56 years Female (DOB:5/30/1960)Reason: eval cervical stenosis for worsening/changes History: c/o Right upper extremity radicular painDiagnosis: Other intervertebral disc degeneration, lumbosacral region. Spondylosis without myelopathy or radiculopathy, cervical regionClinical question: hx Left lumbar lami. Eval for changes, worsening stenosisPROVIDER/ATTENDING NAME: EDWIN RAMOS EDWIN RAMOS The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology. No abnormal mass lesions are identified in the cervical spine. The patient status post anterior fusion from C3 through C7.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 or neural foramina. There are endplate and uncovertebral osteophytes present this level associated with loss of disc space height and a disc bulge. There is some narrowing of the neural foramina which is worse on the right side. There is some mild encroachment of the right-sided exiting nerve roots within the neural foramen. Findings are unchanged when compared to the prior exam.At C4-5 there is no significant compromise to the spinal canal or neural foramina.At C5-6 there is no significant compromise to the spinal canal or neural foramina.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.The vertebral artery flow voids appear to be intact.Incidental note is made of a 12 mm cystic lesion in the right thyroid lobe when compared to prior exams it does not appear to have changed significantly.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. Patient appears to be status post lower lumbar spine surgery at L4-5 level.At L5-S1 there is loss of disc space height this desiccation and endplate reactive changes. The endplate reactive changes are bright on T1. There is an associated disc bulge at this level and there is associated effacement of the fat at the left lateral recess with encroachment of the nerve roots at the left lateral recess. There are some mild encroachment of the left-sided exiting nerve roots within the neural foramen due to endplate osteophytes and disc material. When compared to the prior exam of 10/19/2015 there is not appear to be a significant change.At L4-5 since the prior exam the patient is undergone surgery with a left-sided laminotomy. There is a loss of disc space height this desiccation and diffuse disc bulge at this level associated with some mild encroachment of the right-sided exiting nerve roots within the neural foramen is not changed significantly since prior exam. There are some mild effacement of the fat at the left lateral recess at this level.. There is a right far lateral disc protrusion at this level.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is a disc bulge present at this level. There is some mild loss of disc space height and disc desiccation at this level.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is a disc bulge present this level associated with some mild loss of disc space height and disc desiccation at this level.At L1-2 there is no significant compromise to spinal canal or neural foramina.
1.There are degenerative changes present in the lumbar spine and status post recent lumbar spine surgery at L4-5..2.There is mild to moderate encroachment of the nerve roots at the left lateral recess as well as within the left neural foramen at L5-S1 due to degenerative changes which are stable since the prior exam.3.There is mild encroachment of the right-sided exiting nerve roots at L4-5 related to a right far lateral disc protrusion. This appears to be stable compared to the prior exam.4.There is mild encroachment of the nerve roots at the left lateral recess at L4-5 is bulge.5.There are mild degenerative changes present in the cervical spine without significant compromise to spinal canal or neural foramina. This findings are stable compared to the prior exam. The patient status post anterior fusion at C4-C7. There is only mild encroachment of exiting nerve roots on the right side at C3-46.There is a 12 mm cystic lesion in the right thyroid lobe which has been present on prior exams and does not appear to have changed significantly