Stature and alignment:
Mildly asymmetric congenital fusion at the level of C3-4 with wasting or narrowing of the disc space C3-4. From superior to inferior the height of the disc space is also narrowed. There is fusion of the posterior elements of the facet joints of C3-4 on the right side or at least on the right side. There is straightening and even mild reversal of the normal cervical lordosis. No definite focal pathological marrow replacement could be demonstrated.
There is mild mass effect centrally on the cervical spinal cord best seen at C5-6 on the right side. There is no frank spinal cord edema. There is dilation of the central spinal cord canal. The central spinal canal is mildly dilated measuring approximately 2mm or just less than 2mm in diameter. Dilated central spinal canal extends from approximately the level C3-4 to level C7. Ther are minimal degenerative changes in the upper thoracic spine with mild narrowing of the spinal canal or neural foramina.
Mild disc osteophytic ridging centrally on the left side without significant spinal canal or neural foraminal narrowing.
At least partial congenital fusion at this level. No significant spinal canal or neural foraminal compromise.
Disc osteophytic ridging causing mild ventral flattening of the thecal sac. Only mild narrowing of the spinal canal or neural foramina.
Superimposed on a broad-based moderate sized disc osteophytic complex is a focal extruded disc herniation right lateral recess. This extruded disc herniation together with the disc osteophytic complex measure 7mm from anterior to posterior and a maximum height of approximately 9mm. This extends into the lateral recess and into the right neural foramen at least at its medial margin. There is mass effect ventrally on the cervical spinal cord. The cervical spinal cord especially right ventrally is moderately flattened. The spinal cord is also deflected posteriorly but without frank spinal cord edema.
Anterior and posterior disc osteophytic ridging, moderate. Moderate ventral flattening of the thecal sac. The spinal canal at this level is also moderately narrowed. The thecal sac tapers to 7.5mm. Left neural foramen is mildly narrowed and the right neural foramen is moderately narrowed at least.
Only mild disc osteophytic ridging without significant spinal canal or neural foraminal stenosis.
At least a mild or borderline degree of congenital spinal canal stenosis is also present.
1. Partial congenital fusion at C3-4.
2. Moderate disc osteophytic ridging at C5-6 and C6-7.
3. Right lateral extruded disc herniation at C5-6 with moderate mass effect on the right lateral recess. Ventral mass effect on the cervical spinal cord, mild to moderate at the level of C5-6 and probably minimal at C6-7.
4. Moderate spinal canal stenosis t C5-6 and C6-7.
5. Centrally expanded spinal cord canal measuring 2mm or less from the level of C3 to C7.
Any help understanding this in layman's terms would be greatly appreciated. I go consult with neuro on Wed. Thanks in advance.
In short, as this is a lengthy report, the worst area is C5-6 with a herniated disc and bone spurs (osteophytes) and nerve impingement (foraminal narrowing) on the right side worse than left side. C6-7 shows nerve impingement, bone spurs and narrowing on both left and right foramen (the bony hole that the spinal nerve passes thru), worse on right.
There is pressure from the bone spurs on the spinal canal. Level C3-4 has been fused since birth and disc is deteroriated somewhat. Your symptoms would likely be nerve pain down right shoulder and arm, neck pain worse on right, and possibly headaches with muscle spasm in neck and shoulder. Have you gotten a report and recommendation from your Dr that ordered this as to treatment?
Last edited by ladybud; 07-16-2012 at 01:25 PM.
Thanks so much for posting Ladybud.
I have been having severe arm shoulder and neck pain and some headaches that felt like tension headaches at the base of my head. This has been going on since mid April. Went to my family dr after a week of dealing with it and she sent me for physical therapy, did that for about three weeks, pain level never decreased and all of the electrodes and moist heat and deep tissue massages that they did hurt more than felt good. Went back to the fam dr in June and she sent me for the MRI (June 19th), now I go to consult with a neuro on Wed.
July 18th to find out what he recommends. I asked my family dr if there were any limitations I should incorporate she said if Imdo something that hurts to stop and not do it.
So do you think I have a lot to worry about?
Thanks again for posting, I really appreciate it.
1. At c5-6 progression in limited to mild disc protrusion towards the right neural foramen. Limited bony protrusion broad based posteriorly. There may now be limited abutment encroachment effect to the right exiting c6root due to mild neural foraminal stenosis.
2. Limited spondylosis other levels without encroachment concerns.