Reason: re evaluated cervical spianl cord after fusion has meatllic hardware cervical spine History: Bilateral hand paresthesia The cervical vertebral bodies are appropriate in overall alignment and height. No abnormal enhancing lesions are identified in the cervical spine. The patient is status post laminectomies at C4 and C5 where there is a pseudomeningocele defect. The patient is also status post posterior fusion at C4, C5 and C6. The cervical spinal cord and mildly deviates into the pseudomeningocele defect. There is a cord signal abnormality with T2 signal hyperintensity within the spinal cord at the C5 vertebral body level. This was also present on the prior exam.At 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. There are large anterior osteophytes present at this level.At C4-5 there is no significant compromise to the spinal canal or neural foramina. There is signal hyperintensity within the disk space at this level with associated contrast enhancement. The endplates appear preserved.At C5-6 there is no significant compromise to the spinal canal or neural foramina.At C6-7 there is no significant compromise to the spinal canal or neural foramina.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact. The right vertebral artery appears to be hypoplastic compared to his unchanged since prior exam
1.Status post laminectomy and fusion in the cervical spine. There is no spinal stenosis currently. The spinal cord mildly deviates into the pseudomeningocele defect. The exam was obtained with the patient in supine position and this effect is presumed to be gravitational.2.A small focus of myelomalacia is redemonstrated in the spinal cord at the C5 vertebral level which is unchanged since the prior exam 2013.3.Some signal changes within the C4-5 disk are suspected to be related to inflammatory reaction but are nonspecific.