85 years Female (DOB: 8/1/1931)Reason: Evaluate for cervical spinal stenosis or neuroforaminal stenosis causing cervical radiculopathy. History: Left upper extremity radicular pain with neck painPROVIDER/ATTENDING NAME: DIONNE J. BLACKMAN DIONNE J. BLACKMAN Cervical spine:There is reversal of the normal cervical curvature centered at C3-4 and C4-5. There is osseous bridging across the C3 and C4 vertebral bodies. To a lesser degree there is some osseous bridging present at C4-5 and C5-6. There appears to be some loss of vertebral body height at C4.At C2-3 there is a diffuse disc bulge associated with thickening of the ligamentum flavum and effacement of spinal fluid ventral and posterior the spinal cord. This appears to have mildly progressed since 5/13/2014. There is associated hypertrophy of the right facet and encroachment of right-sided exiting nerve roots is also present on the prior examAt C3-4 there are large endplate osteophytes present and uncovertebral osteophytes associated with effacement of spinal fluid ventral to the spinal cord but not posterior the spinal cord. There is redemonstration of encroachment of left-sided exiting nerve roots related to endplate osteophytes and uncovertebral osteophytes this level.At C4-5 there is no significant compromise to the spinal canal. There are endplate uncovertebral osteophytes present this level with narrowing of the neural foramina bilaterallyAt C5-6 there is no significant compromise to the spinal canal. There are endplate uncovertebral osteophytes present this level with narrowing of the neural foramina bilaterally but worse on the right side.At C6-7 there is no significant compromise to the spinal canal. There are endplate uncovertebral osteophytes present this level with narrowing of the neural foramina bilaterally. There is some encroachment of the exiting nerve roots at this level. This appears to have been present on the prior exam as wellAt C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.
1.There is redemonstration of multilevel degenerative changes in the cervical spine with findings compatible with mild to moderate spinal stenosis at C2-3 as well as neural foraminal encroachment of exiting nerve roots worse at C2-3 and C6-7 bilaterally as well as the left side at C3-4. The C2-3 stenosis appears to have progressed relative to the prior exam.2.There is reversal of the normal cervical curvature in the upper cervical spine with some loss of vertebral body height at C4 and some osseous bridging along some of the upper cervical spine vertebrae.