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  • Lee Marie
    Participant
    Post count: 1

    Exam : MR – CERVICAL SPINE (C-) CPT 72141 –

    Room Description : Dart Siem Espr 1.5

    Technique : Sag STIR, Sag T2 3d space, Sag T1, Ax 3DT2*
    GRE, Sag and Ax T2 reformats

    Final Report

    HISTORY:
    Neck pain with bilateral upper extremity radiculopathy and numbness
    for over 6 months.

    FINDINGS:
    Comparison is made with previous examination from December 2015.

    Procedure: Noncontrast MRI cervical spine.

    From the skull base to T4 was imaged. There is mild reversal of the
    cervical lordosis. Vertebral height is maintained.

    At C2/C3 and at C3/C4, no disc bulge or lateralizing disc herniation
    is present.

    At C4/C5, there is minimal posterior bulging of the annulus. Minor
    uncovertebral joint hypertrophy is present without causing significant
    foraminal encroachment.

    At C5/C6, there is mild disc space narrowing with small anterior
    marginal osteophyte formation. Disc space narrowing has slightly
    progressed when compared to previous examination. Broad-based disc
    osteophyte complex causes mild thecal impression contacting the
    ventral cord. Disc osteophyte complex has slightly enlarged when
    compared to previous examination. The dorsal subarachnoid space is
    maintained. Uncovertebral joint hypertrophy results in severe right
    and moderate left foraminal stenosis, unchanged.

    At C6/C7, there is minimal posterior bulging of the annulus.

    At C7/T1, no disc bulge or lateralizing disc herniation is present.

    No intrinsic cord signal abnormality is identified. There is stable
    patchy increased T2 signal again identified within the mid pons
    possibly secondary to chronic small vessel ischemic change.

    There is again diffuse enlargement of the thyroid gland, mildly
    increased in T2 and STIR signal.

    IMPRESSION:Noncontrast MRI cervical spine.
    1. Mildly advanced cervical spondylosis again greatest at C5/C6. At
    this level, there is a slightly enlarged broad-based disc osteophyte
    complex contacting the ventral cord. No evidence for underlying cord
    signal abnormality or limiting central stenosis. Uncovertebral joint
    hypertrophy again results in severe right and moderate left C5-C6
    foraminal narrowing with neural impingement.
    2. Chronic diffusely enlarged thyroid gland with diffusely increased
    T2 and STIR signal. Clinical and laboratory correlation is advised to
    assess for possible thyroiditis.
    3. Stable nonspecific mildly increased T2 signal within the pons
    possibly secondary to chronic small vessel ischemic change.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8459

    Your symptom discussion is not thorough enough to give me insight into your problems. Please see this section to better describe your symptoms. https://neckandback.com/conditions/how-to-describe-your-history-and-symptoms-of-neck-shoulder-and-arm-pain/

    Dr. Corenman

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