68 years Male (DOB:2/14/1948)Reason: assess for structural abnormalities History: upper extremity weakness, poor grip strengthPROVIDER/ATTENDING NAME: DAVID M LIEBOVITZ DAVID M LIEBOVITZ Cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology. Patchy foci of signal hyperintensity within the spinal cord at the C3-4 and C6-7 levels predominantly involving the cord more centrally. This is partly obscured by patient motion. There is mild reversal of the normal cervical curvature.At C2-3 there is no significant compromise to the spinal canal or neural foramina. There is right-sided facet hypertrophy of moderate degree at this levelAt C3-4 there is no significant compromise to the spinal canal. There are endplate uncovertebral osteophytes present at this level which are worse on the left versus the right side. There is some ossification of the posterior longitudinal ligament at this level as well there is encroachment of left-sided exiting nerve root effacement of spinal fluid ventral but not posterior to the spinal cord at this level. Overall there is mild spinal stenosis at this level.At C4-5 there is no significant compromise to the spinal canal. There are uncovertebral osteophytes present bilaterally at this level associated with encroachment of left-sided exiting nerve rootsAt C5-6 there is no significant compromise to the spinal canal. There are endplate and uncovertebral osteophytes present this level with narrowing and mild encroachment of left-sided exiting nerve roots.At C6-7 there is no significant compromise to the spinal canal. There are endplate and uncovertebral osteophytes present this level with narrowing and mild encroachment of left-sided exiting nerve roots. Overall there is mild spinal stenosis 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.The cervical spine exam is degraded by patient motion.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.At L4-5 there is no significant compromise to spinal canal or neural foramina. There is disc desiccation and a disc bulge present at this level associated with ligamentum flavum hypertrophy. There is a effacement of spinal fluid surrounding the nerve roots within the thecal sac at this level. There is effacement of the fat at the lateral recess bilaterally at this level. Overall there is moderate spinal stenosis at this level.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is a disc bulge at 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.
1.There are multilevel degenerative changes present in the cervical spine with encroachment of left-sided exiting nerve roots at C3-4 and C4-5 and to a lesser degree at C5-6. There is mild spinal stenosis present at C3-4 and C6-7.2.There is some cord signal abnormalities suspected (the exam is degraded by patient motion) at the C34 and C6-7 levels which probably represents some degree of myelomalacia possibly representing spondylitic myelopathy. It is nonspecific. Please correlate with patient's clinical symptoms. Please note the cervical spine exam is degraded by patient motion which will obscure evaluation of more subtle abnormalities.3.There is moderate spinal stenosis present at C4-5 as a result of degenerative changes.