Diagnosis: Other spondylosis with myelopathy, cervical region Spinal stenosis, lumbar regionClinical question: hx cervical myelopathy. Evaluate for progressionSigns and Symptoms: gait instability Cervical spine:The cervical vertebral bodies are appropriate in overall height. The cervical spinal cord has normal signal characteristics and overall morphology.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 loss of disc space height, disc desiccation and a broad-based left lateral recess disc extrusion present with flattening of the spinal cord and effacement of spinal fluid ventral and posterior the spinal cord. There is narrowing of the neural foramina bilaterally with encroachment of the exiting nerve roots bilaterally at this level related to disc material. Overall there is moderate to severe spinal stenosis at this level. Compared to the prior exam from 1/21/2013 there is minimal progression.At C4-5 there is disc desiccation and a diffuse disc bulge associated with encroachment of the exiting nerve roots within the neural foramina bilaterally and effacement of spinal fluid ventral and posterior the spinal cord as well as posterior ligamentous hypertrophy. There is some flattening of the spinal cord present. Overall there is a moderate to severe degree of spinal stenosis at this level. Compared to the prior exam from 1/21/2013 there is not appear to be any significant progression.At C5-6 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with flattening of the spinal cord and bilateral encroachment of exiting nerve roots within the neural foramina. Overall there is a moderate to severe degree of spinal stenosis at this level. There is some cord signal hyperintensity present. Compared to the prior exam from 1/21/2013 there is not appear to be any significant progression.At C6-7 there is a diffuse disc bulge present associated with some partial effacement of spinal fluid ventral and posterior the spinal cord and encroachment of the exiting nerve roots bilaterally. Compared to the prior exam from 1/21/2013 there is not appear to be any significant progression.At C7-T1 there is a disc bulge present associated with encroachment of the exiting nerve roots within the right neural foramen. Compared to the prior exam from 1/21/2013 there is not appear to be any significant progression.The vertebral artery flow voids appear to be intact.Lumbar spine:Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall height. The conus medullaris on sagittal imaging is grossly intact.No abnormal enhancing lesions are appreciated in the lumbar spine.At L5-S1 there is a right paramedian broad-based disc protrusion present which mildly impresses on the nerve root at the right lateral recess. There is loss of disc space height and disc desiccation at this level.At L4-5 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with bilateral facet hypertrophy and partial effacement of the fat at the lateral recesses sees. There is a mild degree of spinal stenosis present at this level. There is effacement of the fat surrounding the exiting nerve roots within the neural foramina bilaterally with some compression of the exiting nerve roots.At L3-4 there is loss of disc space height, disc desiccation and diffuse disc bulge associated bilateral facet and ligamentum flavum hypertrophy. There is effacement of the fat at the lateral recess bilaterally at this level and crowding of the nerve roots within the thecal sac. There is a moderate to marked degree of spinal stenosis at this level which has mildly progressed since the 9/22/2014 exam. There is mild (1mm) anterior subluxation of L3 on L4.At L2-3 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with partial effacement of the fat at the lateral recesses bilaterally. There is narrowing of the neural foramina bilaterally with partial effacement of the fat surrounding the exiting nerve roots within the neural foramina. There is crowding of the nerve roots within the thecal sac at this level. Overall there is a moderate degree of spinal stenosis present at this level which has mildly progressed since the 9/22/2014 exam. At L1-2 there is no significant compromise to spinal canal or neural foramina.
1.There are multilevel degenerative changes present in the cervical spine with moderate to severe spinal stenosis at C3-4, C4-5, C5-6 as well as encroachment of the exiting nerve roots bilaterally at these levels as well as the right side at C7-T1. There is mild encroachment of exiting nerve roots at C6-7. Compared to the prior exam from 2013 does not appear to be significant progression.2.There are multilevel degenerative changes present in the lumbar spine with moderate spinal stenosis at L3-4 and L2-3 which has mildly progressed since the 9/22/2014 exam. There is encroachment of the exiting nerve roots bilaterally at L3-4 and L2-3.