43 years Female (DOB:5/17/1973)Reason: demyelinating lesion? History: weakness, hx ms PROVIDER/ATTENDING NAME: JACQUELINE T. BERNARD JACQUELINE T. BERNARD Cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. There is a T2 signal hyperintense focus present along the right posterior lateral aspect of the spinal cord at the C3-4 vertebral level. This was also present on the 9/21/2015 exam. There is no associated mass effect. This does not enhance following gadolinium administration.There is a T2 hyperintense lesion present along the left posterior lateral aspect of the spinal cord at the C2-3 disc space level. This was also present on the prior exam. There is no mass effect associated with it. This does not enhance following gadolinium administration.There is a punctate size T2 hyperintense focus at the right lateral aspect of the spinal cord at the C4 vertebral body level which is also unchanged. This does not enhance following gadolinium administration. This does not enhance following gadolinium administration.There is a T2 hyperintense ill-defined focus present at the left hemicord at the C6 vertebral body level. There is some vague contrast enhancement associated with this. This was not clearly present on the prior exam.There is a T2 hyperintense enhancing lesion present at the right hemicord at the C7-T1 disc space level . This was not clearly present on the prior exam.No abnormal enhancing lesions are appreciated in the cervical spine.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 is a disc bulge present at this level associated bilateral uncovertebral osteophytes and mild narrowing of the neural foramina.At C4-5 there is no significant compromise to the spinal canal or neural foramina.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 is small.MRI thoracic spine:There is a contrast enhancing lesion present within the posterior midline aspect of the spinal cord at the T6-7 disc space level. This is associated with T2 signal hyperintensity and mild mass effect. Additional lesions are present in the thoracic spinal cord at the T5-6 level along the anterior and right side of the peripheral spinal cord, at the T5 vertebral level along the left posterior lateral hemicord at the right posterior lateral aspect of the spinal cord with some punctate enhancement, at the T3 vertebral level at the right hemicord where there is some contrast enhancement and at the C7-T1 level there is also some contrast enhancementNonenhancing lesions are also present in the lower thoracic spinal cord at T8-9 level, T9-10 level and T10 level which are not associated with the mass effect or contrast enhancement..The thoracic vertebral bodies are appropriate in the overall alignment and height. There is no compromise of thoracic spinal canal or exiting nerve roots.
1.Since the prior exam patient has accumulated new lesions in the lower cervical spinal cord which display contrast enhancement suggestive of active plaque formation. 2.There are multiple lesions throughout the thoracic spinal cord which are compatible with demyelinating disorder some of which display contrast enhancement at C7-T1, T3 and T6-7. Additional nonenhancing lesions suggestive of nonacute plaque are present elsewhere in the thoracic spinal cord.