Diagnosis: Ataxia, unspecified Disease of spinal cord, unspecifiedClinical question: eval postop changesSigns and Symptoms: s/p cervical decompression The cervical vertebral bodies are appropriate in overall alignment and height. The patient status post laminectomies at C3, C4, C5 which is new since the prior exam. There is redemonstration of atrophy of the cervical spinal cord associated with signal change from the C1 level down to the C7 level. There is a fluid collection present behind the thecal sac extending throughout the laminectomy sites.At C2-3 there is no significant compromise to the spinal canal or neural foramina. There is a disc bulge present at this level. There is partial effacement of spinal fluid ventral and posterior the spinal cord at this level.At C3-4 there is loss of disc space height, disc desiccation, diffuse disc bulge, endplate and uncovertebral osteophytes and effacement of spinal fluid ventral and posterior the spinal cord. There is narrowing of the neural foramina bilaterally at this level with encroachment of exiting nerve roots. Despite laminectomy there is effacement of spinal fluid ventral and posterior the spinal cord.At C4-5 there is loss of disc space height, disc desiccation, diffuse disc bulge, endplate and uncovertebral osteophytes and effacement of spinal fluid ventral and posterior the spinal cord. There is narrowing of the neural foramina bilaterally at this level with encroachment of exiting nerve roots. Despite laminectomy there is effacement of spinal fluid ventral and posterior the spinal cord.At C5-6 there is loss of disc space height, disc desiccation, diffuse disc bulge, endplate and uncovertebral osteophytes and effacement of spinal fluid ventral and posterior the spinal cord. There is narrowing of the neural foramina bilaterally at this level with encroachment of exiting nerve roots. Despite laminectomy there is effacement of spinal fluid ventral and posterior the spinal cord.At C6-7 there is diffuse disc bulge associated with loss of disc space height and disc desiccation, endplate osteophytes and uncovertebral osteophytes with encroachment of the exiting nerve roots bilaterally within the neural foramina and effacement of spinal fluid ventral and posterior the spinal cord. At this level cord signal change appears to be relatively stableAt C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.
1.Since the prior exam, the patient has undergone laminectomies at C3, C4 and C5. 2.There is a fluid collection present at the laminectomies site. There is multilevel spinal stenosis present from the C2-3 level down to the C6-7 level. In part it is possible that the spinal stenosis is related to the fluid collection.3.There is multilevel bilateral neural foramen encroachment of exiting nerve roots present at C3-4, C4-5, C5-6 and C6-7.