49-year-old male with a 30 year history of IV heroin abuse here with severe low back pain. Tender to palpation along L4-L5 with mild weakness in left leg. Evaluate for cord compression; suspect epidural abscess. Multilevel mild degenerative changes in the cervical and lumbar spine without high-grade spinal canal stenosis. The vertebral bodies are appropriate in the overall alignment and height. The spinal cord has normal signal characteristics and overall morphology. There is no compromise of the spinal cord. At L5-S1 there is a disc bulge and disc desiccation present.There are degenerative changes present in the cervical spine with the right-sided uncovertebral osteophytes and disc material at C5-6 and C6-7 and some encroachment of the right-sided exiting nerve roots at C6-7.
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 cord compression is identified. There are some degenerative changes present in the lower cervical spine and lower lumbar spine with suggestion of encroachment of right-sided exiting nerve roots at C6-7.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.