51 years Male (DOB:8/22/1964)Reason: eval for cord compression, History: hx of compression, recent cervical surgery, past hx of lumbar spinal hematomaPROVIDER/ATTENDING NAME: DAVID HOWES DAVID HOWES The patient is status post cervical spine surgery with multilevel laminectomies at C4, C5 and C6. There is signal hyperintensity on T2 imaging within the cervical spinal cord at the C4 level. This was present on the 1/28/2016 exam. There are signal changes within the soft tissues behind the thecal sac at the surgical site.There are degenerative changes present in the lower lumbar spine without spinal stenosis.The vertebral bodies are appropriate in the overall alignment and height. The spinal cord has normal signal characteristics and overall morphology. There is no compromise of the spinal cord.
1.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. No cord compression is identified.2.Due to the screening nature of this protocol details are not as evident on imaging as dedicated protocols of the spine.3.There is cord signal change present at the C4 vertebral body level. This is not adequately evaluated on this exam. It was present on the preoperative exam from 1/28/2016.4.There are degenerative changes present in the lower lumbar spine. Please refer to MRI from 1/28/2016 for further comments