66 years Female (DOB:4/9/1949)Reason: r/o cervical spondylosis, ro/ cord impingement History: neck pain, brisk reflexes, lower extremity sensory symptomsPROVIDER/ATTENDING NAME: HELENE G. RUBEIZ HELENE G. RUBEIZ Cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology. There is mild reversal of normal cervical curvature. There is multilevel disc desiccation present.At C2-3 there is no significant compromise to the spinal canal or neural foramina.At C3-4 there is no significant compromise to the spinal canal. There is mild loss of disc space height, disc desiccation and a disc bulge at this level associated with bilateral uncovertebral osteophytes and narrowing of the neural foramina bilaterally.At C4-5 there is no significant compromise to the spinal canal. There is a loss of disc space height, disc desiccation and disc bulge at this level associated bilateral uncovertebral osteophytes and encroachment of the exiting nerve roots within the neural foramina bilaterally.At C5-6 there is no significant compromise to the spinal canal. There is a loss of disc space height, disc desiccation and disc bulge at this level associated bilateral uncovertebral osteophytes and encroachment of the exiting nerve roots within the neural foramina bilaterally but worse on the right side when compared to the left.At C6-7 there is no significant compromise to the spinal canal or neural foramina. There is a mild disc bulge present this levelAt 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 height. The conus medullaris on sagittal imaging is grossly intact. The patient is status post intraspinous fixation at L4-5. There is mild anterior subluxation of L4 and L5.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is loss of disc space height, disc desiccation and a diffuse disc bulge at this level associated with chronic endplate reactive changes and some mild narrowing of the spinal canal. There is mild facet and ligamentum flavum hypertrophy at this level.At L4-5 there is mild anterior subluxation of L4 on L5 associated with loss of disc space height, disc desiccation and diffuse disc bulge as well as bilateral facet hypertrophy. There is crowding of the nerve roots within the thecal sac at this level and overall a moderate degree of spinal stenosis. The exiting nerve roots within the neural foramina are surrounded by fat at this level. The spinal stenosis is regressed compared to the 10/2/2012 exam.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is disc desiccation and mild bilateral facet and ligamentum flavum hypertrophy at this level.At L2-3 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with mild facet and ligamentum flavum hypertrophy. There is partial effacement of the spinal fluid surrounding the cauda equina at this level. Overall there is a moderate degree of spinal stenosis at this level. This has progressed since the prior exam of 10/2/2012.At L1-2 there is no significant compromise to spinal canal or neural foramina.There are Schmorl's nodes present at T12-L1. There is a vertebral body hemangioma present at T12 and another one at T11
1.The patient is status post intraspinous posterior fusion at L4-5 since the prior exam. There is spinal stenosis at L4-5 has regressed compared to the prior exam but is still present.2.Moderate spinal stenosis due to degenerative changes at L2-3 has developed since the prior exam from 2012.3.Degenerative changes are present in the cervical spine mainly resulting in encroachment of exiting nerve roots within the neural foramina at C3-4, C4-5 and C5-6.