Reason: demyelinating lesion History: right leg weakness and numbness Thoracic spine:Vertebral body heights are within normal limits. Alignment is within normal limits. No abnormal marrow signal. No abnormal enhancement. No abnormal signal within the cord. No significant spinal or neural foraminal stenosis.Multiple bilateral renal cysts. The largest one measures approximately 3.5 cm in the right kidneyLumbar spine:There is a compression fracture at L1 with 50% loss of vertebral body height and mild increased T2 STIR signal and enhancement along the superior endplate. No abnormal signal within the cord or conus which ends at L1-L2..T12-L2: Minimal diffuse disc bulge. No spinal canal or neural foraminal stenosis.L1-L2: There is no significant compromise to spinal canal or neural foramina this level.L2-L3: There is no significant compromise to spinal canal or neural foramina this level.L3-L4: There is no significant compromise to spinal canal or neural foramina this level.L4-L5: There is a diffuse disc bulge present with superimposed central extrusion extending superiorly behind the inferior endplate of L4. There is loss of disc space height and some disc desiccation at this level. There is moderate facet arthropathy with synovial effusions and moderate ligamentum flavum thickening at this level. The fat at the lateral recess is bilaterally effaced at this level. There is crowding of the nerve roots within the thecal sac. There is moderate central canal stenosis. The neural foramina are narrowed at this level, however, the fat surrounding the exiting nerve roots is preserved. There is mild anterior subluxation of L4 on L5.L5-S1: Mild diffuse disc bulge No spinal canal or neural foraminal stenosis. There is disc desiccation, loss of disc space height, endplate reactive changes and Schmorl nodes present at this level.There are 2 cysts adjacent to the L5 spinous process with peripheral enhancement. One to the right of the spinous process measures 6 mm diameter whereas one to the left of the L5 spinous process measures 5 mm. There is associated ill-defined enhancement in the adjacent soft tissues.
1.No abnormal signal within the cord to suggest demyelinating disease.2.There is a compression fracture present at L1 associated with findings suggesting subacute stage.3.There are degenerative changes present in lumbar spine with moderate spinal stenosis at L4-5 as detailed above4.There are cystic lesions adjacent to the L5 spinous process associated with findings suspicious for adjacent inflammation. The possibility that these are infectious in origin cannot be excluded. Although unusual it could also be degenerative in nature possibly related to Baastrup's disease with bursal fluid.5.Multiple renal cystic lesions.Findings discussed with Dr. Del Brutto at 10:45 AM on 7/27/2015.