Acute and chronic back pain, rule-out fracture, worsening disk protrusion, cord compression. Thoracic Spine:Vertebral body heights in the thoracic spine are normal without evidence of compression fracture. Alignment is maintained. Patient motion limits evaluation for cord signal abnormalities, however, no definite cord signal abnormality is appreciated. No abnormal enhancement. There are mild degenerative changes with small disk bulges, most prominent at the T10-T11 level, with there is a disk protrusion resulting in mild spinal canal stenosis with effacement of the left greater than right ventral thecal sac. Appearance is unchanged since 6/23/2014. Dorsal thecal sac is preserved.There is no high grade spinal canal or neural foramina stenosis at any level in the thoracic spine.Lumbar Spine:Please note for the purposes of numbering, the most inferior well-defined disk space is labeled L5-S1 consistent with prior numbering.Again seen is mild congenital narrowing of the spinal canal. Vertebral body heights are within normal limits. Alignment is within normal limits. Bone marrow signal is benign. The conus medullaris is normal in position.Multilevel degenerative changes are seen, as described below:L1-L2: No significant disc disease. No spinal canal or neural foraminal stenosis.L2-L3: There is a right paracentral disk protrusion which effaces the right lateral recess and not significantly change since prior. There is mild central spinal canal stenosis on a congenital basis and related to prominence of the dorsal epidural fat. There is mild right neural foramina narrowing and minimal on the left.L3-L4: There is disk dessication and mild disk bulge with small central protrusion component versus osteophyte. There is mild spinal canal stenosis, which is predominantly on a congenital basis. There is a small right dorsal annular fissure. There is mild to moderate spinal canal stenosis on the right and mild on the left. Mild facet arthropathy.L4-L5: There is disk dessication and bulge with small left dorsal annular fissure. There is mild right and moderate to severe left neural foraminal stenosis. There is mild facet arthropathy. There is mild central canal stenosis predominantly on a congenital basis.L5-S1: There is transitional anatomy. There is disc dessication and mild disk bulge. There is mild left neural foramina stenosis. No significant right neural foramina narrowing. No spinal canal stenosis.There is edema involving the paraspinous musculature with bilateral superficial fluid collections right larger than left extending along the muscle fascial planes from T12 to L3. There is peripheral enhancement. Collection on the right measures up to 15 mm in thickness and 36 mm in the AP dimension. Smaller fluid collections on the left measure approximately 6 mm in thickness.
1. Mild degenerative changes in the thoracic spine without significant spinal canal or neural foramina stenosis. There is a small disk protrusion at the left T10-T11 level with mild spinal canal stenosis and not significantly changed since prior. No compression fractures in the thoracic or lumbar spine. 2. Degenerative changes in the lumbar spine not significantly changed since prior. There is mild spinal canal stenosis, which is mostly on a congenital basis. No high-grade spinal canal stenosis is appreciated at any level. There is effacement of the right lateral recess at the L2-L3 level and multilevel neural foramina narrowing, relatively worse at the L4-L5 level where there is moderate to severe left foraminal stenosis.3. Multiple small fluid collections involving the bilateral paraspinous musculature from T12 to L3 levels. There is mild peripheral enhancement. Fluid may be related to inflammatory process with muscle injury/myositis/myonecrosis or perhaps prolonged supine position; however given multiple loculations of fluid and mild peripheral enhancement, abscesses are not excluded. Consider ultrasound-guided aspiration. No evidence of epidural abscess or discitis-osteomyelitis. Dr. Ali discussed findings with Dr. Sheth at 1538 hrs on 3/12/2015.