Status post fusion, now with left lower extremity weakness There are postsurgical changes of prior anterior cervical fusion at the C4-C5 levels. There is at least moderate degree of spinal canal stenosis at the C4-C5 and to a lesser degree C5-C6 and C3-C4 levels which appears improved since remote cervical spine MRI dated 4/5/2011. There may be cord signal abnormality at this level related to myelomalacia although not well assessed.There is mild spinal canal stenosis at the T11-T12 level. No significant spinal canal stenosis in the thoracic spine. There are postsurgical changes of laminectomy and posterior spinal fusion from L3 to L6. There is ill-defined STIR signal at the level of the lumbar thecal sac, much of which is likely artifactual. There is no discrete epidural hematoma evident within the limits of the artifact. Lumbar disc bulges extending into the neural foramina are again seen. Surgical drain is in place.Vertebral body heights and alignment are grossly maintained in the cervical, thoracic, and lumbar spine aside from loss of cervical lordosis.
This is a limited exam specific for the exclusion of cord compression only and does not exclude more subtle lesions such as intrinsic cord abnormalities. No findings to suggest acute cord compression are appreciated. Assessment of the lumbar spine is somewhat limited due to the spinal fusion hardware. There is also at least moderate degree of spinal canal stenosis evident at the C4-C5 and C5-C6 levels which appears overall improved when compared to prior preoperative cervical spine MRI dated 4/5/2011.Due to the screening nature of this protocol, details are not as evident on imaging as dedicated protocols of the spine and dedicated cervical and lumbar spine imaging can be considered as clinically warranted.