This 66-year-old male presents with cervical spine pain. History of osteoarthritis of cervical spine, unspecified spinal osteoarthritis complication status. Status post cervical spinal fusion. Cervical radiculopathy.
(QUIZ ANSWER) PRIMARY FINDING:
Multilevel cervical spondylosis.
Using the diagnostic web viewer, we have provided images that assist in telling our clinical story. Areas of significance are indicated below.
Unremarkable upper lung fields and visualized brachial plexus elements.
Normal vertebral marrow signal. Status post C5 through C7 ACDF.
Normal craniocervical junction and cervical cord signal intensity.
C1-2: Moderate arthrosis.
C2-3: No compressive discopathy. Shallow concentric mixed spondylotic disc displacement.
C3-4: Moderate bilateral facet arthropathy, concentric mixed spondylotic protrusion, mild biforaminal stenosis.
C4-5: Concentric caudally migrated mixed spondylotic disc displacement effacing the ventral cord. Moderately severe biforaminal stenosis contributed to by moderate bilateral facet hypertrophy.
C5-6: Concentric mixed spondylotic protrusion, moderate bilateral facet arthropathy, mild biforaminal stenosis.
C6-7: Broad concentric mixed spondylotic protrusion. Mild to moderate biforaminal stenosis.
C7-T1: Rightward eccentric mixed spondylotic disc displacement. Mild right foraminal stenosis.
1. Status post C5 through C7 ACDF.
2. Multilevel cervical spondylosis including C3-4 concentric protrusion with biforaminal stenosis and C4-5 central caudally migrating protrusion effacing the ventral cord surface associated with bilateral facet arthropathy and causing moderately severe biforaminal stenosis greater on the right than the left side.
3. Please see body of report for detailed level-by-level additional findings.
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