MRI OF THE CERVICAL SPINE WITH/ WITHOUT CONTRAST
IMPRESSION:
1. Findings suggestive of a cervical syrinx corresponding to the levels of C6 and C7. No abnormal enhancement on postgadolinium T1-weighted images.
2. Mild degenerative disk disease and cervical spondylosis. Disk bulge at T2-3 with mild central stenosis. No axial imaging at this level.
INDICATIONS: Closed head injury.
TECHNIQUE: Multiplanar spin echo and gradient echo imaging of the cervical spine is performed with and without contrast. A total volume of 16cc Magnevist was administered for postgadolinium images.
FINDINGS
SPINAL CORD: there is an abnormal intramedullary cord signal. On axial images it is central and corresponds to the levels of C6 and C7. No significant enhancement on postgadolinium T1-weighted images. Findings compatible with cervical syrinx. No associated cord atrophy at the level of the syrinx.
C3-4: Uncovertebral and facet arthropathy. Small central broad-based disk bulge. No significant central canal stenosis. However, question mild symmetrical bilateral forminal narrowing.
C6-7: There is a broad-based annular bulge and mild central canal stenosis.
There is evidence of a disk degeneration corresponding to the level of T2-3 where there is the suggestion of a broad-based central disk bulge resulting in mild central stenosis. However, there is no axial imaging at this level.
End of Diagnostic Report.
HISTORY:
This is a male who suffered trauma to his right orbit and intracranial injury. On examination the patient was minimally responsive and intubated. Review of the CT scan demonstrates a right lateral wall fracture with minimal displacement.
EXAMINATION:
He has some withdrawl to pain on the right side, but is not moving his right side nearly as well as his left. He is not following commands. His right pupil is 4mm and minimally reactive.
The CT of the head shows a contusion in the basal ganglia area which probably is an area of the internal capsule which could have explained why he is not moving his right side well. Right now he is in a cervical collar.
(All notes written by therapists)