Presentation
35-year-old male patient presents with 2 weeks of gait disturbance, bilateral upper limit sensory changes, spastic gait, and bilateral sustained clonus.
Patient Data
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Straightening of the cervical spine lordosis. Vertebral bodies have normal height, signal, and alignment.
C3/4: broad-based posterior disc osteophyte complex minimally flattening the cord. Disc-osteophyte complexes moderately to severely stenosing both intervertebral foramina at this level.
C4/5: broad-based posterior disc osteophyte complex with a right paracentral extrusion compressing the cord. There are moderate canal stenosis and moderate increased cord signal on T2 at this level. Disc-osteophyte complexes moderately to severely stenosing both intervertebral foramina at this level.
C5/6: broad-based posterior disc osteophyte complex touching the cord. Disc-osteophyte complexes moderately stenosing the intervertebral foramen on the left and severely on the right.
C6/7: broad-based posterior disc osteophyte complex touching the cord. Disc-osteophyte complex mildly stenosing the intervertebral foramen on the right.
The cord is otherwise unremarkable in caliber and appearance, with no abnormal enhancement. No abnormal flow-voids. Paravertebral soft tissues are unremarkable.
Case Discussion
Multilevel disc disease and foraminal stenosis with canal stenosis and compressive myelopathy at C4/5.