46 years Female (DOB:3/7/1970)Reason: possible osteoporosis, radiculopathy, facet joint inflammation History: pain in multiple sitesPROVIDER/ATTENDING NAME: ANDREA H. SHASHOUA ANDREA H. SHASHOUA Cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. There is some subtle T2 signal hyperintensity present along the cervical spinal cord which is suspected to be artifactual.. The patient status post anterior fusion using anterior plate and screws at C6-7.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 or neural foramina. There is left-sided facet hypertrophy at this level associated with mild narrowing of the left neural foramen.At C5-6 there is no significant compromise to the spinal canal or neural foramina. There are small uncovertebral osteophytes at this level associated with a disc bulge.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. 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 a mild levocurvature to the upper thoracic spine.Lumbar spine:Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall alignment and height. There are 4 nonrib-bearing lumbar-type vertebrae and a sacralized lumbar vertebra present. The conus medullaris on sagittal imaging is grossly intact.At L5-S1 there is no significant compromise to spinal canal or neural foramina.At L4-5 there is loss of disc space height, disc desiccation and broad-based central disc protrusion associated with some partial effacement of the fat at the lateral recesses bilaterally. There is mild encroachment of the nerve roots at the lateral recesses at this level which is worse on the right when compared to the left side.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is some disc desiccation and a mild disc bulge at this level.At L2-3 there is no significant compromise to spinal canal or neural foramina.At L1-2 there is no significant compromise to spinal canal or neural foramina.
1.Please note that L5 is sacralized with articulation with the sacral ala.2.There are multilevel degenerative changes present in the lumbar spine. There is some mild to moderate encroachment of nerve roots of the right lateral recess at L4-5 due to degenerative changes.3.Patient status post cervical spine surgery. There is no significant compromise to the cervical spinal canal or exiting nerve roots.4.No compression fractures are identified in the spine.