Male, 64 years old, with a left C6 radiculopathy clinically. Previous history of fasciculations of the left hand and forearm, status post foraminotomy on the left years ago because of weakness. Postoperative findings are seen along the posterior elements on the left at C6-7 suggesting at least partial laminectomy and facetectomy.Mild reversal of the normal cervical lordosis is seen, likely degenerative in nature. Sagittal alignment is otherwise unremarkable. Vertebral body heights are grossly preserved. Degenerative endplate signal abnormality is seen at C4, C5 and C6. No worrisome marrow replacement or evidence of significant marrow edema is observed.The visualized spinal cord is free of pathologic signal abnormality. Level specific findings are detailed as follows:C2-3: Left greater than right facet hypertrophy. Right paracentral and foraminal disc osteophyte formation resulting in effacement of the right lateral recess, but no significant generalized canal stenosis and no cord impingement. The right neural foramen is severely narrowed. The left neural foramen is patent. No significant interval change at this level.C3-4: Bilateral facet hypertrophy. Right paracentral and foraminal disc osteophyte formation which effaces the right ventral thecal sac and mildly deforms the ventral spinal cord. Mild generalized spinal canal stenosis. Moderate to severe bilateral foraminal narrowing. No significant interval change at this level.C4-5: Mild bilateral facet hypertrophy. Broad disc osteophyte formation slightly asymmetric to the right. Effacement of the ventral thecal sac with slight flattening of the ventral cord. Mild generalized spinal canal narrowing. Severe right and moderate to severe left foraminal narrowing. No significant interval change at this level.C5-6: Right facet hypertrophy. Broad posterior disc osteophyte formation with a new small left lateral recess disc extrusion with mild caudal migration. No cord impingement or significant spinal canal narrowing. Severe left and moderate to severe right foraminal narrowing. C6-7: Disc osteophyte formation asymmetric to the left and particularly along the left uncovertebral joint. Superimposed PLL thickening is also seen below the disc space level. These findings contribute to produce a mild to moderate spinal canal stenosis with very slight impingement of the spinal cord. Severe left and moderate right foraminal narrowing. Postoperative findings as discussed above. No significant interval change at this level.C7-T1: Bilateral facet hypertrophy. Left subarticular and foraminal zone disc osteophyte formation. No significant generalized spinal canal stenosis. Severe left and mild right foraminal narrowing. No significant interval change at this level.
1.New small left lateral recess disc extrusion with mild caudal migration at C5-6 may correlate with C6 radiculopathy symptoms. Significant foraminal narrowing is also evident at most of the additional cervical levels as detailed above are otherwise not significantly changed.2.Stable degenerative spinal canal stenosis is seen at multiple levels, most severely affecting the C6-7 level where there is a mild to moderate stenosis and slight impingement of the spinal cord. No spinal cord signal abnormality to suggest cord edema at this or any other level.