Hi, I am a 43 yr. Old female having some problems with my left side of neck, shoulder and blade, radiating down left arm/forearm to my hand. I am experimenting muscle spasms in all areas mentioned above, this is all due to accident I recently had falling out of my high-rise truck. Lol by the way my truck was parked in driveway, I slipped getting out of the truck door (i know it sounds strange right). Any way I have been seeing an orthopedic surgeon, he has given me a cortisone shot in left arm and it has had no results so far, also put me on pain meds and ibuprofen. In the meantime suggested I go for some pt, well I went and they said it would not help and called my Dr. And suggested a mri.... Ortho Dr. Ordered the mri and here are the results below:

july 8, 2004
*mri left shoulder
history: shoulder pain
comparison: none
�i skipped the rest and went to impression�
impression:
1. Mild tendinopathy anterior insertion supraspinatus tendon.

2. Mild degenerative changes acromioclavicular joint left shoulder.

(to me this seemed okay with left shoulder I think so far?) <~~ my personal input

*mri cervical spine
history: pain and spasm left neck into left shoulder
comparison: cervical spine x-rays from ortho surgeons
technique: sitting sagittal t1 and t2 sequences. Axial t2 seq.

C2-3 level is considered normal
c3-4 level is considered normal
c4-5 level is considered normal

c5-6 level demonstrates a small posterior central disk herniation, which touches the anterior thecal sac. The spinal cord is displaced posteriorly to the right. This is due to a large left paracentral to left lateral disk herniation at the c6-7 level, which extends in to the left lateral recess and left neural foramen. This pushes on the spinal cord displacing the spinal cord posteriorly to the right. There may be mild cord compression. There appears to be severe left neural foraminal stenosis. The axial images do not go completely through this disk herniation. Additional axial images for c4 through t1 may be helpful to further evaluate the c5-6 and c6-7 levels entirely.


Impression:
1. Small posterior central disk herniation c5-6 level. This may actually represent a superiorly extruded disk fragment from the c6-7 level where there is a large left paracentral to left lateral disk herniation. This displaces the spinal cord posteriorly to the right with possible mild cord compression. There appears to be severe left neural foraminal stenosis at c6-7.

2. C6-7 disk herniation is not entirely imaged on the axial seq. Additional axial images for c4 through t1 may be helpful for further evaluation.


�additional mri orderedon: july 12, 2004 at stand-up mri facility�
results below:

mri cervical spine
clinical indications: pain radiating to left shoulder.

Comparison: to july 8, 2004
technique: sitting axial t2 sequences from c4 through t1, sagittal t2 sequences.


Additional sagittal and axial t2 seq. Were obtained to fully evaluate the c5 and c6-7 levels.


Findings:
c5-6 level demonstrates mild degenerative disc disease. There appears to be a small posterior central disc herniation, which may actually be separate from the larger superiorly extruded disc fragment at c6-7. There is mild central canal stenosis with mild right neural foraminal stenosis.


C6-7 level demonstrates a large left paracentral to left lateral disc herniation, which extends into the left spinal cord and into the origin of the left neural foramen. This is displacing the spinal cord posteriorly to the right. There may be mild cord compression. This extends to the origin of the left neural foramen with moderate to severe left neural foraminal stenosis and possible impingement of the left c7 nerve root. This fragment is extruded superiorly towards the c5-6 level. There does appear to be a small separate disc herniation at c5-6, which is separate from the larger superiorly extruded c6-7 disc fragment.


C7-t1 level is considered normal.

Impression:
1. Mild posterior central disc herniation at c5-6.

2. Large left paracentral to left lateral disc herniation at c6-7. This is displacing the spinal cord posteriorly to the right with possible mild cord compression. There is moderate to severe stenosis of the origin of the neural foramen with possible impingement of the left c7 nerve root. The disc fragment extrudes superiorly towards the c5-6 level.

End of reports!


1. Next visit to my ortho Dr. He now gave me another cortisone shot on my left side of neck and for me to visit him in a week. If the shot does not work, we need to go to next step.

2. Dr. Said next step is an epidural steroid injections! Can anyone give me a hint to how this procedure is done and what type of doctor does this? Could this be helpful in my case or useless? If this does not work on to the final step.
3. Next and final step he suggested a spinal fusion of c6-7! Wow, is this really the final step it seems extreme to me can you give me some helpful hints to other treatments if possible? I am really scared please help me!!!! p.S. Sorry for the non capital letters in my message I guess this is just the way it turned out???