DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

Comparison is made to an earlier exam.

TECHNIQUE:  Multiplanar images were obtained using multiple pulse sequences to the lumbar spine. Because of the postoperative nature of the lumbar spine, additional axial and sagittal postgadolinium T1-weighted images were obtained.

Plain films are not available for comparison; therefore, it will be assumed there is a normal complement of lumbar vertebrae. Scanning was performed on 0.3-Tesla open bore scanner.

FINDINGS:  The examination shows lumbar vertebrae to be in normal overall alignment with preservation in vertebral body heights and normal signal within the marrow. For descriptive purposes of this study, fairly small disc is noted at the S1-S2 interspace. The tip of the conus lies near the lower body of L1; we believe this nomenclature is the same as that used on the prior exam.

Transaxial images show postsurgical changes from prior right semi-hemilaminectomy at the S1 vertebra. Examination does show the presence of a small annular disc bulge and perhaps some early annular spurring; however, the traversing S1 nerve roots are unimpeded, and there is no evidence of recurrent focal disc herniation. There is some normal enhancement seen involving the soft tissues, presumably of a postoperative nature.

At the L4-L5 level, there is likewise no evidence of focal disc herniation or significant central spinal stenosis.

The L3-L4 interspace shows trace annular bulging without focal disc herniation or stenosis. L1-L2 and L2-L3 interspaces show a normal appearance on sagittal imaging.

IMPRESSION:  MR examination of the lumbar spine with postsurgical changes from previous right semi-hemilaminectomy at L5-S1 level on the right.

While there may be some minimal annular bulging and annular spurring at this level, there is no discrete focal disc herniation, and traversing S1 nerve roots are not compromised.

The remainder of the lumbar interspaces may show some very minimal disc bulging, however, no focal disc herniation or central spinal stenosis. The cause of the patient’s right lower extremity radicular symptoms cannot easily be explained on the basis of findings.

Thank you for your kind referral.

NAME OF STUDY:  Left shoulder MRI.

TECHNIQUE:  Routine MRI was performed. There were several reattempts and then fast-scan imaging was performed due to the patient’s pain and difficulty holding still.

STUDY FINDINGS:  There was much abnormality noted around the humerus. We see complete retraction of the supraspinatus and infraspinatus muscle and tendon. This would suggest a full tear of both of those tendons near the insertion site. We also see a significant tear, although not all of the tendon is torn, of the subscapularis tendon. The biceps tendon is not normally located at its most superior components. It may be either partially torn or minimally displaced towards the joint space. This is noted on both the axial and coronal imaging.

Significantly, we see abnormal signal within the humerus itself. It is located predominantly just below the humeral head and crosses midline. This would suggest the possibility of small incomplete fractures, bone contusion around them all or related contusion.

The humeral head is located slightly higher in the glenoid than normally seen and occupies the subacromial space. This is again probably secondary to the retraction of the muscle and tendons of the supraspinatus and infraspinatus structures.

There is moderate degenerative disease of the AC joint with fluid in the joint space. No significant caudal or cephalad spurring is noted, just some mild inferior spurring.

There is some degenerative change noted of the anterior glenoid labral regions. No full detachment of the labrum is present.

IMPRESSION:
1.  Full muscle and tendon retraction of the supraspinatus and infraspinatus structures.
2.  Partial muscle and tendon retraction of the superior aspect of the subscapularis structure.
3.  Other partial tearing or dislocation of the superior aspect of the biceps tendon, which is not normally identified. It may be dislocated to the anterior joint space area.
4.  Bruising and possible microfractures to the humerus just below the humeral head.

DATE OF STUDY: MM/DD/YYYY

INDICATION FOR STUDY: Unusual new and prolonged headaches.

TECHNIQUE AND FINDINGS: FLAIR imaging in both axial and sagittal planes suggests some high signal within the pituitary gland itself. Although the posterior pituitary gland can produce some higher signal, the amount that is seen is slightly greater than is commonly noticed. We would suggest that the patient return for a dedicated pituitary study, which is performed with and without contrast using thin section imaging, should there be a clinical and laboratory concern of the pituitary gland itself.

The size of the pituitary gland is upper limits of normal. The unusual signal could indicate that there is some microadenoma or perhaps another insult to this area but usually that would be accompanied by other laboratory changes.

The remaining portion of the examination suggests a small amount of ethmoid sinusitis but is otherwise within normal limits. There is no mass or mass effect otherwise suggested. No territorial large vessel insult or small vessel insult or white matter demyelination is present.

The craniocervical junction is within normal limits. The brainstem is intact.

IMPRESSION:
1. There is a questionable area of slightly higher signal within the pituitary gland than is commonly seen. Although the overall size is upper limits of normal, this can sometimes be seen with various types of insult, including a microadenoma. Should there be clinical and/or laboratory abnormality with regards to pituitary function, one might want to proceed with a dedicated MRI study of the pituitary gland for which contrast is typically used.
2. Otherwise within normal limits with the exception of some mild ethmoid sinusitis.

MRA OF THE CIRCLE OF WILLIS

The patient has a small or thin basilar artery on this examination. We do see bilateral presence of posterior communicating arteries, which appear to be the primary inflow to the posterior cerebral arteries.

At no point on this examination is there evidence of an aneurysmal change. The middle cerebral, anterior cerebral, and distal internal carotid arteries, and the A1 branches are all felt to be within normal limits. The anterior communicating artery is also unremarkable.

IMPRESSION:
1. No evidence of aneurysmal disease.
2. There is a small or attenuated basilar artery noted on this examination. However, this appears to be compensated by the presence of bilateral posterior communicating arteries feeding into both of the posterior cerebral arteries. This is a normal variant.

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MRI OF THE BRAIN WITH AND WITHOUT CONTRAST AND MRA OF CIRCLE OF WILLIS

DATE OF STUDY: MM/DD/YYYY

The patient was extremely claustrophobic and agitated and did move somewhat during this examination. Both a brain MRI and a circle of Willis were able to be performed over time.

BRAIN MRI WITH AND WITHOUT CONTRAST

There is no enhancing mass, mass effect, or midline shift.

There is no large territorial defect, effacement of the sulci, or midline shift.

There are two small white matter areas of demyelination on the FLAIR images just adjacent to the mid section of the right lateral ventricle. No significant edema is noted around them. These could indicate small foci of demyelination from small vessel infarct as well as some other causes. There is one small area of similar white matter demyelination at the gray-white matter junction at the posterior left frontal lobe. This too measures only about 1 to 2 mm.

There is some mild atrophy noted bilaterally.

There is some mild compensation of the ventricular system.

Craniocervical junction is normal. No Chiari malformation is seen. The cerebellopontine angle and IAC regions appear unremarkable.

There is some minimal ethmoid sinus disease.

IMPRESSION:
1. Two small white matter areas of change on the FLAIR images are noted adjacent to the right lateral ventricle in the anterior parietal region. These present with no surrounding edema and no enhancement. They are most likely the sequela of small vessel insult. A similar small density is seen in the posterior left frontal lobe.
2. Mild and diffuse atrophy is present with compensatory enlargement of the ventricular system.
3. No abnormal enhancement. No evidence of mass or significant territorial vascular insult.

MRA OF CIRCLE OF WILLIS

There is some movement artifact.

There is some mild atherosclerotic disease suggested of the basilar artery and both of the distal internal carotid arteries. It is mild and diffuse in both of those areas. No evidence of focal stenosis of significance is seen. No evidence of aneurysmal disease is noted of the basilar artery tip or of the middle cerebral artery, ICA branching distribution, or of the anterior cerebral artery or the anterior communicating artery.

This examination does not demonstrate the presence of posterior communicating arteries. It can be that their flow is so small as to not be detected on MRI.

The flow pattern of the middle cerebral arteries though somewhat attenuated distally and bilaterally is otherwise symmetric and without a focal area of significant narrowing or constriction.

IMPRESSION:
1. Mild atherosclerotic disease of the distal internal carotid arteries bilaterally and of the basilar artery.
2. No focal area of significant constriction or absence of flow. No aneurysmal changes. Both distal middle cerebral arteries do show some attenuation.

DATE OF STUDY: MM/DD/YYYY

INDICATION FOR STUDY: Severe right arm pain.

TECHNIQUE AND FINDINGS: Comparison is made with the earlier scan. Sagittal and axial images were obtained. The craniocervical junction is within normal limits. There is some reversal of the normal curvature centered at approximately C4-5. There are posterior osteophytes at C5-6. The spinal cord is normal in location and signal intensity. The patient was in a lot of pain, and the scan time was therefore decreased.

At C7-T1, there is no focal disc disease.

At C6-7, there is a combination of posterior osteophytes and disc bulge that has a right paramedian component, which slightly flattens the anterior CSF space. This has not changed compared to the prior study.

At C5-6, there is a disc bulge combined with some posterior osteophytes, which does causes some narrowing of that right neural foramina and slightly flattens the anterior CSF space. This has not particularly changed compared to the prior study either.

At C4-5, there is near obliteration of the anterior CSF space due to a combination of bone and disc. In addition, there is a central disc protrusion that extends inferior to the disc space and causes some concavity of the spinal canal suggestive of progression of the disc protrusion/herniation in this area.

At C3-4, there is a disc bulge that has a subtle central component, which slightly indents the anterior CSF space. This has not significantly changed either.

IMPRESSION:
1. At C4-5, the disc protrusion seen previously, that was small and central, appears to have progressed and does cause more mass effect on the anterior CSF space and causes some concavity of the spinal canal. This disc does extend slightly inferior to the disc space. There is some right neural foraminal narrowing due to a combination of bone and disc at this level.
2. The right neural foraminal narrowing at C5-6 due to a combination of bone and disc is stable.
3. At C3-4, the subtle central disc protrusion is not significantly changed.
4. At C6-7, the disc bulge that has a slight right paramedian protrusion combined with posterior osteophytes is also not changed.

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CERVICAL SPINE MRI

DATE OF STUDY: MM/DD/YYYY

INDICATION FOR STUDY: Right neck pain.

TECHNIQUE AND FINDINGS: This examination is somewhat limited as the patient repeatedly needed to get up from the table for pain and it was restarted. It is felt adequate, however, for diagnosis.

The craniocervical junction is normal. The upper part of the cervical cord is not compressed. In the mid portion of the cervical cord, we do see significant bone and disc disease, which does compress the cervical cord in combination fashion and produces a relative stenosis. This is seen at C4-5, C5-6, and at C6-7.

At C3-4, we see a very small left-sided uncinate spurring, which minimally narrows the left neural foramen. The right neural foramen is widely patent, and the spinal canal is within normal limits.

At C4-5, we see some midline vertebral body spurring and a modest annular bulge. This, with some facet degenerative disease, does narrow the AP diameter moderately such that the CSF fluid around the cord is compressed, and the cord is moderately flattened. The AP diameter is less than 10 mm.

At C5-6, we see a central disc process and endplate spurring as well as bilateral uncinate spurring. The combination produces trilateral narrowing of the spinal canal and bilateral neural foraminal narrowing. Most of the disc disease is more central. It is moderate in nature only.

At C6-7, we see a very large midline and right recess disc herniation. This presents also with some facet hypertrophy and significantly obscures the right recess and right neural foramen. The left neural foramen is moderately narrowed due predominantly to bony disease. Two sets of axial films were attempted due to the patient’s movement. One was filtered and one was unfiltered. The unfiltered images do suggest that the nerve root may exit above the bony protuberance to the left. It may not be as definitely compromised, as we can clearly see the right recess and neural foramen.

At C7-T1, we see that the spinal canal now opens up to a more normal caliber once again. CSF surrounds the cord, which appears of normal size and dimension, and both the neural foramina appear patent.

IMPRESSION:
1. Large midline and right recess disc herniation at C6-7. This in combination with some endplate spurring and facet hypertrophy significantly compresses the right recess and neural foramen and minimally to moderately compresses some bony disease, the left neural foramen.
2. At both C5-6 and slightly less so at C4-5, we see flattening of the cord due predominantly to bony and mild disc disease and loss of the cerebrospinal fluid space producing a relative stenosis. At C5-6, the suggestion of bilateral neural foraminal narrowing is also present due again to a combination of predominantly bone but secondarily disc disease of an annular nature, and at C4-5, there is some minimal narrowing to the left present.
3. No cystic change is suggested within the cord at this time. Cannot rule out some edema, however, directly behind the areas of narrowing that was described above. The largest area of focal disc disease is to the right at C6-7, and this disc does appear to ascend cephalad behind the lower portion of the C6 vertebral body minimally.