Right lower extremity giving out, follow-up laminoplasty, more stiffness. Cervical spine: Craniovertebral junction appears within normal limits. The cervical vertebral bodies are appropriate in height. Alignment is grossly maintained. Interval straightening of the cervical spinal curvature is noted compared to the preoperative study, finding which may be in part positional and can be correlated with radiographs. Bone marrow signal is benign.Postsurgical changes of laminoplasty are again seen from C3 through C7 with decompression of the spinal canal. There remains diminished CSF spaces at the C3-C4 level but clearly improved since prior study. Thinning of the cord with T2 hyperintensity involving the dorsal aspect of the cord at the C3-C4 level is again seen and consistent with myelomalacia.No new cord signal abnormality or evidence of residual high-grade spinal canal stenosis is appreciated at any level. There is moderate to severe neural foraminal stenosis at C2-C3, C3-C4, C4-C5, C5-C6, and C6-C7 as seen previously related to pronounced uncovertebral hypertrophy.There is small residual postoperative fluid collection in the posterior paraspinous soft tissues at the C6 level.Lumbar spine: For the purposes of this dictation, consistent with prior reports, the lowest visualized intervertebral disc space is labeled L4-S1. There are 4 nonrib bearing lumbar vertebrae labeled L1-L4Conus terminates normally at the L1 level and is unremarkable in signal. Vertebral body heights are within normal limits. There is grade 1 anterolisthesis of L2 on L3 which appears slightly worse since prior study from 7/29/2015 and suggests possible instability at this level. There is advanced facet arthropathy in this level with fluid in the facet joints appearing similar to prior.Multilevel degenerative changes include disc desiccation and mild height loss at the L2-L3, L3-L4, L4 S1 levels not significant changed since prior.Individual levels as below:T12-L1: No significant disc disease. No spinal canal or neural foraminal stenosis.L1-L2: No significant disc disease. Mild ligamentum flavum hypertrophy and facet arthropathy. No spinal canal or neural foraminal stenosis.L2-L3: Diffuse disc bulge with uncovering of the disc and superimposed central extrusion extending 8 mm superiorly which is similar to prior. Moderate ligamentum flavum thickening and facet arthropathy, left greater than right. Moderate spinal canal stenosis appears slightly worse since prior from 7/29/2015 but slightly better than 7/5/2014 study. There is mild to moderate right and moderate left neural foraminal stenosis at this level which appears worse.L3-L4: Mild disc bulge, ligamentum flavum thickening and facet arthropathy is unchanged. Mild spinal canal stenosis is unchanged. Moderate left and mild right neural foraminal stenosis is unchanged.L4-S1: Diffuse disc bulge, asymmetric to the right, is unchanged. Facet arthropathy and ligamentum flavum thickening is unchanged. No significant central canal stenosis. Narrowing of the right lateral recess with contact of the descending right S1 nerve root is unchanged. Moderate bilateral neural foraminal stenosis is unchanged.
1. Postsurgical changes of cervical laminoplasty from C3 to C7 with decompression of the spinal canal. No significant change in cord T2 hyperintensity with cord thinning at the C3-C4 level consistent with myelomalacia. No new cord signal abnormality or evidence of residual high-grade stenosis in the cervical spine.2. Moderate to severe neural foraminal stenosis bilaterally from C2-C3 to the C6-C7 levels as seen previously.3. Compared to the preoperative study, there has been some straightening of the cervical spinal curvature. While this may be in part positional, further assessment with radiographs can be considered.4. Please note transitional anatomy in the lumbar spine with numbering scheme as above. Multilevel degenerative changes in the lumbar spine are again seen. Compared to 7/29/2015, there appears to be slight worsening of anterolisthesis at the L2-L3 level and can be correlated with dynamic radiographs for dynamic instability. Moderate spinal canal stenosis at this level also appears slightly worse since 7/29/2015 but improved since 7/5/2014 study, when there was a larger disc herniation. Please see details above regarding neural foraminal stenosis in the lumbar spine.