57 years Female (DOB:3/30/1959)Reason: eval for stenosis History: Difficulty raising arms above head. Numbness in both handsPROVIDER/ATTENDING NAME: EDWIN RAMOS EDWIN RAMOS Cervical spine:The cervical vertebral bodies are appropriate in overall height. The cervical spinal cord has normal signal characteristics and overall morphology. There is mild reversal of the normal cervical curvature present. There is mild bilateral facet hypertrophy at this level. At C2-3 there is no significant compromise to the spinal canal or neural foramina. There is very mild anterior subluxation of C2 on C3. At C3-4 there is no significant compromise to the spinal canal. There are left-sided uncovertebral osteophytes associated with disc material and encroachment of left-sided exiting nerve roots within the neural foramen. There is facet hypertrophy present bilaterally at this level but worse on the left than the right side.At C4-5 there is no significant compromise to the spinal canal or neural foramina.At C5-6 there are endplate and uncovertebral osteophytes associated with loss of disc space height this desiccation and diffuse disc bulge. There is narrowing of the neural foramina bilaterally which is worse on the left side where there is some encroachment of the left-sided exiting nerve roots. There is also effacement of spinal fluid ventral and posterior the spinal cord with a mild to moderate degree of spinal stenosis resulting.At C6-7 there is no significant compromise to the spinal canal or neural foramina. There is some disc desiccation and a mild disc bulge at this level.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.Lumbar 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. The patient status post posterior fusion using pedicle screws and interconnecting rods L34 level. There is a disc spacer present anteriorly at L3-4. The patient status post laminectomy at this level.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is mild facet and ligamentum flavum hypertrophy at this level.At L4-5 there is no significant compromise to spinal canal or neural foramina. There is a diffuse disc bulge present at this level associated with some narrowing of the neural foramina bilaterally and some effacement of the fat at the lateral recesses sees at this level disc material extends into the neural foramina bilaterally. Neuroforamina are partially obscured from artifact from the adjacent pedicle screws.At L3-4 there is metal artifact present from pedicle screws which partially obscures visualization at this level.At L2-3 there is metal artifact present from pedicle screws which partially obscures visualization at this level.At L1-2 there is no significant compromise to spinal canal or neural foramina.
1.There are degenerative changes present in the cervical spine with mild to moderate spinal stenosis at C5-6 associated bilateral encroachment of exiting nerve roots as well as encroachment of left-sided exiting nerve roots at C3-4.2.The patient status post anterior and posterior fusion with laminectomy at L3-4. There is no spinal stenosis appreciated in the lumbar spinal canal.3.There are degenerative changes present in the lumbar spine. Effect at the L4-5 level is not clear based on this exam. There appears to be some narrowing of the neural foramina but no convincing evidence for encroachment of exiting nerve roots. However, the exam is partially degraded by metal artifact from adjacent pedicle screws.