Cervical spine disc herniation on left side, sciatica. Lumbago, cervicalgia Cervical spine: Examination of the cervical spine is slightly motion degraded. No abnormal signal is definitively appreciated within the cervical cord. Craniovertebral junction appears within normal limits. The cervical vertebral bodies are appropriate in height. There is loss of normal cervical lordosis with with mild retrolisthesis of C5 on C6 and C6 on C7. Bone marrow signal is benign with signal changes related to degenerative disease. There is loss of disc height throughout the cervical spine, worst at the C6-C7 level. Multilevel degenerative changes, as described below:C2-3: No significant compromise to the spinal canal or left neural foramen. Minimal right neural foraminal narrowing. Bilateral facet arthropathy.C3-4: There is mild spinal canal stenosis with partial effacement of the ventral and dorsal thecal sac. Mild to moderate left and mild right neural foraminal narrowing. Bilateral facet arthropathy.C4-5: There is moderate spinal canal stenosis related to disc osteophyte complex and ligamentum flavum thickening effacing the ventral and dorsal thecal sac. There is mild bilateral neural foraminal stenosis. There is facet arthropathy on the right with mild surrounding inflammatory changes.C5-6: There is moderate spinal canal stenosis related to disc osteophyte complex and ligamentum flavum thickening effacing the ventral and dorsal thecal sac. There is moderate to severe bilateral neural foraminal stenosis related to uncovertebral hypertrophy and facet arthropathy.C6-7: There is moderate spinal canal stenosis related to disc osteophyte complex and ligamentum flavum thickening effacing the ventral and dorsal thecal sac. There is moderate to severe left and moderate right neural foraminal stenosis related to uncovertebral hypertrophy and facet arthropathy.C7-T1: No significant compromise to the spinal canal. Minimal bilateral neural foraminal narrowing. Facet arthropathy.The vertebral artery flow voids appear to be intact. Paraspinous soft tissue structures appear within normal limits.Lumbar spine: Five lumbar type vertebral bodies are presumed to be present. Vertebral body heights are within normal limits. There is loss of normal lumbar lordosis. Alignment is otherwise within normal limits. There is significant loss of disc height at the L5-S1 level. Bone marrow signal is benign. The conus medullaris is normal in position.There appears to be congenital narrowing of the lumbar spinal canal with superimposed multilevel degenerative changes as described below: L1-L2: No significant disc disease. No spinal canal or neural foraminal stenosis.L2-L3: There is mild to moderate degree of spinal canal stenosis related to examination of disc bulge, ligamentum flavum thickening, epidural fat, and facet arthropathy. There is mild right and mild to moderate left neural foraminal stenosis.L3-L4: There is moderate degree of spinal stenosis stenosis related to disc bulge, facet arthropathy, ligamentum flavum thickening, and epidural fat. There is mild to moderate bilateral neural foraminal stenosis.L4-L5: There is mild to moderate spinal canal stenosis related to ligamentum flavum thickening, facet arthropathy, and mild disc bulge. Effacement of the left lateral recess is also noted. There are small foraminal disc protrusions. There is moderate left and mild to moderate right neural foraminal stenosis. L5-S1: Severe loss of disc height. No significant spinal canal stenosis. Mild facet arthropathy. There is mild to moderate left and mild right neural foraminal stenosis.Paraspinous soft tissues are within normal limits.
1. Moderate degenerative changes throughout the cervical spine with moderate spinal canal stenosis at C4-C5, C5-C6, and C6-C7. There is also multilevel neural foraminal stenosis, worst at C5-C6 where there is moderate to severe bilateral neural foraminal stenosis. Facet arthropathy is also noted at multiple levels which may also be contributing to patient's neck pain.2. Multilevel degenerative changes in the lumbar spine with superimposed on congenital narrowing of the lumbar spinal canal. There is moderate degree of spinal canal stenosis at the L3-L4 levels and mild to moderate degrees of neural foraminal narrowing as detailed above.