Reason: assess for recurrence of cervical spinal stenosis History: progressive gait impairment, myelopathy CERVICAL SPINE:Findings of C3-C6 laminectomy with interval evolution of postsurgical changes including resolution of the previously seen fluid collection in surgical bed. The cranial-cervical junction is normal. There is mild kyphotic angulation of the lower cervical spine, grossly similar to the prior exam. The vertebral body heights are preserved accounting for endplate degeneration. There is near complete loss of intervertebral disc space at C6-7, which appears similar to prior. There has been interval increase in the degree of edematous signal change at C6-7. There is no definite cord signal abnormality.Degenerative changes are specified by the intervertebral level as follows: C2-3: Facet hypertrophy. Ligamentum flavum thickening. Mild posterior disk osteophyte formation. Mild to moderate spinal canal stenosis. No significant foraminal narrowing. No interval changes. C3-4: Posterior spinal canal decompression. Facet hypertrophy. Severe left and mild right foraminal narrowing, unchanged.C4-5: Posterior spinal canal decompression. Very mild posterior disk osteophyte formation. No spinal canal stenosis. Mild to moderate right and mild left neuroforaminal stenosis.C5-6: Posterior spinal canal compression. Mild posterior disk osteophyte. No spinal cord impingement. Facet hypertrophy. Moderate to severe left and mild to moderate right neuroforaminal narrowing, unchanged. C6-7: Moderate posterior disk osteophyte formation which contributes to a moderate spinal canal stenosis with mild deformation of the spinal cord but without significant cord signal abnormality. Moderate bilateral, left greater than right , foraminal narrowing. Findings are unchanged. C7-T1: No significant spinal canal or neuroforaminal stenosis. LUMBAR SPINE:Five lumbar type vertebral bodies are presumed to be present. The vertebral body heights are well-maintained. There is moderate to severe loss of the intervertebral disc space at L4-L5, which appears increased from the prior exam. There is disc desiccation at L5-S1, which was present previously. No focal marrow signal abnormality is appreciated. The conus medullaris on sagittal imaging is grossly intact. A simple cyst is noted in the right kidney, unchanged.T12-L1: There is no significant compromise to spinal canal or neural foramina.L1-L2: There is no significant compromise to spinal canal or neural foramina.L2-L3: Mild disc bulge and ligamentum flavum hypertrophy. Minimal neuroforaminal stenosis bilaterally. There is no significant compromise to the spinal canal.L3-L4: Ligamentum flavum hypertrophy and mild facet arthropathy. Mild neuroforaminal stenosis bilaterally. There is no significant compromise to spinal canal.L4-5: Ligamentum flavum hypertrophy and severe facet arthropathy. There is grade 2 anterolisthesis of L4 on L5 with uncovering of the intervertebral disc at this level, which appears slightly increased from the previous exam. There is severe neuroforaminal stenosis, which likely results in impingement of the L4 nerve roots. Mild to moderate narrowing of the central spinal canal. There is also partial effacement of the lateral recesses, which is worse on the right.L5-S1: Ligamentum flavum hypertrophy and mild facet arthropathy. There is no significant compromise to spinal canal or neural foramina.
1. Grade 2 anterolisthesis of L4 on L5 with severe neuroforaminal stenosis and likely impingement of the L4 nerve roots. This can be further assessed with dynamic radiographs. There is mild to moderate spinal canal stenosis at this level which is slightly worse.2. Expected evolution of postsurgical findings of C3-C6 laminectomy. There is mild progression of cervical degenerative changes although the mild to moderate spinal canal stenosis at C2-C3 and up to moderate spinal canal stenosis at the C6-C7 level are not significantly changed. No new cord signal abnormality.