degrees of neural foraminal encroachment in the lower cervical spine at other levels (detailed above) and mild degrees of spinal stenosis at C5-6 and C6-7.