Neoplasm related pain (acute) (chronic) [G89.3], Reason for Study: ^Reason: metastatic prostate cancer with bone lesions History: metastatic prostate cancer with bone lesions 68 years Male (DOB:6/9/1948)Reason: metastatic prostate cancer with bone lesions History: metastatic prostate cancer with bone lesionsPROVIDER/ATTENDING NAME: MAGDALENA ANITESCU MAGDALENA ANITESCU For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. There are multifocal mixed lytic and sclerotic metastatic lesions involving thoracolumbar spine, sacrum as well as bilateral ilium.In particular, there is about 5% compression fracture of L3 vertebral body with the bone marrow edema.In addition, soft tissue extension through the anterior epidural space from T12 vertebral body is also seen which suggest possible tumor extension.The spine alignment is anatomic. The signal of the visualized cord is normal. The conus medullaris terminates at the T12.Degenerative changes are specified by the intervertebral level as follows: T12-L1: Complete replacement of normal fatty marrow of T12 vertebral body indicate metastatic lesion. Anterior epidural space extension of soft tissue lesion from the T12 vertebral body metastasis. The soft tissues about the thecal sac and extends through bilateral neural foramen results minimal to mild neural foraminal stenosis. L1-L2: There is a sclerotic metastatic lesion on the right anterior aspect of the L1 vertebral body, however, other portion of the vertebral bodies are osteophytic lesion. No neuroforaminal narrowing or spinal stenosis. L2-L3: Diffuse metastasis lesion involvement of L2 vertebral body. No neuroforaminal narrowing or spinal stenosis. L3-L4: There is relatively well circumscribed metastatic lesion on the left anterior aspect of L3 vertebral body with a sclerotic margin. Diffuse bulging of disc with bilateral ligamentum flavum thickening results minimal to mild spinal canal stenosis. L4-L5: May new sclerotic metastatic lesion on the left side of vertebral body of L4 with associated osteolytic lesion. Diffuse bulging of disc. No neuroforaminal narrowing or spinal stenosis. L5-S1: Several nodular osteolytic metastatic lesion involving L5 vertebral body as well as left posterior lamina. Diffuse bulging of disc. No neuroforaminal narrowing or spinal stenosis.
1. Multifocal vertebral body metastatic lesions including thoracic, lumbar and sacral vertebrae, as well as bilateral iliac bones.2. Epidural extension of metastatic lesion is seen at the level of T12 vertebral body.3. Minimal to mild spinal canal stenosis due to degenerative changes of lumbar spine.4. Spinal cord signal intensity is normal.