Demographics:
78 years old, Male
Indication:
Fall, lower extremity weakness
Findings
- No acute fracture or traumatic malalignment
- Circumferential epidural hematoma extending from the foramen magnum at least through the level of C5 with evaluation below the level of C5 limited by attenuation artifact from the shoulders
- Resultant multilevel crowding of the spinal canal with areas of cord deformity, most notably along the left ventral aspect of the cord at the level of C3
- Trace anterolisthesis of C5 on C6, likely degenerative in etiology
- Multilevel advanced cervical spondylosis and facet joint arthrosis
- Osteopenia
Diagnosis
Spinal epidural hematoma
Sample Report
No acute fracture or traumatic malalignment.
Circumferential epidural hematoma extending from the foramen magnum at least through the level of C5 with evaluation below the level of C5 limited by attenuation artifact from the shoulders. Resultant multilevel crowding of the spinal canal with areas of cord deformity, most notably along the left ventral aspect of the cord at the level of C3. MRI could further evaluate for associated cord or ligamentous injury if clinically indicated.
Discussion