Diagnosis: Backache, unspecifiedClinical question: Hx of Infantile cerebral palsy, c/o of several months of whole back pain. Also 2 5x5cm soft tissue lesions in upper back (c/f lipomas)Signs and Symptoms: months of whole back painComments: Pt has a VP shunt Checked annually by. Dr. D. Trim. | Cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. There is a high signal focus within the central portions of the spinal cord at the C3-4 level associated with volume loss.At C2-3 there is no significant compromise to the spinal canal or neural foramina.At C3-4 there is a disk bulge present at this level associated with extruded disk material tracking behind the C3 vertebral body and into the neural foramina. There is bilateral uncovertebral osteophyte formation present as well as end plate osteophyte formation. There is moderate encroachment of the right exiting nerve roots at this level and mild encroachment of the left exiting nerve roots at this level. There is disk dessication and loss of disk space height at this level. Overall there is moderate spinal stenosis at this level.At C4-5 there is loss of disk space height, disk dessication and a disk bulge present at this level. There is bilateral uncovertebral osteophyte formation (right worse than left) present as well as end plate osteophyte formation. There is moderate encroachment of the right exiting nerve roots at this level . Overall there is mild to moderate spinal stenosis at this level.At C5-6 there is loss of disk space height, disk dessication and a disk bulge present at this level. There is bilateral uncovertebral osteophyte formation (left worse than right) present as well as end plate osteophyte formation. There is moderate encroachment of the left exiting nerve roots at this level . Overall there is mild to moderate spinal stenosis at this level.At C6-7 there is no significant compromise to the spinal canal or neural foramina.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.MRI thoracic spine:The thoracic vertebral bodies are appropriate in the overall alignment and height. The thoracic spinal cord has normal signal characteristics and overall morphology. There is no compromise of thoracic spinal canal or exiting nerve roots. There are fatty masses in the subcutaneous tissues of the left mid back at the levels of the spinous processes of T6-T9Lumbar 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.At L4-5 there is no significant compromise to spinal canal or neural foramina. There loss of disk space height and a disk bulge at this level eccentric to the right with mild to moderate encroachment of the nerve roots at the left lateral recess.At L3-4 there is no significant compromise to spinal canal or neural foramina.At L2-3 there is no significant compromise to spinal canal or neural foramina.At L1-2 there is no significant compromise to spinal canal or neural foramina.
1.Myelomalacia at the C3-4 level.2.Multilevel degenerative changes are present in the cervical spine with encroachment of the left exiting nerve roots at C5-6, the right exiting nerve roots at C4-5, moderate spinal stenosis at C3-4, and mild to moderate spinal stenosis at C4-5 and C5-6.3.Mild to moderate encroachment of the nerve roots at the left lateral recess at L4-5 due to a disk bulge.4.Lipomas in the in the subcutaneous tissues of the left mid back at the levels of the spinous processes of T6-T9