Diagnosis: Cervical disc disorder with myelopathy, unspecified cervical regionClinical question: history of herniated cervical discSigns and Symptoms: numbness tingling weakness 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 straightening of the normal cervical curvature present. Overall the alignment of the cervical vertebrae is stableAt C2-3 there is no significant compromise to the spinal canal or neural foramina.At C3-4 there is no significant compromise to the spinal canal or neural foramina.At C4-5 there is no significant compromise to the spinal canal or neural foramina.At C5-6 there is a diffuse disc bulge present associated with endplate and uncovertebral osteophytes and encroachment of the neural foramina bilaterally with encroachment of the exiting nerve roots. Some disc material extrudes behind the adjacent endplates and encroaches the nerve roots at the right lateral recess and neural foramen more than the left. There is effacement of spinal fluid ventral and posterior the spinal cord with mild to moderate spinal stenosis. Overall when compared to the exam from 11/13/2010 there does not appear to be a substantial change.At C6-7 there is loss of disc space height, disc desiccation, endplate and uncovertebral osteophytes as well as a disc bulge associated with effacement of fat surrounding the exiting nerve roots within the neural foramina bilaterally. There is effacement of spinal fluid ventral and posterior the spinal cord at this level with mild to moderate degree of spinal stenosis. Overall there is very mild progression of the spinal stenosis at this level.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 at C5-6 and C6-7 where there is mild to moderate spinal stenosis and neural foraminal encroachment of exiting nerve roots. There is a subtle progression of the spinal stenosis at C6-7 when compared to the prior exam. The spinal stenosis at C5-6 remains stable.