Neck pain, left hand numbness and tingling. History of cervical and lumbar fusion, status post MVA x2. Cervical: Craniovertebral junction demonstrates moderate degenerative changes but is otherwise within normal limits. The cervical vertebral bodies are appropriate in height. There are changes related to previous posterior decompression and fusion from C3 through C6 (laminectomy, dual posterior rods and lateral mass screws that are bilateral C3, C5 and C6 and only on the left at C4). There is solid osseous fusion anteriorly and posteriorly. There is mild cervical kyphosis with apex at the C4-C5 level. Alignment is otherwise maintained. Bone marrow signal is benign.No abnormal cord signal. There is effacement of the dorsal thecal sac at the C2-C3 level with mild impression on the dorsal cord. There is also mild spinal canal stenosis at the C7-T1 level related to disc bulge. Spinal canal is well decompressed from C3 to C6. There is loss of disc height at the C6-C7 and C7-T1 levels. Individual levels as below:C2-3: Minimal narrowing of the spinal canal. No significant neural foraminal stenosis.C3-4: No significant compromise to the spinal canal. Mild left worse than right neural foraminal stenosis. C4-5: No significant compromise to the spinal canal. There is mild to moderate right and mild left neural foraminal narrowing.C5-6: No significant compromise to the spinal canal or left neural foramina. Mild right neural foraminal narrowing.C6-7: Uncovertebral hypertrophy with mild to moderate right and minimal left neural foraminal narrowing. No significant spinal canal stenosis.C7-T1: There is disc bulge, uncovertebral hypertrophy, and bilateral facet arthropathy which result in mild to moderate bilateral neural foraminal stenosis, right worse in left. There is mild mild spinal canal stenosis.The vertebral artery flow voids appear to be intact. Paraspinous soft tissue structures appear within normal limits.Lumbar: Five lumbar type vertebral bodies are presumed to be present. Vertebral body heights are within normal limits. There is mild loss of normal lumbar lordosis. There is minimal anterolisthesis of L3 on L4 and L4-L5 with evidence of prior interbody fusion at these levels. Posterior fusion hardware is also seen at L4-L5 with bilateral paraspinous rods and pedicle screws. Bone marrow signal is benign.Multilevel degenerative changes are seen, as described below:L1-L2: No significant disc disease. No spinal canal or neural foraminal stenosis.L2-L3: There is loss of disc space with disc bulge, with arthropathy, ligamentum flavum thickening resulting in mild to moderate spinal canal stenosis. There is minimal bilateral neural foraminal narrowing.L3-L4: Anterior fusion. Minimal spinal canal narrowing related to facet arthropathy and ligamentum flavum thickening above the level of the laminectomy. No significant neural foraminal stenosis.L4-L5: Anterior and posterior fusion. Spinal canal is surgically decompressed. Susceptibility artifact limits evaluation; within this limitation, mild right worse in left neural foraminal stenosis is suspected, but no high-grade neural foraminal stenosis is evident.L5-S1: Left-sided facet arthropathy with mild left neural foraminal stenosis. No significant right neural narrowing. No significant spinal canal stenosis.Bilateral renal cysts.
1. Postsurgical changes of prior laminectomy and C3 to C6 fusion with solid osseous fusion anteriorly and posteriorly. There are degenerative changes at the C7-T1 level with mild spinal canal stenosis and mild to moderate neural foraminal stenosis at this level. Otherwise no high-grade spinal canal or neural foraminal stenosis is seen in the cervical spine.2. Postsurgical changes of interbody fusion at L3-L4 and L4-L5 as well as posterior decompression and fusion at L4-5. Degenerative changes are seen including mild spinal canal stenosis at the L2-L3 level. There is also mild bilateral L2-L3 and mild left L5-S1 neural foraminal stenosis. No high-grade spinal canal or neural foraminal stenosis in the lumbar spine.