62-year-old male with weakness, ataxia, multiple falls, perianal anesthesia and decreased rectal tone. Evaluate for stenosis or cord compression. The vertebral bodies are appropriate in the overall alignment and height. There are multiple disc-osteophyte complexes in the cervical spine with evidence of cord signal abnormality at the C3-4 level, indicating cord edema. There are multiple discs protrusions involving the lower lumbar lumbar spine with some narrowing of the spinal canal. There is a sigmoid curvature to the spine with levoscoliosis of the lower spine and dextroscoliosis of the upper spine.
This is a limited exam specific for the exclusion of cord compression only and does not exclude more subtle lesions such as intrinsic cord abnormalities. There is abnormal cord signal indicating cord edema at the C3-4 level. There is a disc-osteophyte complex and facet degenerative disease at this level. These findings are compatible with spondylotic myelopathy at this level. Please refer to the dedicated MRI C-spine for further characterization which as since been performed. Additional degenerative changes are seen in the cervical and lumbar spine. 