Physical exam
Awake alert and oriented x3. No acute distress.
Hearing is intact to the spoken word. Respirations are unlabored.
Global sagittal and coronal balance are within normal limits.
Skin on the neck is healthy with no rashes, lesions or surgical scars.
No excessive kyphosis or scoliosis.
No palpable abnormal masses or nodules. No point tenderness, no step-off.
Cervical range of motion is limited by pain and stiffness.
Bilateral upper extremity range of motion is within normal limits with minimally increased pain.
No obvious shoulder, elbow, or wrist pathology bilaterally.
Right upper extremity muscle tone and strength are normal.
Left upper extremity muscle tone and strength are normal.
Sensation to light touch is intact in bilateral upper extremities.
Bilateral upper extremity reflexes are normal and symmetric with no long tract signs.
Bilateral upper extremities are well perfused with no signs of DVT.
IMAGING:
AP and Lat upright C-spine films in office were independently reviewed and show cervical spondylosis with retrolisthesis of C5
CT Cervical spine shows severe spondylosis worse from C5-7 with a grade 1 spondylolisthesis at C3-4, C4-5.
MRI Cervical Spine shows severe central stenosis and bilateral foraminal stenosis C5-6