Diagnosis: Unspecified rotator cuff tear or rupture of right shoulder, not specified as traumatic Other shoulder lesions, right shoulder Other cervical disc degeneration, unspecified cervical region Other cervical disc displacement, unspecified cervical regionClinical question: eval for disc herniationSigns and Symptoms: neck pain for years on and off now new left arm weakness and tingling hand and scapular dyskinesis The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology. There is straightening of the normal cervical curvature present.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.At C4-5 there is mild loss of disc space height, disc desiccation, endplate reactive changes and a diffuse disc bulge associated with small uncovertebral osteophytes. The endplate reactive changes are bright on T1-weighted imaging. There is no significant compromise to the spinal canal at this level.At C5-6 there is mild loss of disc space height, diffuse disc bulge as well as endplate and uncovertebral osteophytes with encroachment of the left-sided exiting nerve roots within the neural foramen due to a left lateral recess disc extrusion associated with some uncovertebral osteophytes. There is no significant compromise to the spinal canal. Compared to the prior exam from 2013 encroachment of the left-sided exiting nerve roots has not significantly changed.At C6-7 there is loss of disc space height, diffuse disc bulge and a left lateral recess disc protrusion which extends into the left neural foramen and encroaches on the left-sided exiting nerve root. There are endplate reactive changes present at this level which are high signal on T2 STIR predominantly located adjacent to the left side of the disc space. Compared to the prior exam from 2013 the endplate reactive changes were not in the subacute stage and there wasn't a significant disc protrusion.At C7-T1 there is no significant compromise to the spinal canal or neural foramina. There is a small central disc protrusion redemonstrated at this level.The left vertebral artery is not readily identified. This is stable since the prior exam.
1.Since the prior exam patient developed a new left lateral recess disc protrusion at C6-7 which encroaches on the left-sided exiting nerve roots. There are endplate reactive changes adjacent to the left lateral recess disc protrusion which are at a subacute stage.2.There is redemonstration of encroachment of left-sided exiting nerve roots at C5-6 related to a disc protrusion.3.There are multilevel degenerative changes present in the cervical spine. 4.The left vertebral artery is not readily identified. This is a chronic finding.