64-year-old male with a history of chronic of lower back pain with new leg weakness and decreased sensation. Evaluate for cord compression. There is trace prominence of the central canal in the mid to lower cervical cord, as seen on prior spine MRI exam from 3/29/2016. The vertebral body heights in the cervical spine are normal. Again seen is partial fusion of the C3 and C4 vertebral bodies. There is mild reversal of cervical lordosis with the apex at the C3-C4 level. There is mild spinal canal stenosis at the C3-C4 and C4-C5 levels similar to prior.The thoracic vertebral body heights and alignment are maintained. No significant spinal canal stenosis is evident. Intraspinal catheter is again noted.Redemonstrated is a severe compression fracture involving the L3 vertebral body with evidence of cement augmentation. There are diminished posterior osseous elements from L3-L4 to the sacrum reflecting combination of prior laminectomies and dysplasia, stable in appearance.Volume loss is again seen involving the spinal cord at the L3-4 level indicating myelomalacia. The spinal cord remains low-lying with the distal neural tissue/conus extending to the L5 level. Septations/adhesions are again noted in the thecal sac from the L5 to S1 levels similar to prior. A lipoma within the thecal sac at the right lateral S1 level is again seen as well as along the distal aspect of the filum in the midline at the S2 level. These findings are stable in appearance.
1.This is a limited exam specific for the exclusion of cord compression only and does not exclude more subtle lesions such as intrinsic cord abnormalities. 2.No high-grade spinal canal stenosis in the cervical or thoracic spine. Mild spinal canal stenosis at C4-C5 again seen. 3.Trace prominence of the central canal/tiny syrinx in the cervical and thoracic cord, which appears not significantly changed.4.No significant change in the severe L3 vertebral body compression fracture with evidence of cement augmentation is unchanged in appearance. No change in the moderate to severe spinal canal stenosis and volume loss in the cord at the this level, consistent with myelomalacia.5.Unchanged appearance of the low-lying conus which extends to the L5 level with adhesions within the distal thecal sac as well as residual lipoma involving the right lateral aspect of the thecal sac at the S1 level and to a minimal degree along the distal filum terminale at the S2 level.6.Degenerative changes at additional levels are assessed on sagittal sequences only but appear grossly unchanged compared to the prior exam.