65 years Male (DOB:7/27/1950)Reason: eval for disc herniation History: c/o neck pain and left arm painPROVIDER/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. No abnormal enhancing lesions are identified in the cervical spine. There is multilevel disc desiccation present.At C2-3 there is no significant compromise to the spinal canal or neural foramina. There are some uncovertebral osteophytes present this level with some mild narrowing of the left neural foramen.At C3-4 there is no significant compromise to the spinal canal . There is a disc bulge present this level. There are uncovertebral osteophytes present at this level associated with encroachment of exiting nerve roots bilaterally.At C4-5 there is no significant compromise to the spinal canal. There is a disc bulge present this level. There are uncovertebral osteophytes present at this level associated with encroachment of exiting nerve roots bilaterally. There is left-sided facet hypertrophy present at this level contributing to further narrowing of the left neural foramen.At C5-6 there is no significant compromise to the spinal canal . There is a disc bulge present this level. There are uncovertebral osteophytes present at this level associated with encroachment of exiting nerve roots bilaterally.At C6-7 there is no significant compromise to the spinal canal or neural foramina. There is mild disc bulge present at this level.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.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 alignment and 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 loss of disc space height, disc desiccation and diffuse disc bulge at this level associated with mild facet hypertrophy. There is narrowing of the neural foramina at this level with mild encroachment of the exiting nerve roots within the neural foramina.At L4-5 there is no significant compromise to spinal canal or neural foramina. There is loss of disc space height, disc desiccation and diffuse disc bulge associated with mild ligamentum flavum hypertrophy. There are some effacement of the fat at the lateral recess bilaterally at this level. There is narrowing of the neural foramina bilaterally. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is loss of disc space height, disc desiccation and diffuse disc bulge at this level associated with mild ligamentum flavum hypertrophy. The fat at the lateral recess is not effaced bilaterally. There is a left far lateral disc protrusion at this level.At L2-3 the patient is status post left hemilaminectomy. There is diffuse disc bulge present at this level. There is thickening of the posterior ligamentous tissues at this level with narrowing of the thecal sac and partial effacement of fluid surrounding the cauda equina. There are acute endplate reactive changes at this level. There is some fluid present along the posterior aspect of the epidural space especially in the right side.At L1-2 there is no significant compromise to spinal canal or neural foramina. There is disc desiccation and a disc bulge at this level.
1.There are multilevel degenerative changes present in the cervical spine was sedated with some encroachment of exiting nerve roots bilaterally at C3-4, C4-5 and C5-6 but worse at C5-6 and on the left-sided C4-5.2.Findings are compatible with mild to moderate spinal stenosis at L2-3 where there is prior surgery. There is soft tissue thickening and fluid along the posterior aspect of the spinal canal at this level. This may be postoperative in nature. It is nonspecific and could potentially represent blood products or infection or soft tissue swelling and edema.3.There is mild to moderate encroachment of the nerve roots at the right lateral recess more than the left at L4-5 due to a disc bulge.