Diagnosis: Cerebral infarction, unspecifiedClinical question: CVA. Brisk reflexes. Evaluate spine per radiology.Signs and Symptoms: brisk reflexes, LE clonus Cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology. There is multilevel disc desiccation present.No abnormal enhancing lesions are appreciated in the cervical spine.At C2-3 there is no significant compromise to the spinal canal or neural foramina.At C3-4 there is no significant compromise to the spinal canal or neural foramina.At C4-5 there is no significant compromise to the spinal canal. There are small uncovertebral osteophytes present at this level with mild narrowing of the left neural foramen.At C5-6 there is no significant compromise to the spinal canal. There are small uncovertebral osteophytes present at this level with mild narrowing of the left neural foramen.At C6-7 there is no significant compromise to the spinal canal or neural foramina.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.MRI thoracic spine:The thoracic vertebral bodies are appropriate in the overall alignment and height. There is a marrow replacing lesion which enhances following gadolinium administration within the T5 vertebral body which measures 10 mm in diameter. The thoracic spinal cord has normal signal characteristics and overall morphology. There is no compromise of thoracic spinal canal or exiting nerve roots. There is mild compression of the left half of the L2 and L3 vertebral body. There is associated enhancement of the L2 and L3 vertebral bodies. On an abdomen CT from 9/21/2015 these appear to be sclerotic in nature. Relatively homogeneously high marrow signal within the L1, L4, L5, and sacrum suggest status post radiation to the lumbosacral spine.There is a small right-sided pleural effusion present.There is a mass which is incompletely included on this exam within the liver.
1.Enhancing masses present within the T5 vertebral body. The possibility this represents metastatic disease is raised. 2.There are compression fractures present at L2 and L3. These are presumably related to metastatic disease.3.There are multilevel degenerative changes present in the cervical spine with encroachment of the exiting nerve roots predominantly on the left side at C4-5 and C5-6.4.There is no evidence for spinal cord compression in the cervical or thoracic spine.5.There is a small right-sided pleural effusion present6.Liver mass. Please refer to CT of the abdomen for further comments.