History of progressive lower extremity weakness and spasticity. Evaluate for myelopathy. Cervical spine:The vertebral body and intervertebral disc heights are maintained. The alignment is anatomic. No bone marrow signal abnormalities. The visualized spinal cord is normal in signal and morphology.C2-C3: No disc bulge, spinal canal stenosis, or neuroforaminal narrowing.C3-C4: Small right paracentral disc osteophyte complex. No significant neural foraminal or spinal canal stenosis.C4-C5: No disc bulge, spinal canal stenosis, or neuroforaminal narrowing.C5-C6: Small generalized disc osteophyte complex eccentric to the right. Mild bilateral neural foraminal stenosis. No spinal canal stenosis.C6-C7: Small generalized disc osteophyte complex. Mild bilateral neural foraminal stenosis. No spinal canal stenosis.C7-T1: No disc bulge, spinal canal stenosis, or neuroforaminal narrowing.Thoracic spine:The vertebral body and intravertebral disc heights are maintained. The alignment is anatomic. Focus of T1 and T2 bright signal within the T9 vertebral body is compatible with an intraosseous hemangioma. The visualized spinal cord is normal in signal and morphology throughout.T1-T2 through T11-12: No disc bulge, spinal canal stenosis, or neuroforaminal narrowing.Lumbar Spine:Vertebral body heights are maintained. There is mild loss of intervertebral disc height at L4-5 and L5-S1 as well as decrease in intervertebral disc signal from L2 to S1 compatible with desiccation. Reactive marrow changes are present in the inferior endplate of L3 and superior endplate of L4. Visualized spinal cord and cauda equina are normal in signal and morphology. The conus medullaris terminates at the L1-2 level.T12-L1: No disc bulge, spinal canal stenosis, or neuroforaminal narrowing.L1-L2: No disc bulge, spinal canal stenosis, or neuroforaminal narrowing.L2-L3: Mild diffuse disc bulge. This creates mild bilateral neural foraminal stenosis. No spinal canal stenosis.L3-L4: Mild diffuse disc bulge, facet arthropathy, and hypertrophy of the ligamentum flavum create moderate left neural foraminal stenosis and mild right neural foraminal stenosis. No significant spinal canal stenosis.L4-L5: Mild diffuse disc bulge, facet arthropathy, and hypertrophy of the ligamentum flavum create severe left and moderate right neural foraminal narrowing.L5-S1: Moderate posterior disc protrusion, facet arthropathy, and hypertrophied ligamentum flavum create moderate to severe right and moderate left neural foraminal stenosis. No central canal stenosis.
1. Normal signal and morphology of the spinal cord throughout the cervical, thoracic, and lumbar spine. No evidence of myelopathy as clinically queried.2. Multilevel degenerative changes in the cervical and lumbar spine as described. Multilevel neuroforaminal stenoses in the lumbar spine are most severe at the left L4-5 and right L5-S1 levels.