61 years Female (DOB:8/30/1954)Reason: worsened neck and upper and lower back pain in pt w known cspine stenosis and lumbar disc ds History: worsened neck and upper and lower back pain in pt w known cspine stenosis and lumbar disc dsPROVIDER/ATTENDING NAME: DEBORAH L. BURNET JAMES MOON MOK 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 mild disc desiccation present.At C2-3 there is no significant compromise to the spinal canal or neural foramina.At C3-4 there is no significant compromise to the spinal canal or neural foramina. At C4-5 there is no significant compromise to the spinal canal or neural foramina. There is mild facet hypertrophy present on the right side at this level.At C5-6 there are endplate and uncovertebral osteophytes present associated with a disc bulge and narrowing of the neural foramina bilaterally with encroachment of the exiting nerve roots. The neural foramen encroachment appears to be worse on the right when compared to the left side at this level. Overall there is a mild degree of spinal stenosis at this level.At C6-7 there are endplate and uncovertebral osteophytes present associated with a disc bulge and narrowing of the neural foramina bilaterally with encroachment of exiting nerve roots.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.There is a right thyroid cystic lesion present which is not completely included on this exam.Lumbar spine:Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall 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 some facet hypertrophy present at this level.At L4-5 there is mild anterior subluxation of L4 on L5. There is moderate facet hypertrophy present at this level. There is no significant, minus the spinal canal or exiting nerve roots. The degree of subluxation is mildly progressed since prior exam this level. Overall there is previously subluxation was a couple millimeters currently its several millimeters. The facet hypertrophy is changed character as the facet joints are narrow where on the current exam.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is mild facet hypertrophy at this level.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.There are some degenerative changes present in the lower lumbar spine worse at L4-5 where there is facet hypertrophy and mild subluxation which has mildly progressed since the prior exam of 7/12/2010.2.There are degenerative changes in the cervical in the cervical spine worse at C5-6 and C6-7 with bilateral neural foramen encroachment of exiting nerve roots at these levels and mild spinal stenosis at C5-6. This has not changed significantly compared to the prior exam.3.A cystic lesion is present in the right thyroid lobe. This is not entirely included on this exam. Please note that MR is not accurate in evaluation of the thyroid gland. Please correlate with clinical symptoms. Please note that the this was obscured on the prior exam due to saturation band and comparison cannot be adequately made.