Diagnosis: Other specified disorders of muscle Altered mental status, unspecified Other specified disorders of muscle Altered mental status, unspecifiedClinical question: patient w/ clonus of right foot, eval for spinal cord lesionSigns and Symptoms: clonus of foot Lumbar spine:Five lumbar type nonrib-bearing vertebral bodies are presumed to be present which are appropriate in overall height. The L5 vertebra is a transitional vertebra and is partially sacralized. The conus medullaris on sagittal imaging is grossly intact.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is facet hypertrophy present at this level.At L4-5 there is no significant compromise to spinal canal. There is loss of disc space height, disc desiccation and diffuse disc bulge at this level associated with the narrowing of the neural foramina bilaterally and mild encroachment of the exiting nerve roots. Overall there is a mild degree of spinal stenosis at this level with some mild to moderate encroachment of exiting nerve roots. The fat surrounding the exiting nerve roots is mildly effaced.At L3-4 there is loss of disc space height, disc desiccation and a diffuse disc bulge associated with marked bilateral facet and ligamentum flavum hypertrophy and mild anterior subluxation of L3 on L4. There is effacement of spinal fluid surrounding the nerve roots within the thecal sac at this level. Overall there is a moderate to severe degree of spinal stenosis at this level. There is encroachment of the exiting nerve roots within the neural foramina bilaterally at this level. The fat surrounding the exiting nerve roots is effaced.At L2-3 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with the mild to moderate bilateral facet and ligamentum flavum hypertrophy. There is mild crowding of the nerve roots at this level. Overall there is a mild degree of spinal stenosis at this level. There is some narrowing of the neural foramina bilaterally at this level associated with some partial effacement of the fat surrounding the exiting nerve roots. Overall there is a mild to moderate degree of encroachment of the exiting nerve roots at this level.At L1-2 there is no significant compromise to spinal canal or neural foramina.Large osteophytes are present at the left sacroiliac joint.A small amount of fluid in the uterus is a nonspecific finding.
1.There is a transitional vertebra present which is labeled L5 for the purpose of this exam. Please note that this may affect enumeration of the lumbar vertebrae.2.There is moderate to severe spinal stenosis at L3-4 due to degenerative changes which is associated with encroachment of the exiting nerve roots at this level bilaterally and some mild subluxation.3.There is a mild to moderate degree of encroachment of exiting nerve roots bilaterally at L4-5 and L2-3.4.There is also mild degree of spinal stenosis at L2-3.5.A small amount of fluid in the uterus is a nonspecific finding. It is incompletely evaluated on this exam.