Diagnosis: Other symptoms and signs involving the musculoskeletal systemDiagnosis Edits: Clinical question: LE weakness, incontinence, and gait instability, evaluate for myelopathySigns and Symptoms: see above Cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology. There is multilevel disc desiccation present.At C2-3 there is no significant compromise to the spinal canal or neural foramina. There is left-sided facet hypertrophy presentAt C3-4 there is no significant compromise to the spinal canal or neural foramina. There is a minor disc bulge present at this levelAt C4-5 there is no significant compromise to the spinal canal. There are some endplate and uncovertebral osteophytes present at this level which narrow the neural foramina bilaterally but worse on the right side were there is some mild encroachment of the exiting nerve roots. This has not changed substantially since the prior exam.At C5-6 there is no significant compromise to the spinal canal . There is loss of disc space height at this level. There is a right lateral recess disc protrusion present at this level which encroaches on the right-sided exiting nerve roots within the neural foramina. This is associated with some uncovertebral osteophytes.At C6-7 there is a diffuse disc bulge associated with endplate and uncovertebral osteophytes and ligamentum flavum hypertrophy. There is partial effacement of spinal fluid surrounding the spinal cord at this level with mild narrowing of the spinal canal at this level. This narrowing has progressed a very little amount since the prior examAt C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.MRI thoracic spine:The thoracic vertebral bodies are appropriate in the overall alignment and height. The thoracic spinal cord has normal signal characteristics and overall morphology. There is no compromise of thoracic spinal canal or exiting nerve roots. There are large cysts present along both kidneys which can also be seen on abdomen CT from 11/20/2014. The one in the left kidney appears to be more complex than the one on the right because it does not follow spinal fluid on all MRI pulse sequences. There are smaller cystic lesions scattered in the kidneys. There is another lesion present along the inferior pole of the right kidney which is complex and hemorrhagic which measures 6 cm x 5.2 cm and has calcifications along its wall as identified on the prior CT.Lumbar spine:Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall height. The conus medullaris on sagittal imaging is grossly intact.At L5-S1 there is no significant compromise to spinal canal. There is bilateral facet hypertrophy present at this level which is worse on the left when compared to the right side. There are some encroachment of the left-sided exiting nerve roots within the neural foramen at this level.At L4-5 there is a diffuse disc bulge present associated with the loss of disc space height, disc desiccation and endplate reactive changes. The endplate reactive changes are bright on T1. The endplates are irregular. There is effacement of the fat at the lateral recess on both left and right side. There is narrowing of the neural foramina present at this level with some mild to moderate encroachment of the exiting nerve roots within the neural foramina. Overall there is a moderate degree to marked degree of spinal stenosis at this level.At L3-4 there is loss of disc space height, diffuse disc bulge, posterior subluxation of L3 on L4 by several millimeters and a diffuse disc bulge. There is effacement of the fat at the lateral recess on both the left and the right side. There is bilateral facet and ligamentum flavum hypertrophy at this level. Some endplate reactive changes are also present at this level. Overall there is a moderate degree to marked degree of spinal stenosis at this level. There is mild encroachment of the exiting nerve roots within the neural foramina at this level.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is a diffuse disc bulge present at this level associated with loss of disc space height and some endplate reactive changes. There is partial effacement of fat at the lateral recess bilaterally at this level. Overall there is mild narrowing the spinal canal at this level.At L1-2 there is no significant compromise to spinal canal or neural foramina.
1.There is encroachment of the right-sided exiting nerve roots within the right C5-6 neural foramen and to a lesser degree right-sided exiting nerve roots at C4-5. This was also present on the 4/10/2009 exam and has not progressed2.There are multilevel degenerative changes present in the cervical spine with some mild narrowing of the spinal canal at the C6-7 level.3.There are multilevel degenerative changes present in the lumbar spine with moderate to marked spinal stenosis at L3-4 and L4-5 associated with encroachment of exiting nerve roots at L4-5 and on the left side at L5-S1. There is mild osseous subluxation of L3 on L4.4.Multiple complex appearing cystic lesions in the kidneys. Please refer to CT of the abdomen from 5/3/2015 and 11/20/2015.