Previous fusion with neck pain. Low back pain, previous L2-L5 laminectomies. CERVICAL SPINE: There is mild anterolisthesis of C7 on T1 of 3 mm. There is anterior spinal fusion at C6-C7 with intervertebral disc spacer and wide decompressive laminectomies at C3-C7. There are endplate degenerative changes at C4-C5 with severe loss of disc space. There is mild loss of disc height at C3-C4, moderate loss of disc height at C5-C6 and severe loss of disc height at C7-T1. There is mild multilevel facet arthropathy. The vertebral body heights are preserved. The spinal cord displays normal signal and morphology. The vertebral bone marrow signal is unremarkable. The paravertebral soft tissues are unremarkable. There is a 10 mm nodule in the left thyroid lobe.C2-C3: Small disc osteophyte complex. No significant spinal canal or foraminal stenosis.C3-C4: Status post laminectomy. Disc osteophyte complex with large left paracentral osteophyte, contributing to mild flattening of the left ventral cord. No significant foraminal stenosis.C4-C5: Status post laminectomy. Disc osteophyte complex with left uncinate spur, contributing to mild left foraminal stenosis. No significant right foraminal stenosis.C5-C6: Status post laminectomy. Small disc osteophyte complex. No significant foraminal stenosis.C6-C7: Status post laminectomy. Disc osteophyte complex with large central bridging osteophyte, contributing to mild left foraminal stenosis and mild flattening of the ventral cord. C7-T1: Status post laminectomy. Small disc osteophyte complex. No significant foraminal stenosis.LUMBAR SPINE: For the purposes of numbering, there are 5 lumbar type vertebral bodies. The vertebral column alignment is within normal limits. The vertebral body heights are preserved. There is mild to moderate multilevel loss of disc height and disc desiccation. The vertebral bone marrow signal is unremarkable. The distal spinal cord and conus are within normal limits with the conus terminating at the L1 level. There is posterior soft tissue edema at the L3-L5 levels. There is a 39 mm left renal cyst.T12-L1: Small central disc protrusion. No significant spinal canal or foraminal stenosis.L1-L2: No significant disc bulge, spinal canal or foraminal stenosis.L2-L3: There is central and paracentral disk extrusion with mild inferior migration of approximately 10 mm and bilateral facet degeneration, contributing to mild spinal canal stenosis and mild bilateral foraminal stenosis. L3-L4: Status post laminectomy. Disc bulge with and bilateral facet degeneration, contributing to mild spinal canal narrowing in the transverse dimension and mild to moderate bilateral foraminal stenosis. L4-L5: Status post laminectomy. Disc bulge with and bilateral facet degeneration, contributing to mild to moderate bilateral foraminal stenosis. L5-S1: Disc bulge with and bilateral facet degeneration, contributing to moderate right and mild left foraminal stenosis.
1. Status post anterior spinal fusion with decompressive laminectomies from C3 to C7. 2. Degenerative changes of the cervical spine with large posterior bridging osteophytes at C3-C4 and C6-C7. There is mild impression on the ventral cord at the left C3-4 and bilateral C6-C7 levels. No high-grade spinal canal stenosis. Foraminal narrowing as detailed above.3. Post-operative changes of the lumbar spine without residual high-grade spinal canal stenosis. There is expected enhancement involving the paraspinous and dorsal epidural soft tissues.4. Degenerative changes of the lumbar spine including disc extrusion at L2-L3, contributing to mild spinal canal stenosis and mild bilateral foraminal stenosis. Additional levels as above.5. 10 mm nodule in the left thyroid lobe, which may be further evaluated with ultrasound as clinically warranted.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.