The following are the reports I have available to me. Trying
to help a family member get the best care. Most of these are
from mid 2003, with reference to a previous exam March 2001.
At this writing the patient is experiencing severe neck
pain, difficulty and pain when raising arms from 45 degrees
below horizontal and up. Also experiences pain in arms,
notable pain in upper under arms and numbness in upper
forearms. Also severe backpain centralized between shoulder
blades and radiating outward, mostly upwards and downwards.
Any help would be greatly appreciated
I'd like to know what is actually happening, the possible
courses of treatment are available, successs rate, etc.
Thank you.
1956 46 YEARS F mild disc protrusion at C6/7 without
significant compression of the neural structures seen.
Comparison with the previous of March 6, 2001 shows
negligible change.
EXAM: ^^ LIMITED SPINE MS SEQ TECHNIQUE: Sagittal FSE T1/T2,
and axial spin echo Tl/FSE T2 images of the lumbar spine,
CLINICAL HISTORY: Back pain radiating to both legs with
bilateral leg weakness. INTERPRETATION: Minimal posterior
disc bulge at Tl 1/T12. Small posterior disc bulge at L4/L5
and L5/S1. None of these mild degenerative changes results
in any significant compression of the neural structures.
Spinal canal and thecal sac are widely patent. The
mtervertebral neural foramina are well preserved with no
significant compression of the neural structures. Incidental
note is made of a small cyst behind the S2 segment likely
due to dilatation of a nerve root sheath of the sacral nerve
root. IMPRESSION: Minimal degenerative changes. No
significant pathology identified.
TECHNIQUE: Sagittal FSE T1/T2. and axial spin echo TI/field
echo T2 images of the cervical spine. CLINICAL HISTORY:
Right C7 radiculopathy in the past.
INTERPRETATION:
Desiccation of the cervical discs seen from C2 down to C7
along with posterior disc bulges from C3 to
C7. A small disc bulges at C3/4, C4/5 and C5/6, causing
minimal indentation of the anterior thecal sac without
compression of the neural structures.
The C6/7 disc bulge is more pronounced with a small
hemiation centrally with minimal indentation of the thecal
sac as well as a more broad based right poslero-lateral disc
protrusion which causes mild flattening of tlie thecal sac
but without compression of the neural structures. No
compression of the nerve roots or spinal cord is identified.
The right posterior disc protrusion at C6/7 is unlikely to
be of clinical significance at this time, although if it was
larger at a previous time, tlus could have caused some right
C nerve root symptoms. The C7 nerve roots are well
visualized with surrounding CSF separating the nerv( roots
from the disc.
IMPRESSION;
Mild to moderate multi-level degenerative disc disease from
C2 to C7 with disc bulge from C3 to C6 anc