74 years Male (DOB: 11/17/1941)Reason: neck pain r/o cervical spinal stenosis History: neck pain r/o cervical spinal stenosisPROVIDER/ATTENDING NAME: JULIE L. OYLER JULIE L. OYLER The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology.There is mild indentation along the posterior aspect of thecal sac at the C1 level. There are some degenerative changes present along the right articulation between C1 and C2. This results in mild indentation along the right half of the thecal sac and encroachment of the right neural foramen at this levelAt C2-3 there is no significant compromise to the spinal canal or neural foramina. There is disc desiccation and a disc bulge at this level.At C3-4 there is loss of disc space height, endplate uncovertebral osteophytes and a diffuse disc bulge associated with right-sided facet hypertrophy. There is partial effacement of CSF ventral to the spinal cord at this level. There is encroachment of the neural foramina bilaterally with encroachment of right-sided exiting nerve roots within the neural foramen more than the left at this level.At C4-5 there is no significant compromise to the spinal canal or neural foramina.At C5-6 there is disc desiccation and diffuse disc bulge associated with uncovertebral osteophytes and encroachment of the neural foramina and exiting nerve roots bilaterally. There is partial effacement of spinal fluid ventral to the spinal cord at this level.At C6-7 there is disc desiccation and diffuse disc bulge associated with loss of disc space height and endplate reactive change. Endplate reactive changes are high signal on T2 and low signal on T1. There are endplate and uncovertebral osteophytes present this level associated with encroachment of the exiting nerve roots bilaterally within this level. There is ligamentum flavum hypertrophy at this level and overall a moderate degree of spinal stenosis.At C7-T1 there is no significant compromise to the spinal canal. There are small uncovertebral osteophytes and some disc material and encroachment of the left-sided exiting nerve roots within the neural foramen at this level.The vertebral artery flow voids appear to be intact. On the right side at the level of the right vertebral artery groove the right vertebral artery flow-void is not entirely seen.
1.There are multilevel degenerative changes present in the cervical spine worse at C6-7 there is moderate spinal stenosis and subacute endplate reactive change. There is encroachment of exiting nerve roots within the neural foramina bilaterally at C3-4, C5-6 and C6-7 and on the left side at C7-T1.2.There are some erosive changes along the right articulation at C1-2. This mildly indents the thecal sac and encroaches on the right-sided exiting nerve roots at C1-2 in general this has the appearance of degenerative change but is incompletely evaluated. Perhaps a CT of the upper cervical spine would help further evaluate this if clinically appropriate. It is also unclear this affects the underlying right vertebral artery based on this exam.