Neck pain and increasing headaches. Buttock pain and shooting pain up the back from the the low spine. History of cervical fusion. Eval for stenosis or abnormality. Cervical spine: Again seen are postsurgical changes of cervical decompression, with laminectomies, and posterior fusion hardware, which extends from C3 to T1 levels. Hardware is better assessed on recent CT study. Spinal canal is well decompressed without significant stenosis at any level. Again noted is mild kyphotic angulation of the lower cervical spine with apex at the C6 level. There is minimal anterolisthesis of C4 on C5 but much improved compared to preoperative CT from 11/1/2013. There is significant loss of disc height at the C6-C7 level and to a lesser degree at the C5-C6 level. Cervical vertebral body heights are maintained. Bone marrow signal is benign. Periscrew lucencies involving the bilateral T1 screws is better appreciated on recent CT.Individual levels as below:At C2-C3, there is minimal left neural foraminal narrowing. No significant spinal canal or right neural foraminal narrowing.At C3-C4, there is mild to moderate right neural foraminal narrowing. No significant spinal canal or left neural foraminal narrowing.At C4-C5, there is mild to moderate right neural foraminal narrowing. No significant spinal canal or left neural foraminal narrowing.At C5-C6, there is a disc osteophyte complex eccentric to the right with uncovertebral hypertrophy. There is mild to moderate right neural foraminal narrowing. No significant spinal canal or left neural foraminal narrowing.At C6-C7, there is minimal right neural foraminal narrowing. No significant spinal canal or left neural foraminal narrowing.At C7-T1, there is small central disc protrusion which is larger compared to 11/1/2013 but with no significant spinal canal or neural foraminal stenosis.Lumbar spine: Five lumbar type vertebral bodies are presumed to be present. As seen on recent CT, there is mild rightward convexity of the spine centered at L3 with slight left lateral translation of L2 on L3. There is minimal grade 1 retrolisthesis of L3 on L4 and L4 on L5. There is slight straightening of the normal lumbar lordosis. There is severe loss of height of the L2-L3 disc and to a lesser degree at the L3-L4 and L5-S1 levels. Vacuum disc phenomena is noted at L2-L3, L3-L4, L4-L5, and L5-S1. There is mild loss of height involving the L3 vertebral body related to advanced endplate changes at the L2-L3 level; vertebral body heights are otherwise maintained without evidence of a compression fracture. Advanced endplate degenerative changes are also well appreciated on recent CT. The conus medullaris is normal in position at the lower L1 level.Multilevel degenerative changes are seen, as described below:L1-L2: Minimal disc bulge. No spinal canal or neural foraminal stenosis.L2-L3: Disc bulge eccentric to the right with prominent right lateral osteophyte. No significant spinal canal or left neural foraminal narrowing. There is mild to moderate right neural foraminal stenosis. There is also displacement of the right extraforaminal L2 nerve root related to the large osteophyte.L3-L4: Mild disc bulge and endplate osteophytes. No significant spinal canal stenosis. There is mild to moderate right greater than left neural foraminal narrowing.L4-L5: There is mild disc bulge and facet arthropathy. There is moderate bilateral neural foraminal narrowing. No significant spinal canal narrowing. L5-S1: Mild disc bulge. No significant spinal canal stenosis. There is mild to moderate bilateral, right worse in left neural foraminal stenosis.Mild facet arthropathy in the lumbar spine. Atrophic changes are noted in the lower lumbar paraspinous musculature. Paraspinous soft tissues are otherwise unremarkable.
1. Postsurgical changes of cervical spine decompression and fusion with hardware extending from C3 to T1 levels. There are periscrew lucencies/loosening involving the bilateral T1 screws which are better assessed on recent CT. There is no significant spinal canal narrowing in the cervical spine. Multilevel mild neural foraminal narrowing as described above, relatively worse at the right C3-4 and C4-5 levels.2. Moderate degenerative changes in the lumbar spine without significant spinal canal stenosis at any level. There is neural foraminal stenosis at right L2-L3 and bilateral L3-L4, L4-L5, and L5-S1 as described above. 3. Advanced disc and endplate degenerative changes in the lumbar spine at L2-L3, L3-L4, and L5-S1.