Male, 59 years old, with history of Klippel-Feil syndrome, presenting with neck pain. Due to the ambiguous appearance of several cervical vertebral body levels, vertebral body numbering is by necessity somewhat arbitrary. Please see the accompanying CT report for further explanation of the numbering rationale.Partial atlantooccipital assimilation is seen with fusion of the left lateral mass and left arch of C1 to the occipital bone. Non fusion of the two halves of the anterior arch of C1 is seen, and the right C1 arch is fused to C2. The C2-C5 vertebral bodies are malformed and there is evidence of osseous fusion across the vertebral bodies and the posterior elements.Extensive disc degeneration is seen at C5-6. Wasp waist morphology is evident between C6 and T1 with fusion across the vertebral bodies and posterior elements at these levels. Fusion across the vertebral bodies and posterior elements is also seen at T2-3 .The visualized spinal cord demonstrates normal signal characteristics and normal morphology throughout. The spinal canal is narrowed at the C4 and C5 levels but this does not appear to result in significant cord deformation. Additional level specific findings are as follows:C2-3: Right neuroforaminal narrowing. No discrete left neural foramen is seen at this level though the left C1-2 neural foramen is capacious. C3-4: Moderate to severe left and mild right foraminal narrowing. Mild generalized spinal canal narrowing. C4-5: Moderate right and mild left foraminal narrowing. Mild generalized spinal canal narrowing. C5-6: Right facet hypertrophy. Posterior disc-osteophyte complex formation. Moderate generalized spinal canal stenosis. Severe right and mild left foraminal narrowing.C6-7: No significant spinal canal stenosis. No significant foraminal narrowing.C7-T1: No significant spinal canal or foraminal stenosis. T1-2: No significant spinal canal or foraminal stenosis.
1.Multiple vertebral body anomalies and osseous fusion compatible with the stated history of Klippel-Feil syndrome.2.Spinal canal narrowing is evident at the C3-C5 levels but without significant cord impingement and no evidence of cord signal abnormality.3.Scattered variable foraminal narrowing as above.