45 years Female (DOB:8/7/1971)Reason: lumbar arthritis History: low back pain with radiculopathyPROVIDER/ATTENDING NAME: DALIA H ELMOFTY DALIA H ELMOFTY 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 some hypertrophy of the posterior longitudinal ligament present.At C2-3 there is no significant compromise to the spinal canal or neural foramina. There is some hypertrophy of the posterior longitudinal ligament present.At C3-4 there is no significant compromise to the spinal canal or neural foramina. There is some hypertrophy of the posterior longitudinal ligament present associated with an impression on the ventral aspect of the thecal sac..At C4-5 there is no significant compromise to the spinal canal or neural foramina. There is a central disc extrusion present at this level with a disc material extending behind the C4 vertebral body. There is effacement of spinal fluid ventral and posterior the spinal cord at this level associated with some deformity of the spinal cord and overall a moderate degree of spinal stenosis. Compared to the exam of 8/10/2013 there may be some mild progressionAt C5-6 there is no significant compromise to the spinal canal or neural foramina. There is a left paramedian disc protrusion present at this level.At C6-7 there is no significant compromise to the spinal canal or neural foramina. There is a minor 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.Cerebellar tonsils are low lying.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 . There is redemonstration of facet hypertrophy at this level bilaterally but worse on the left versus the right side associated with mild encroachment of left-sided exiting nerve roots within the neural foramen. There is some disc desiccation at this level.At L4-5 there is a diffuse disc bulge present associated with bilateral facet and ligamentum flavum hypertrophy. There is effacement of the fat at the lateral recess bilaterally at this level as well as crowding of nerve roots. Overall this has progressed since the prior exam. There is moderate spinal stenosis present at this level. Although the neural foraminal are narrowed, within the right neural foramen the exiting nerve roots are surrounded by fat. Within the left neural foramen there is mild encroachment of left-sided exiting nerve roots.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is a mild disc bulge present at this level as well as some ligamentum flavum hypertrophy. There is mild narrowing of the spinal canal this level.At L2-3 there is no significant compromise to spinal canal or neural foramina.At L1-2 there is no significant compromise to spinal canal or neural foramina.There are multiple ovarian cystic lesions present which are incompletely visualized on this exam. They were also present on the prior exam. It is inconclusive whether they are larger on the current versus the prior exam because cannot entirely included on this exam.
1.There are degenerative changes present in the lower lumbar spine. There is a moderate degree of spinal stenosis present at L4-5 and some mild encroachment of the left-sided exiting nerve roots at L4-5 and L5-S1 within the neural foramen. This has mildly progressed compared to the prior exam.2.There are degenerative changes present in the cervical spine worse at C4-5 where there is a disc extrusion resulting in moderate spinal stenosis. This appears to be only slightly worse on the current versus the prior exam3.There are multiple ovarian cystic lesions present. They are incompletely evaluated on this exam.