Clinical Consultation – Cord Compression with Myelomalacia
From: William J Owens Jr DC DAAMLP
Today was a BUSY day! Here is another patient that came in to the office and referred for MRI of the cervical spine post MVA. AGAIN, her neurological physical examination was NORMAL. She was referred after the FIRST visit. This was a decision made on the traumatic nature of the injury and the fact that she had demonstrated ligamentous instability on plain film radiographs. Further evaluation of soft tissues in the cervical is warranted using MRI. I have attached her MRI as well as the RADIOGRAPHS. When these things happen, we call the PCP to tell them what is going on, we send our report as well as the MRI reports to their office. I also attache my CV. From the specialist, I called the surgeon today (FRIDAY), took a snap shot of the MRI slides below on my iPhone and asked when the SOONEST he could get her in was, he is seeing her Monday AM. That is how triage and coordination of care works, that is WHY I am always discussing building your network of providers…When you see LIGAMENT LAXITY, you have to FIND OUT WHY…
Definition – Myelo [‘spinal cord’] malacia [‘softening’] is a descriptive term for changes seen within the spinal cord on MRI images which indicate a loss of spinal cord volume. As a descriptive term there are a variety of disease processes which can cause this and it would generally be considered a significant finding, as the spinal cord does not repair itself readily, and therefore loss of spinal cord tissue is permanent.
PLAIN FILM RADIOGRAPHS – CERVICAL SPINE
CLINICAL INDICATION: This is a patient with history of motor vehicle accident 07/31/17 who presents with neck and back pain and numbness in the right hand.
FINDINGS: Five views of the cervical spine including flexion and extension views demonstrate no evidence of acute compression fractures of the visualized vertebral bodies of the cervical spine.
There is reversal of normal cervical lordosis.
There are spondylotic changes with endplate spurring/osteophytes most prominent at C5-C6 level and associated with disc space narrowing and anterior bridging osteophytes and to a lesser extent at C6-C7 and C4-C5.
Mild facet joint arthropathy involving mid and lower cervical spine levels noted. Mild anterolisthesis of C4 over C5 on the flexion view noted. Slight anterolisthesis of C3 over C4 on the flexion view noted. There is correction of the anterolisthesis on the extension view at both levels of C3-C5 and C4-C5. No evidence of induced malalignment on the extension view noted.
IMPRESSION:
1.REVERSAL OF NORMAL CERVICAL LORDOSIS WHICH MAY MIGHT BE SECONDARY TO MUSCULAR SPASMS.
2.PROMINENT DISC SPACE NARROWING AND ANTERIOR BRIDGING OSTEOPHYTES AT C5-C6 LEVELS.
3.SLIGHT DISC SPACE NARROWING AND MILD SPONDYLOTIC CHANGES AT THE LEVELS OF C4-C5 AND C6-C7.
4.MILD FACET JOINT ARTHROPATHY INVOLVING MID AND LOWER CERVICAL SPINE LEVELS.
5.MILD ANTEROLISTHESIS OF C4 OVER C5 AND SLIGHT ANTEROLISTHESIS OF C3 OVER C4 ON THE FLEXION VIEW NOTED AND CORRECTED ON THE EXTENSION VIEW.
6.DYNAMIC MOTION X-RAY EVALUATION OF THE CERVICAL SPINE IS A MORE SENSITIVE STUDY TO RULE OUT SPONDYLOLISTHESIS AND LIGAMENTUS INSTABILITY/LAXITY, INCLUDING C1-C2 JUNCTION.
6.DYNAMIC MOTION X-RAY EVALUATION OF THE CERVICAL SPINE IS A MORE SENSITIVE STUDY TO RULE OUT SPONDYLOLISTHESIS AND LIGAMENTUS INSTABILITY/LAXITY, INCLUDING C1-C2 JUNCTION.
7.IF SYMPTOMS PERSIST OR CLINICALLY WARRANTED, FURTHER EVALUATION WITH FOLLOW-UP MRI OF THE CERVICAL SPINE WITHOUT CONTRAST COULD BE OBTAINED FOR FURTHER ASSESSMENT AND TO RULE OUT INTERVERTEBRAL DISC PATHOLOGY.
MRI OF THE CERVICAL SPINE
CLINICAL INDICATION: Patient injured in a motor vehicle crash dated 7/31/2017 with neck pain.
IMAGING SEQUENCES: A variety of spin-echo pulse sequences as well as inversion recovery and gradient echo techniques were utilized to evaluate the cervical spine in the sagittal and axial planes.
FINDINGS: There is marked straightening of the normal cervical lordosis. The vertebral bodies are normal in contour and signal intensity at all pulse sequences. The facet joints are normally aligned bilaterally. Evaluation of the intervertebral discs demonstrates varying degrees of loss of the normal height, signal and architecture associated with the C4-C5 through C6-C7 interspaces. Evaluation of the cervical cord demonstrates an area of mild increased cord signal at a level of compression associated with the C5-C6 disc. No acute abnormalities are detected at the craniocervical junction. The prevertebral soft tissues are normal in appearance. Evaluation of the axial images are as follows:
C2-C3 and C3-C4: There is no evidence of disc herniation, canal stenosis, foraminal narrowing or arthritic change.
C4-C5: There is a 3 mm central herniation of the nucleus pulposus of the protrusion type effacing the thecal sac. There is mild canal stenosis. There is no cord impingement. The foramina are patent. No arthritic changes are seen.
C5-C6: There is a 5.75 mm right paramedian herniation of the nucleus pulposus with an extruded configuration. There is stenosis and compression of the right paramedian ventral cord. There is mild central increased cord signal compatible with edema or myelomalacic change. There is bilateral foraminal stenosis secondary to hypertrophic uncovertebral joint changes.
C6-C7: There is a broad-based 2.5 mm herniation of the nucleus pulposus of the protrusion type. There is mild stenosis. There is no cord compression. The foramina are patent. No arthritic changes are seen.
C7-T1: No abnormality is seen.
IMPRESSION:
1.STRAIGHTENING OF THE NORMAL CERVICAL LORDOSIS.
2.C4-C5: 3 MM CENTRAL HERNIATION OF THE NUCLEUS PULPOSUS OF THE PROTRUSION TYPE WITH MILD SECONDARY CANAL STENOSIS.
3.C5-C6: 5.75 MM RIGHT PARAMEDIAN HERNIATION OF THE NUCLEUS PULPOSUS OF THE EXTRUSION TYPE. THERE IS STENOSIS WITH COMPRESSION OF THE RIGHT PARAMEDIAN VENTRAL CORD. THERE IS MILD INCREASED CENTRAL CORD SIGNAL AT THE LEVEL OF COMPRESSION. THE FINDINGS ARE COMPATIBLE WITH EITHER EDEMA AND/OR MYELOMALACIC CHANGE. THERE IS BILATERAL FORAMINAL STENOSIS.
4.C6-C7: 2.5 MM BROAD-BASED HERNIATION OF THE NUCLEUS PULPOSUS OF THE PROTRUSION TYPE WITH MILD STENOSIS.
2.C4-C5: 3 MM CENTRAL HERNIATION OF THE NUCLEUS PULPOSUS OF THE PROTRUSION TYPE WITH MILD SECONDARY CANAL STENOSIS.
3.C5-C6: 5.75 MM RIGHT PARAMEDIAN HERNIATION OF THE NUCLEUS PULPOSUS OF THE EXTRUSION TYPE. THERE IS STENOSIS WITH COMPRESSION OF THE RIGHT PARAMEDIAN VENTRAL CORD. THERE IS MILD INCREASED CENTRAL CORD SIGNAL AT THE LEVEL OF COMPRESSION. THE FINDINGS ARE COMPATIBLE WITH EITHER EDEMA AND/OR MYELOMALACIC CHANGE. THERE IS BILATERAL FORAMINAL STENOSIS.
4.C6-C7: 2.5 MM BROAD-BASED HERNIATION OF THE NUCLEUS PULPOSUS OF THE PROTRUSION TYPE WITH MILD STENOSIS.
Preliminary report faxed, spoke with Linda on 9/15/2017 at 2:25 PM, results will be given to Dr. Curtin. (rc)
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