How to deal with minimal focal protrusion and desiccation of the cervical and lumbar spine?

Hi,

Thanks for your query.

I can understand your concerns.

I have checked the attached reports (attachment removed to protect the patient's identity). From what you mentioned, there are two possible differential diagnosis:

1. Headache and neck pain due to cervical disk prolapse. The data you provided supports the diagnosis of neck muscles, painful spasms, pain moving down the right arm, and the CT (computed tomography) findings.

2. For migraine, the data you provided that supports this diagnosis is the episodic nature of the headache, which is on and off and affects one side. The CT (computed tomography) findings are mild, not severe.

Please, provide details to give an accurate diagnosis and decision :

1. Is the headache and neck pain associated with certain neck positions or movements?

2. For how long does the headache last? And how frequent is it?

3. Does it respond to painkillers and Paracetamol?

In my opinion, the headache and neck and shoulder pain are due to disk prolapse, but I recommend further discussion and follow-up to exclude migraine. We can discuss the management after excluding migraine. It will include some local medications and oral medications besides physiotherapy and lifestyle modifications.

I recommend that you follow up and provide me with more details for more accurate advice.