Female 44 years old Reason: Met Breast Cancer, known spine mets, s/p xrt L2-l4 and L3 kyphoplasty History: lower back pain Again seen are bilateral pars defects with grade 1 anterolisthesis of L5 on S1 which is unchanged compared to the exam from 9/19/2014. The remainder of the alignment of the lumbar spine is within normal limits. Redemonstrated is an L3 compression fracture with approximately 50% loss of height. There is evidence of kyphoplasty material within the vertebral body of L3 which is better seen on the recent CT from 2/2/2016. The remainder of the vertebral body heights are preserved. There is variable disc desiccation and severe loss of disc height involving the L5-S1 level which is unchanged. There is mild loss of disc height at the remainder of the lumbar levels. The spinal cord displays normal signal and morphology. The paravertebral soft tissues are unremarkable. Degenerative changes are seen in the cervical spine as described below:T12-L1: There is no significant compromise to spinal canal or neural foramina.L1-L2, L2-3: No disc bulge. Mild facet arthropathy. No spinal canal foraminal stenosis.L3-4: No disc bulge. Mild facet arthropathy. With comparison to the prior CT, kyphoplasty cement is visualized in the anterior left epidural region with effacement of the left lateral recess which is unchanged. No significant spinal canal or neural foraminal stenosis.L4-5: No disc bulge. Severe facet arthropathy. No spinal canal or neural foraminal stenosis.L5-S1: Again seen is grade 1 anterolisthesis of L5 on S1 with uncovering of the disc and moderate facet hypertrophy which causes severe bilateral neuroforaminal stenosis. There is mild spinal canal stenosis.
1.No evidence of new osseous metastatic disease.2.Degenerative changes most severe at the L5-S1 level where there is grade 1 anterolisthesis, severe bilateral neural foraminal stenosis and mild spinal canal stenosis which is not significantly changed from the previous exam.3.Interval kyphoplasty of the L3 vertebral body with no change in the degree of height loss. With comparison to the prior CT, kyphoplasty cement is visualized in the anterior left epidural region with effacement of the left lateral recess, a finding which is unchanged. There is no significant spinal canal or neural foraminal stenosis at this level.