PATIENT NUMBER: LL127262 PATIENT: GUTIERREZ, MICHELLE DATE OF BIRTH: 09/02/1966 PHYSICIAN: DONALD SACHS.MD DATE: 08/21/2014 EXAMINATION: MRI C SPINE TECHNIQUE: Sagittal T1, sagittal T2 with axial T2 gradient images were obtained. FINDINGS: There is no focal marrow replacement. No compression fracture is identified. There is disc bulge and osteophyte anteriorly at C4-5 and C5-6. There is no syrinx identified in the cord. The atlantoaxial joint has hypertrophic changes. In the upper thoracic spine there is no canal stenosis identified. The visualized portion of the base of the skull is unremarkable. The STIR sequences demonstrate no signs of edema. At C2-3 there is no canal stenosis. The neural foramina are patent. At C3-4 there is disc bulge with a right central disc herniation with mild canal stenosis without cord compression. The neural foramina demonstrate narrowing towards the right mild in severity. At C4-5 there is a disc bulge with a disc herniation with severe canal stenosis with cord compression identified. There is narrowing of the canal down to 4 mm. There is posterior ligament hypertrophy identified. There is severe bilateral foraminal stenosis identified. At C5-6 there is disc bulge with a left central disc herniation identified with moderate to severe canal stenosis with cord indentation towards the left with foraminal narrowing bilaterally moderate to marked in severity. At C6-7 there is disc bulge with a right central disc herniation without canal stenosis. The neural foramina demonstrate mild narrowing towards the left. At C7-T1 there is a focal left central disc herniation without canal or foraminal stenosis. IMPRESSION: 1. C4-5 DISC BULGE WITH SEVERE CANAL STENOSIS WITH CORD COMPRESSION WITH SEVERE BILATERAL FORAMINAL STENOSIS. 2. C5-6 DISC BULGE WITH DISC HERNIATION EXTENDING TO THE LEFT OF MIDLINE WITH MODERATE TO SEVERE CANAL STENOSIS WITH CORD INDENTATION WITH MODERATE TO SEVERE BILATERAL FORAMINAL STENOSIS. 3. C3-4 RIGHT CENTRAL DISC HERNIATION WITH MILD CANAL STENOSIS WITHOUT FORAMINAL NARROWING. (CONTINUED ON THE FOLLOWING DATE OF BIRTH: 09/02/1966 PHYSICIAN: DONALD SACHS.MD DATE: 08/21/2014 MRI C SPINE EXAMINATION: 4. C6-7 DISC BULGE WITH A FOCAL RIGHT CENTRAL DISC HERNIATION WITH MILD CANAL STENOSIS WITH MILD LEFT FORAMINAL NARROWING. 5. C7-T1 FOCAL LEFT CENTRAL DISC HERNIATION WITHOUT CANAL OR FORAMINAL STENOSIS. Thank you for this referral. Jayson A. Lord, M.D. Diplomate, American Board of Radiology Dictated but not reviewed to expedite delivery JL/axiommti6 Dd: 08/21/2014 Dt: 08/21/2014
Posted on: Sat, 23 Aug 2014 09:26:05 +0000
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