What does this MRI report for muscle spasms in neck and shoulder indicate?
Exam Number: 0000 Report Status: Signed
Type: MRI CERVICAL W WO/CONTRAST
Date/Time: 02/14/2015 15:00
Ordering Provider: Sunwoo, XXXXXXX W. Dr.
EXAMS: 0000 MR/MRI CERVICAL W WO/CONTRAST
HOW IS PATIENT TRANSPORTED? SI - STRETCHER,IV
Isolation Precautions: S - Standard
REASON FOR TEST? 46 ADMIT W/ HEADACHE AFTER TRAUMA
TEST DETAIL: concern for dural tear
PT BEEN PREMEDICATED/PREHYDRATED(F9)? I - IV FLUIDS
HISTORY: HEADACHE AFTER TRAUMA 2 WEEK: concern for dural tear.
COMPARISONS: 1/8/14 x-ray.
TECHNIQUE: MRI sagittal T1, T2, proton density, and stir weighted
imaging. Axial T2, proton density fat saturation, and volume
gradient imaging cervical spine. Post contrast axial and coronal
FINDINGS: No fracture or subluxation evident. T1 body 1 cm T2
hyperintense T1 isointense lesion.
There is a mild posterior disc protrusion/osteophyte ridging at
the C6 level without canal or foraminal stenosis. No cord signal
abnormality is evident.
No epidural or paraspinal collection is seen. No cerebellar
tonsillar descent is seen.
IMPRESSION: No evidence CSF leak. Minor degenerative disc
disease. T1 lesion, could be atypical hemangioma, if clinical
concern for metastatic lesion exists, can evaluate with CT.
Electronically Signed by Kee Y. Chung, M.D. on 2/14/2015 5:12 PM
Skeletal muscle relaxants/Physiotherapy/Calcium and vitamin D levels.
Thanks for being on healthcaremagic.com.
I am Dr.Ajay Panwar,a neurologist, here to answer your query.
I have gone through the detailed MRI cervical spine report,as you have mentioned here.
I am of the opinion that your pain is primarily muscle related.Stress headache can be one strong possibility,as well.Stress can bring tension in muscles of head and neck region and hence,can present with headache and neck pain.
I suggest you to start therapy with skeletal muscle relaxants.At the same time,please visit a physiotherapist and learn the cervical spine exercises.They will help a lot.
Further,calcium and vitamin D levels should be evaluated and if deficient,should be supplemented.
Hope that I have answered your query.If you have some further questions,I shall be glad to have you in follow-up.
Antineuralgics and NSAIDS
Thanks for being in follow-up.
In my opinion you should be on a combination of Non steroidal anti inflammatory drugs(NSAID) like Naproxen along with antineuralgics like amitriptyline.Vitamin D supplementation should continue.
Hope that helps.If you have some further questions,I shall be glad to answer.
The User accepted the expert's answer
Get personalised answers from verified doctor in minutes across 80+ specialties
- Symptoms of neck muscle spasm
- Neck shoulder muscle spasm causes
- What causes painful muscle spasms in tongue and neck
- Neck muscle spasm treatment
- What are the available solutions for muscle spasms in neck
- Chronic neck muscle spasm
- Neck muscle spasm and dizziness
- Diagnosis of neck muscle spasm
- Muscle spasms and pulsating in neck
- Neck muscle spasm causes