84 years Male (DOB:8/23/1931)Reason: worsening pain, h/o stenosis History: painPROVIDER/ATTENDING NAME: STACIE KAYE LEVINE STACIE KAYE LEVINE Cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology.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 small uncovertebral osteophytes at this levelAt C4-5 there is loss of disc space height, disc desiccation and a diffuse disc bulge associated with ligamentum flavum hypertrophy and bilateral uncovertebral osteophyte formation. The osteophyte formation is worse on the left compared to the right side. It is encroachment of left-sided exiting nerve roots. There is partial effacement of spinal fluid ventral and posterior the spinal cord at this level. The spinal cord is not flattened. Overall compared the prior exam there is greater narrowing of the spinal canal at this level and greater encroachment of the exiting nerve roots in the left side.At C5-6 there is no significant compromise to the spinal canal. There is disc desiccation, uncovertebral osteophyte formation and a disc bulge at this level which is similar to the prior exam. There is narrowing of the neural foramina at this level with encroachment of left-sided exiting nerve roots which has not significantly progressed relative to the prior exam.At C6-7 there is no significant compromise to the spinal canal. There is disc desiccation and a disc bulge at this level associated with endplate and uncovertebral osteophytes and narrowing of the neural foramina bilaterally. These findings were also present on the prior exam. There is a hypointense lesion on all pulse sequences located along the posterior inferior aspect of the 6 vertebral body which was not readily depicted on the prior exam. It measures approximately 6 mm.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.MRI thoracic spine:The thoracic vertebral bodies are appropriate in the overall alignment and height. The thoracic spinal cord has normal signal characteristics and overall morphology. There is no compromise of thoracic spinal canal or exiting nerve roots. There is multilevel loss of disc space height present associated with disc desiccation and minor disc bulges.There are small pleural effusions present.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.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 as well as facet hypertrophy. There are some mild encroachment of the nerve roots of the right lateral recess at this level as a result of combination of disc bulge and facet hypertrophy.At L4-5 there is no significant compromise to spinal canal or neural foramina. There is loss of disc space height, disc desiccation and facet hypertrophy at this level associated with mild anterior subluxation of L4 on L5. The patient appears to be status post right hemilaminectomy at.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is some disc desiccation and a minor 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.There is a large left-sided cystic lesion along the left kidney at this level which is not entirely included on this exam. It measures 64 x 51 mm coronal dimensions on the scout images.
1.There are multilevel degenerative changes present in the cervical spine which have mildly progressed compared to the 2012 exam. There is a mild to moderate degree of spinal stenosis present at C4-5 and encroachment of left-sided exiting nerve roots at C4-5 and C5-6 and bilateral exiting nerve roots at C6-7.2.There is a new lesion present within the C6 vertebral body which was not present on prior exams. I suspect this is degenerative in nature. A CT of the cervical spine with help further assess this.3.There are degenerative changes present in the lumbar spine with some mild encroachment of the nerve roots at the right lateral recess at L5-S1 and some minor subluxation at L4-5.4.There is some mild degenerative changes present in the thoracic spine without significant compromise spinal canal or neural foramina.5.There are very small pleural effusions present.6.There is a cystic lesion in the left kidney measuring just over 6 cm in diameter. It is not completely included on this exam.7.Status post lumbar spine surgery.