62 years Male (DOB:12/29/1953)Reason: hx cervical stenosis. Eval for abnormality. History: Left arm pain/ hx ulnar nerve decomp. Claw handPROVIDER/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. The patient status post anterior fusion at 3 C6-7 with anterior plate and screws.At C2-3 there is no significant compromise to the spinal canal or neural foramina. There is a broad-based central disc protrusion present this level which is unchanged compared to the prior examAt C3-4 there is redemonstration of a broad-based left lateral recess disc protrusion which encroaches on the left-sided exiting nerve roots within the neural foramen. There are some endplate and uncovertebral osteophytes at this level and There are some endplate reactive changes present which are bright on T2 STIR and dark on T1.At C4-5 there is loss of disc space height, disc desiccation and a disc bulge associated with endplate and uncovertebral osteophytes. There is partial effacement of spinal fluid ventral but not posterior the spinal cord at this level. There is narrowing of the neural foramina bilaterally with encroachment of the exiting nerve roots within the neural foramina bilaterally this was also present on the previous exam and has not changed substantially.At C5-6 there is some loss of disc space height, diffuse disc bulge and ligamentum flavum hypertrophy associated with some uncovertebral osteophytes bilaterally and encroachment of the exiting nerve roots within the neural foramina bilaterally due to disc material and uncovertebral osteophytes. These findings were also present on the previous exam and have not changed substantially. Overall there is a mild to moderate degree of spinal stenosis at this level which is also stable compared to the prior exam.At C6-7 there is no significant compromise to the spinal canal or neural foramina.At C7-T1 there is no significant compromise to the spinal canal or neural foramina. There is a small central disc protrusion present at this levelThe vertebral artery flow voids appear to be intact.There is a disc bulge at T2-T3 associated with neural foramen encroachment of exiting nerve roots. This remains stable compared to the previous exam.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 loss of disc space height, disc desiccation and diffuse disc bulge associated with the narrowing of the neural foramina more on the left than the right side. There is associated facet hypertrophy at this level. There are some encroachment of the left-sided exiting nerve roots within the neural foramen at this level. There are some endplate reactive changes at this level which are high signal on T1 and T2. There is a right lateral recess disc protrusion at this level which extrudes behind the adjacent S1 segment and encroaches on the nerve root at the right lateral recess.At L4-5 there is no significant compromise to spinal canal or neural foramina. There is some loss of disc space height and a disc bulge at this level associated with facet and ligamentum flavum hypertrophy.At L3-4 there is no significant compromise to spinal canal or neural foramina.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is a disc bulge present at this level and a right far lateral disc protrusion there is crowding of the nerve roots within the thecal sac at this level and overall a mild to moderate degree of spinal stenosis.At L1-2 there is no significant compromise to spinal canal or neural foramina.
1.There are multilevel degenerative changes present in the cervical spine with mild to moderate spinal stenosis at C5-6 and mild spinal stenosis at C3-4 which has not progressed significantly since the previous exam. Associated encroachment of exiting nerve roots at C3-4, C4-5 , C5-6 and T2-3 has also not progressed significantly compared to the prior exam.2.Since prior exam some endplate reactive changes at C3-4 have entered acute or subacute phase. This would suggest some active inflammation predominantly on the left side at this level.3.There is a right lateral recess disc extrusion at L5-S1 which encroaches on the nerve roots at the right lateral recess (probably right S1 nerve roots).4.There are degenerative changes present lumbar spine with associated mild-to-moderate spinal stenosis at L2-3 and encroachment of the left-sided exiting nerve roots at L5-S1 (probably left L5 nerve roots).