Malignant neoplasm of unspecified site of unspecified female breast [C50.919], Reason for Study: ^Reason: evaluating for cord compression and vertebral fracture. Patient with metastatic breast cancer and worsening back pain History: back pain For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. There is about 50% height loss of L4 vertebral body with replacement of normal bone defect appropriate with T1 low signal intensity lesions indicating pathologic fracture.There are multifocal bone marrow replacing lesion which show Gad enhancement involving T12, L1, L2, L3, L5, S1, coccyx and bilateral ilium indicating metastatic lesions.There is normal lumbar lordosis. The spine alignment is anatomic. The signal of the visualized cord is normal. The conus medullaris terminates at the T12-L1 level. There is no evidence of abnormal enhancement, cord compression or mass. Degenerative changes are specified by the intervertebral level as follows: T12-L1: Disc desiccation. There is focal bulging of disc central to right which abuts thecal sac. No neuroforaminal narrowing or spinal stenosis. L1-L2: Disc desiccation, no neuroforaminal narrowing or spinal stenosis. L2-L3: Disc desiccation, diffuse bulging of disc, no neuroforaminal narrowing or spinal stenosis. L3-L4: Diffuse bulging of disc, mild to return protrusion of fracture fragment of L4 vertebral body associated with bilateral ligamentum flavum thickening causing severe spinal canal stenosis. L4-L5: Disc desiccation, diffuse bulging of disc associated with bilateral ligamentum flavum thickening indicate mild to moderate spinal canal stenosis. L5-S1: no neuroforaminal narrowing or spinal stenosis.
1. Compression fracture, 50%, L4 with minimal retropulsion of fracture fragment result severe spinal canal stenosis at the level of L3-4.2. Multifocal various extent metastatic lesions involving L spine, sacrum, coccyx and bilateral ilium as described above.