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What does this MRI report for muscle spasms in neck and shoulder indicate?

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Posted on Fri, 20 May 2016
Question: I have a severe muscle spasm in my neck shoulder. I am having trouble holding up my head could this provide any insight or is it all muscle . Should I see neurologist or spine dr or pup
Details
Study Result
     
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
Other Precautions:*
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
T1 imaging.

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



doctor
Answered by Dr. Ajay Panwar (19 minutes later)
Brief Answer:
Skeletal muscle relaxants/Physiotherapy/Calcium and vitamin D levels.

Detailed Answer:
Hi XXXXX,
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.

Regards
Dr.Ajay Panwar,
MD,DM(Neurology)
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ajay Panwar (6 minutes later)
They gave me valium for muscle relaxant it is not helping also I am profoundly vitamin d deficient and on a prescription for vit d I take 1 x a week for 7 weeks now pt won't evaluate until march 14
doctor
Answered by Dr. Ajay Panwar (19 hours later)
Brief Answer:
Antineuralgics and NSAIDS

Detailed Answer:
Hi,
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.

Regards
Dr.Ajay Panwar,
MD,DM(Neurology)


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Answered by
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Dr. Ajay Panwar

Neurologist

Practicing since :2007

Answered : 1827 Questions

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What does this MRI report for muscle spasms in neck and shoulder indicate?

Brief Answer: Skeletal muscle relaxants/Physiotherapy/Calcium and vitamin D levels. Detailed Answer: Hi XXXXX, 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. Regards Dr.Ajay Panwar, MD,DM(Neurology)