65 years Male (DOB:10/28/1950)Reason: assess for cervical radiculopathy and progression of cervical spinal stenosis History: radicular pain in the RUEPROVIDER/ATTENDING NAME: KOUROSH REZANIA KOUROSH REZANIA The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology. No abnormal mass lesions are identified in the cervical spine. The patient status anterior fusion from C4 through C6 using anterior plate and screws.At C2-3 there is a diffuse disc bulge present associated with ligamentum flavum hypertrophy. There is associated effacement of spinal fluid ventral and posterior the spinal cord. This has not changed substantially compared to the previous exam.At C3-4 there is no significant compromise to the spinal canal or 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. There is a disc bulge present at this level which narrows the neural foramina. It is associated with small uncovertebral osteophytes. Overall there is mild encroachment of the exiting nerve roots within the neural foramina.At C7-T1 there is no significant compromise to the spinal canal or neural foramina. There is a disc bulge present at this level mildly narrowing the neural foramina at this level.The vertebral artery flow voids appear to be intact.
The patient is status post anterior fusion from C4 through C6. There is redemonstration of degenerative changes of the cervical spine associated with spinal stenosis at C2-3 and some narrowing of neural foramina at other levels. These findings are stable compared to the previous exam from 10/17/2015.