 CERVICAL SPINE: The vertebral body heights are preserved. There is mild to moderate loss of disc height at multiple levels. There are subcentimeter cystic foci in the posterior aspects of the C3 and C7 vertebra, which are likely degenerative in nature. There is loss of the usual cervical lordosis and a congenitally narrow spinal canal. In conjunction with multilevel degenerative spondylosis, there is spinal canal stenosis with mild impingement of the spinal cord. However, the spinal cord displays normal signal. The paravertebral soft tissues are unremarkable. Additional findings by level:C2-C3: Posterior disc osteophyte complex with effacement of the ventral CSF space, flattening of the ventral cord and thickening of the ligamentum flavum contribute to moderate spinal canal stenosis, but no significant neural foramen stenosis.C3-C4: Posterior disc osteophyte complex, central to slightly asymmetric to the right, with flattening of the ventral cord and thickening of the ligamentum flavum contribute to moderate spinal canal stenosis and mild bilateral neural foramen stenosis. C4-C5: Posterior disc osteophyte complex with mild flattening of the ventral cord, bilateral uncinate spurs and thickening of the ligamentum flavum contribute to moderate spinal canal stenosis and moderate right and mild left neural foramen stenosis.C5-C6: Posterior disc osteophyte complex, bilateral uncinate spurs, thickening of the ligamentum flavum and right greater than left facet arthropathy contribute to moderate spinal canal stenosis and moderate bilateral neural foramen stenosis.C6-C7: Posterior disc osteophyte complex, bilateral uncinate spurs, and thickening of the ligamentum flavum contribute to mild spinal canal stenosis and mild bilateral neural foramen stenosis.C7-T1: No significant spinal canal or neural foramen stenosis.THORACIC SPINE: The vertebral column alignment is within normal limits. The vertebral body heights are preserved. There is mild multilevel loss of disc height. The vertebral bone marrow signal is unremarkable. There are mild disc bulges of the thoracic spine. There is a small central disc protrusion at T6-T7 with mild indentation of the ventral cord. There is no associated spinal cord signal abnormality. The paravertebral soft tissues are unremarkable.LUMBAR SPINE: There is a compression fracture of the L1 vertebral body with approximately 50% loss of height centrally and mild posterior retropulsion. There is linear enhancement and high T2 signal within the vertebral body. There is no significant central spinal stenosis at this level. There is a compression fracture of the L5 vertebral body with approximately 75% loss of height centrally and 10 mm of posterior retropulsion, contributing to severe central spinal stenosis and compression of the cauda equina nerve roots. There is linear enhancement along the fracture cleft. There is also diffuse high T2 signal within the vertebral body, which extends into the posterior elements as well. There is soft tissue T2 hyperintensity and enhancement at the L4-L5 level, adjacent to the spinous processes, but no discrete fluid collection. Additional findings by level:T12-L1: L1 vertebral body fracture with mild retropulsion and moderate bilateral facet arthropathy and thickening of ligamentum flavum with minimal spinal canal and bilateral neural foramen stenosis.L1-L2: Mild disc bulge and moderate bilateral facet arthropathy, but no significant spinal canal or neural foramen stenosis.L2-L3: Mild disc bulge, thickening of the ligamentum flavum and moderate bilateral facet arthropathy, contributing to minimal bilateral neural foramen stenosis, but no significant spinal canal stenosis.L3-L4: Mild disc bulge, thickening of the ligamentum flavum and moderate bilateral facet arthropathy, contributing to mild spinal canal narrowing and mild bilateral neural foramen stenosis.L4-L5: L5 vertebral body compression fracture with moderate retropulsion. Disc bulge, thickening of the ligamentum flavum and moderate bilateral facet arthropathy, contributing to severe spinal canal stenosis, compression of the cauda equina and severe right and mild left neural foramen stenosis.L5-S1: Vacuum disc phenomenon, bilateral facet hypertrophy, and ligamentum flavum thickening with mild bilateral neural foramen stenosis, but no significant spinal canal stenosis.
1. L5 vertebral compression fracture with edema, 75% loss of height, and 10 mm of retropulsion superimposed upon underlying degenerative changes, contributing to severe spinal canal stenosis with compression of the cauda equina and severe right and moderate left foraminal stenosis at the L4-L5 level.2. L1 vertebral compression fracture with mild edema, 50% loss of height, and slight retropulsion, but no significant spinal canal stenosis.3. Multilevel degenerative cervical spondylosis and a congenitally narrow spinal canal, contributing to moderate spinal canal stenosis at C2-C3 to C5-C6 and variable degrees of multilevel foraminal stenosis.Findings discussed with Dr. Zimmerman on 12/31/2014 at 11:35 a by Dr. Wu. 