Upper extremity pain, neck pain. Patient also has back pain and lower extremity pain. History of cervical disc herniation, now with worsening symptoms. Evaluate for herniation/stenosis. Cervical:Craniovertebral junction appears within normal limits. The cervical vertebral bodies are appropriate in height. There is loss of normal cervical lordosis with mild kyphosis which appears positional. Bone marrow signal is benign.The cervical spinal cord has normal signal characteristics and overall morphology.Degenerative changes are seen in the cervical spine as described below:C2-3: Small disc osteophyte complex. No significant compromise to the spinal canal or neural foramina.C3-4: Small disc osteophyte complex and uncovertebral hypertrophy. There is no significant spinal canal stenosis. There is mild right relatively worse than left neural foraminal stenosis. C4-5: There is disc osteophyte complex, loss of disc height, and bilateral uncovertebral hypertrophy. There is moderate spinal canal stenosis including mild deformity of the cervical cord without cord signal abnormality. There is moderate to severe left and moderate right neural foraminal stenosis similar to prior. Again seen small Schmorl's node involving the right aspect of the inferior C4 endplate.C5-6: Small disc osteophyte complex and uncovertebral hypertrophy. No significant spinal canal stenosis. There is moderate to severe left and moderate right neural foraminal stenosis, similar to prior. C6-7: Minimal disc osteophyte complex. No significant compromise to the spinal canal or neural foramina.C7-T1: No significant compromise to the spinal canal. There is uncovertebral hypertrophy and facet arthropathy with minimal narrowing of the neural foramina.The vertebral artery flow voids appear to be intact. Paraspinous soft tissue structures appear within normal limits.Lumbar:Five lumbar type vertebral bodies are presumed to be present. Vertebral body heights are within normal limits. There is exaggeration of lumbar lordosis as well as grade 1 anterolisthesis of L4 and L5. Bone marrow signal is benign. Schmorl's node is noted involving the superior endplate of L2. The conus medullaris is normal in position.Multilevel degenerative changes are seen, as described below:L1-L2: Minimal disc bulge as well as facet arthropathy. There is no significant spinal canal stenosis. No significant neural foraminal narrowing.L2-L3: Minimal disc bulge and facet arthropathy. There is no significant spinal canal stenosis. No significant neural foraminal narrowing. L3-L4: Minimal disc bulge. Advanced bilateral facet arthropathy and ligamentum flavum thickening which contribute to mild narrowing of the spinal canal in the lateral dimension. Otherwise no significant central canal stenosis. There is mild to moderate bilateral neural foraminal narrowing.L4-L5: There is grade 1 anterolisthesis with disc uncovering and advanced bilateral facet arthropathy. Disc desiccation and mild disc height loss. There is moderate spinal canal stenosis. There is also moderate left neural foraminal stenosis with possible impingement of the left L4 nerve root. There is also mild to moderate right neural foraminal narrowing.L5-S1: There is disc desiccation and moderate disc height loss. There is also a disc bulge and bilateral facet arthropathy. No significant associated central canal stenosis. There is moderate left worse than right neural foraminal stenosis where there may be impingement of the exiting L5 nerve roots.
1. Multilevel degenerative changes in the cervical spine. There is moderate spinal canal stenosis at the C4-C5 level related to combination of disc and osteophyte, similar to prior. There is also significant neural foraminal stenosis at the C4-C5 and C5-C6 levels.2. Multilevel degenerative changes in the lumbar spine. There is moderate spinal canal stenosis at the L4-L5 level related to advanced bilateral facet arthropathy and grade 1 anterolisthesis. There is also significant neural foraminal narrowing at the left L4-L5 and bilateral L5-S1 levels. Please see additional details above.