63 years Male (DOB:12/18/1952)Reason: prior acdf History: samePROVIDER/ATTENDING NAME: MICHAEL J LEE MICHAEL J LEE 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. The patient is status post anterior fusion at C3-4.There is mild thickening of the cruciate ligaments at C1-2.At C2-3 there is no significant compromise to the spinal canal or neural foramina. There is a small central disc protrusion at this level. There is mild facet hypertrophy at this level.At C3-4 there is no significant compromise to the spinal canal or neural foramina. The patient status post anterior fusion at this level.At C4-5there are endplate uncovertebral osteophytes present associated with a disc bulge and hypertrophy of the ligamentum flavum. There is effacement of spinal fluid ventral and posterior the spinal cord and flattening of the spinal cord at this level. Overall there is a moderate degree of spinal stenosis at this level. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat.At C5-6 there is no significant compromise to the neural foramina. There is a disc bulge present at this level associated with mild ligamentum flavum hypertrophy. There is partial effacement of spinal fluid ventral and posterior the spinal cord and overall a mild degree of spinal stenosis.At C6-7 there is no significant compromise to the spinal canal or neural foramina. There is a left paramedian small disc protrusion present at this level which partially effaces spinal fluid ventral to the left hemicord.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact. The right vertebral artery is small.Lumbar spine:Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall alignment and height. The conus medullaris on sagittal imaging is grossly intact.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is a mild disc bulge present this level associated with facet hypertrophy. The facet hypertrophy is worse on the right compared to the left side.At L4-5 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with bilateral facet and ligamentum flavum hypertrophy. There is triangulation of the thecal sac associated with effacement of fat at the lateral recess is at this level. There is encroachment of the nerve roots at the lateral recess bilaterally at this level and mild to moderate degree of spinal stenosis. This has not substantially changed compared the prior exam.At L3-4 there is loss of disc space height, disc desiccation and endplate reactive changes. Endplate reactive changes are bright on T2 STIR imaging and lower signal on T1 imaging. This indicates that the endplate reactive changes are in the subacute stage. There is effacement of the fat at the lateral recess bilaterally at this level and crowding of nerve roots and overall a moderate to severe degree of spinal stenosis. The exiting nerve roots are surrounded by fat within the neural foramina . This has not substantially changed compared to the prior exam the exception that inflammatory changes are new since then and the ligamentum flavum is thicker.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is ligamentum flavum hypertrophy present at this level.At L1-2 there is no significant compromise to spinal canal or neural foramina.
1.There are degenerative changes present cervical spine worse at C4-5 where there is a moderate degree of spinal stenosis associated with some flattening of the spinal cord due to degenerative changes. There is mild spinal stenosis at C5-6.2.There are degenerative changes present in the lumbar spine worse at L3-4 there is a moderate to severe degree of spinal stenosis associated with subacute inflammatory changes at the endplates. This has not substantially changed compared to the prior exam the exception that inflammatory changes are new since then and the ligamentum flavum is a little thicker.