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1. Mild disc space narrowing at C6-7.
Dictated by: Bruce Goethe, MD on 10/15/2015 4:42 PM.
Electronically signed by: Bruce Goethe, MD on 10/15/2015 4:44 PM.Narrative
EXAMINATION: Cervical Spine, Three Views or LessHISTORY: Neck pain.
FINDINGS: AP and lateral views.
Comparison with the complete examination performed on 09/19/07. No evidence
of fracture, subluxation, or other acute bony abnormality. Very mild disc
space narrowing at C6-7. The other disc spaces and vertebral body heights are
well-maintained.Component Results
There is no component information for this result.General Information
Collected:
10/14/2015 1:48 PMResulted:
10/15/2015 4:44 PMOrdered By:
MIRIAM A SCHERRER, PA-CImpression
1. No evidence for disc herniation or significant spinal canal stenosis in the lumbar region. There is mild narrowing of the left L5-S1 neural foramen, the other lumbar neural foramina appear to be reasonably patent. Mild disc bulging at the L4-L5 and
L5-S1 levels.
2. No compromise of the conus medullaris or cauda equina.
3. No unusual enhancement of the lumbar spine.Dictated by: David Patrick DO on 11/3/2016 1:03 AM.
Electronically signed by: David Patrick DO on 11/3/2016 1:16 AM.Narrative
EXAMINATION: MRI Lumbar Spine without and with IV Contrast
TECHNIQUE: Magnetic resonance imaging of the lumbar spine was performed utilizing a multiecho, multiplanar technique before and after administration of intravenous contrast (12 mL of MultiHance).DATE: 11/3/2016 12:47 AM
COMPARISON: MRI thoracic spine performed 3/20/2015, CT pelvis performed 1/16/2014INDICATION: 30-year-old female presents with low back pain, abdominal pain, urinary retention, 2 episodes of urinary incontinence.
ENCOUNTER: Not Applicable.
_________________________FINDINGS:
1. The lumbar vertebral bodies have normal height, marrow signal and gross alignment.
2. The visualized distal spinal cord is normal in appearance, the conus medullaris ending in appropriate location at the level of the L1-L2 disc space.
3. The contrast enhanced images demonstrate no unusual enhancement of the conus medullaris or cauda equina. There is no unusual enhancement of the lumbar vertebral bodies or lumbar paraspinal soft tissues.
4. The lumbar spinal canal is diminutive in caliber on a developmental basis.Disc levels:
L1-L2: No significant abnormality.
L2-L3: No significant abnormality.
L3-L4: Minimal disc bulge. No significant abnormality.
L4-L5: Disc height well-maintained. Mild diffuse disc bulge. The bulging disc effaces the ventral aspect of the thecal sac and results in mild reduction in thecal sac caliber. The bulging disc effaces both L5 nerve root sleeves as it exits the thecal sac
(6:30). No significant spinal canal stenosis. The neural foramina are patent bilaterally. Facet joints within normal limits.L5-S1: Mild loss of disc height with a degree of disc desiccative change. There is eccentric disc bulging posterior laterally on the left. There is a small posterior annular tear posterior laterally on the left. There is no spinal canal or right neural
foraminal stenosis. There is mild left neural foraminal stenosis. Minimal facet joint arthropathy.
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Name: Jessica Sue Wilson | DOB: 12/23/1985 | MRN: 0005526298 | PCP: BRANDIE R YANCY, PA
MRI Spine Cervical WO Con – DetailsStudy Result
Impression
1. Small central disc protrusion at C4-C5 causing mild central stenosis
without foraminal stenosis.
2. Moderate disc space narrowing at C6-C7 with associated degenerative change
has worsened since the prior study. Mild central and right foraminal stenosis
and moderate left foraminal stenosis there.Dictated by: Patrick Sorek, MD on 1/7/2019 11:52 AM.
Electronically signed by: Patrick Sorek, MD on 1/7/2019 11:55 AM.Narrative
EXAMINATION: MRI Cervical Spine without ContrastHISTORY: Cervical Radiculopathy; Neck pain, initial exam.
TECHNIQUE: Sagittal T1, T2 and STIR. Axial T2 and gradient-echo.
COMPARISON: MR cervical spine March 20, 2015. Plain film examination cervical
spine October 14, 2015.ENCOUNTER: Not Applicable
FINDINGS:
Interval worsening of degenerative changes in the cervical spine. No
compromise of the craniocervical junction. At C2-C3 there is no disc
herniation or spinal stenosis.At C3-C4 there is minor disc bulge without spinal stenosis.
At C4-C5 there is small central disc protrusion effacing ventral subarachnoid
space and causing mild impression on the cord without cord compression or
foraminal stenosis.At C5-C6 mild endplate degenerative change without spinal stenosis.
At C6-C7 there is now moderate disc space narrowing with broad-based spur
disc complex causing mild right and moderate left foraminal stenosis. Mild
effacement ventral subarachnoid space.At C7-T1 mild facet degenerative changes have worsened since the prior study.
No central or foraminal stenosis evident.Component Results
There is no component information for this result.General Information
Collected:
01/07/2019 7:54 AMResulted:
01/07/2019 11:55 AMOrdered By:
DANIEL J COZZATI, PA-CResult Status:
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