74 years Female (DOB:4/14/1942)Reason: eval for abnormality/ disc hern. History: c/o ataxia, LBP and right hip pain. LE weaknessPROVIDER/ATTENDING NAME: EDWIN RAMOS EDWIN RAMOS Cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology. There is straightening of the normal cervical curvature. There is fusion of the C3-4 and C6-7 vertebral bodies. There are some mild signal hyperintensity on T2 STIR imaging within the C4 and C5 vertebral bodies.At C2-3 there is no significant compromise to the spinal canal or neural foramina. There is some disc desiccation at this level.At C3-4 there is no significant compromise to the spinal canal or neural foramina. There are some ventral osteophytes present this level which effaces spinal fluid ventral to the spinal cord. The spinal cord is mildly deformed at this level. There is osseous fusion across the C3-4 disc.At C4-5 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with endplate osteophytes and uncovertebral osteophytes as well as ligamentum flavum hypertrophy. The spinal fluid ventral and posterior the spinal cord is effaced and there is flattening of the spinal cord. There is severe spinal stenosis at this level. There is narrowing of the neural foramina bilaterally with encroachment of the exiting nerve roots bilaterally at this level.At C5-6 there is loss of disc space height, disc desiccation and a left paramedian broad-based disc protrusion associated with effacement of the spinal fluid ventral and posterior the spinal cord and some mild flattening the spinal cord. There is some hypertrophy of the ligamentum flavum at this level. Overall there is moderate to severe spinal stenosis at this level. There is narrowing of the neural foramina bilaterally with encroachment of the exiting nerve roots bilaterally at this level. Encroachment of exiting nerve roots appears to be worse on the left versus the right sideAt C6-7 the disc space is obliterated and there is fusion of the C6 and C7 vertebral bodies. There are some left paramedian osteophyte formation which extends into the left neural foramen at this level. It is associated with encroachment of left-sided exiting nerve roots and encroachment of the left hemicord.At C7-T1 there is no significant compromise to the spinal canal . There is encroachment of the right-sided exiting nerve roots within the neural foramen at this level due to disc material.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 height. The conus medullaris on sagittal imaging is grossly intact.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is mild ligamentum flavum hypertrophy at this level.At L4-5 there is a diffuse disc bulge associated with loss of disc space height and disc desiccation as well as some endplate osteophytes. There is ligamentum flavum hypertrophy at this level. There is effacement of the CSF surrounding the nerve roots at this level and effacement of the fat at the lateral recess bilaterally at this level. Overall there is moderate spinal stenosis at this level. There is narrowing of the neural foramina at this level which is slightly worse on the right versus the left side. There is some mild to moderate encroachment of the exiting nerve roots within the neural foramen at this level. There are some Schmorl's nodes at this level.At L3-4 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with some Schmorl's nodes. There is mild anterior subluxation of L3 on L4. There is bilateral facet hypertrophy at this level and ligamentum flavum hypertrophy. There is effacement of spinal fluid surrounding the nerve roots at this level. Overall there is moderate spinal stenosis at this level. There is encroachment of the exiting nerve roots within the neural foramina at this level as a result of disc material and facet hypertrophy. There are some endplate reactive changes present at this level especially on the right side where there is T2 STIR signal hyperintensity adjacent to the disc spacesAt L2-3 there is no significant compromise to spinal canal or neural foramina. There is a Schmorl's node present at this level.At L1-2 there is no significant compromise to spinal canal or neural foramina.In general, the right kidney appears smaller than the left kidney.
1.There are multilevel degenerative changes present in the cervical spine with severe spinal stenosis at C4-5 and moderate to severe spinal stenosis at C5-6 as well as encroachment of the left hemicord. There is encroachment of exiting nerve roots bilaterally at C4-5 and C5-6 and on the left side at C6-7. Endplate reactive changes appear to be more in the subacute phase at C5-62.There are degenerative changes present in the lumbar spine worse at L3-4 and L4-5. There is moderate spinal stenosis at each of these levels as well as a mild degree of anterior subluxation of L3 and L4. There is also encroachment of the exiting nerve roots bilaterally at L3-4 and to a lesser degree at L4-5. Endplate reactive changes appear to be more in the subacute phase at L3-4 eccentric towards the right.3.The right kidney appears to be smaller than the left kidney.