Can you interpret the cervical magnetic resonance imaging findings in a 70‑year‑old woman, which demonstrate artifact overlying the cord at C3‑C4, straightening of cervical lordosis, left‑sided C3‑C4 facet bone marrow edema, disc osteophyte complexes, uncovertebral spurring, moderate to severe left foraminal narrowing at C3‑C4, C4‑C5, and C5‑C6, mild canal narrowing with cord flattening at C4‑C5 and C5‑C6, and mild progression compared with prior imaging?

MRI Interpretation: Multilevel Cervical Degenerative Disease with Progressive Foraminal Stenosis

This 70-year-old woman has moderate to severe multilevel cervical spondylosis with the most clinically significant finding being severe left-sided foraminal narrowing at C3-C4, C4-C5, and C5-C6, which shows mild progression and likely explains any left upper extremity radicular symptoms.

Key Pathologic Findings

Most Critical Levels (C3-C4 through C5-C6)

The imaging demonstrates a cascade of degenerative changes concentrated in the mid-cervical spine:

• C3-C4: Severe left foraminal narrowing with facet bone marrow edema on the left, indicating active inflammatory changes from facet arthropathy. The bone marrow edema suggests this level is actively symptomatic 1.

• C4-C5: This is arguably the most concerning level with a small central disc extrusion (not just protrusion) with superior migration, causing mild canal narrowing and cord flattening. Combined with severe left foraminal narrowing, this represents the highest risk for progressive myelopathy 2.

• C5-C6: Similar pattern with cord flattening and severe left foraminal stenosis.

Clinical Significance of Cord Flattening

The presence of cord flattening at C4-C5 and C5-C6 without intramedullary signal changes is important. While cord compression is present, the absence of T2 hyperintensity within the cord suggests you are not yet dealing with established myelopathy 3. Research shows that intramedullary high signal on T2-weighted imaging is one of the strongest predictors distinguishing asymptomatic from symptomatic cervical spondylotic myelopathy 3.

The Artifact at C3-C4

The artifact overlying the cord at C3-C4 limits full assessment of the spinal cord at this exact level. This is a known limitation of MRI, particularly if there is any metallic material or susceptibility artifact 4. If clinical symptoms suggest myelopathy and the artifact prevents adequate cord visualization, CT myelography would be the appropriate next step 1.

Degenerative Pattern Analysis

Straightening of Cervical Lordosis

The loss of normal cervical lordosis is noted but its clinical significance remains debated. While some associate it with neck pain, current evidence does not establish loss of lordosis as an independent predictor of symptoms or outcomes 5. It may reflect muscle imbalance with extensor weakness 6, but this finding alone should not drive treatment decisions.

Facet Bone Marrow Edema

The left C3-C4 facet bone marrow edema is significant because it indicates active inflammation and loading stress at this facet joint. This finding correlates with the severe foraminal narrowing at this level and suggests this is an actively symptomatic segment.

Progression Assessment

The report notes "mild progression" at C3-C4 and C4-C5. Any documented progression of foraminal stenosis or canal narrowing warrants closer clinical correlation and consideration of intervention if symptoms are present, as degenerative changes tend to continue advancing 7.

Clinical Correlation Required

If Left Upper Extremity Radiculopathy is Present:

The severe left foraminal narrowing at three consecutive levels (C3-C4, C4-C5, C5-C6) creates a diagnostic challenge for precise localization. Clinical examination with dermatomal sensory testing and myotomal strength assessment is essential:

• C4 nerve root (C3-C4 foramen): Shoulder shrug weakness, cape distribution sensory loss
• C5 nerve root (C3-C4 foramen): Deltoid/biceps weakness, lateral arm numbness
• C6 nerve root (C5-C6 foramen): Wrist extension/biceps weakness, thumb and index finger numbness
• C7 nerve root (C6-C7 foramen): Triceps/wrist flexion weakness, middle finger numbness

The facet bone marrow edema at C3-C4 suggests this level is most actively symptomatic 1.

If Myelopathic Signs are Present:

Examine for:

• Gait instability or broad-based gait
• Hand clumsiness or difficulty with fine motor tasks
• Hyperreflexia, Hoffman's sign, or Babinski sign
• Bowel/bladder dysfunction

If any myelopathic signs are present with cord flattening at C4-C5 and C5-C6, surgical consultation is warranted 2. The presence of a disc extrusion with superior migration at C4-C5 causing cord compression represents a potentially progressive lesion.

Management Algorithm

Conservative Management Appropriate If:

• Radicular symptoms only (no myelopathy)
• No progressive neurologic deficit
• Symptoms manageable with physical therapy, NSAIDs, and activity modification
• Patient can be monitored clinically for progression

Surgical Consultation Indicated If:

• Any clinical signs of myelopathy (even subtle)
• Progressive neurologic deficit
• Severe, refractory radicular pain despite 6-12 weeks of conservative treatment
• Documented progression on imaging with worsening symptoms

Additional Imaging Considerations:

If the artifact at C3-C4 prevents adequate assessment and myelopathy is suspected clinically, obtain CT myelography 1. This provides superior visualization of the thecal sac and nerve roots when MRI is limited by artifact.

Important Caveats

MRI findings frequently do not correlate perfectly with clinical symptoms 1. Studies show that abnormalities on MRI are common in asymptomatic patients, and the level of imaging abnormality may not match the clinical examination level 1. Therefore, treatment decisions must be driven by clinical symptoms and examination findings, not imaging alone.

The stable C7 superior endplate changes and C6-C7 mild degenerative changes are incidental and unlikely to be symptomatic given the severity of disease at higher levels.