Spine damage

1. Multilevel spondylosis with mild effacement of thecal sac at C6-7, lateral recess narrowing at C5-6 and foraminal encroachment at C3-4 as described.

2. The cervical cord appears unremarkable.

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Radiologist/Resident/RPA/USP: Mohammad Asad, M.D

I have personally reviewed the images, finalized the report and E-signed: Mohammad Asad, M.D at 7/17/2023 7:39 AM

WORKSTATION: DSV10

MDOC:

ORDER DATE: 7/16/2023 10:35 AM PROCEDURE: MRI CERVICAL SPINE WO CONTRAST REASON FOR EXAM: Other Comments; ADDITIONAL HISTORY: Patient states skydiving injury 1/2022 entire left side was paralyzed, lt sided weakness, trouble walking, bilateral leg weakness. No Ca hx. – MRI CERVICAL SPINE Technique: T1, fat saturation T2 and gradient-echo sagittal. Gradient-echo and 3D gradient-echo axial. Comparison: No previous relevant studies available for correlation. FINDINGS: There is no evidence of acute osseous fracture. Vertebral body height and alignment are preserved. There is no evidence of bone marrow replacement process. The intervertebral discs are not significantly narrowed. There is mild C5-6 and moderate C6-7 anterior spurring noted. C2-3: No disc herniation, central canal stenosis or significant neural foraminal encroachment is seen. C3-4: Uncovertebral spurring and facet arthropathy is causing moderate to severe right foraminal encroachment without significant central canal stenosis. C4-5: No disc herniation, central canal stenosis or nerve root impingement is seen. C5-6: Tiny osteophyte disc complex is seen causing mild-to-moderate left and mild right lateral recess narrowing. C6-7: Central disc protrusion/herniation is seen causing mild effacement thecal sac without significant central canal stenosis. C7-T1: No disc herniation, central canal stenosis or nerve root impingement is seen. There is no focal signal abnormality within the cervical spinal cord.

Redemonstration of syrinx seen at the level of T10 measuring 2 x 0.6 cm without significant change.

Spinal fusion changes are seen at T10-T12 with bipedicle screws at T10 and T12.

Moderate chronic compression fracture T11.

Mild chronic compression of superior endplate of T6 along with small Schmorl’s node.

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Radiologist/Resident/RPA/USP: Waseem Ullah, M.D. I have personally reviewed the images, finalized the report and E-signed: Waseem Ullah, M.D. at 7/18/2023 8:18 AM

WORKSTATION: DSV10

MDOC:

ORDER DATE: 7/17/2023 8:29 PM PROCEDURE: MRI THORACIC SPINE WO CONTRAST REASON FOR EXAM: Syringomyelia or syringobulbia; ADDITIONAL HISTORY: Table formatting from the original note was not included.; Left leg weakness ; Ongoing left-sided weakness most notable in the left lower extremity ; Traumatic brain injury with loss of consciousness, sequela Secondary to sky diving incident. Previous MRI.; Table formatting from the original note was not included.; Left leg weakness, Ongoing left-sided weakness most notable in the left lower extre – MRI THORACIC SPINE Technique: T1 and T2-weighted images were obtained in axial and sagittal planes. Comparison: 7/9/2022 FINDINGS: There is redemonstration of syrinx seen at the level of T10 measuring 2 x 0.6 cm without significant change. Spinal fusion changes are seen at T10-T12 with bipedicle screws at T10 and T12. Moderate chronic compression fracture T11. Mild chronic compression of superior endplate of T6 along with small Schmorl’s node. The rest of the vertebral bodies are maintained in height and signal throughout. There is decrease in height and signal of intervertebral discs throughout. There is no disc herniation or central canal stenosis. The foramina are patent.

1. Resistive vertebra at lumbosacral junction with partially lumbarized S1.

2. Large left central inferiorly extruded disc herniation resulting in mild central canal and severe left lateral recess stenosis and impingement of left S1 nerve root.

The findings are progressed since prior examination. Recommend neurosurgical evaluation.

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Radiologist/Resident/RPA/USP: Waseem Ullah, M.D. I have personally reviewed the images, finalized the report and E-signed: Waseem Ullah, M.D. at 7/18/2023 7:54 AM

WORKSTATION: DSV10

MDOC:

ORDER DATE: 7/17/2023 8:29 PM PROCEDURE: MRI LUMBAR SPINE WO CONTRAST REASON FOR EXAM: Other Comments; Left leg weakness ADDITIONAL HISTORY: Table formatting from the original note was not included.; Left leg weakness, Ongoing left-sided weakness most notable in the left lower extremity ; Traumatic brain injury with loss of consciousness, sequela Secondary to sky diving incident. Previous MRI. – MRI LUMBAR SPINE Technique: T1and T2 weighted images were obtained in axial and sagittal planes. Comparison: MRI 7/9/2022 FINDINGS: The conus medullaris ends at L1/2 and is normal. There is transitional vertebra at lumbosacral junction with the partially lumbarized S1. Fusion changes at seen at S1/2 resulting in susceptibility artifact at that level. Likely hemangioma L4. There is decrease in height and signal of intervertebral discs at L4/5 and L5/S1. T12/L1 through L3/4 levels show no disc herniation or central canal stenosis. The foramina are patent. L4/5 level shows mild diffuse disc bulge extending to bilateral foramina. Mild bilateral facet disease and infolding of ligamentum flavum. The central canal and bilateral lateral recess are patent. Mild bilateral foraminal stenosis. L5/S1 level shows large left central inferiorly extruded disc herniation resulting in mild central canal and severe left lateral recess stenosis and impingement of left S1 nerve root. The findings have significantly worsened than prior examination. Moderate bilateral facet disease. Mild right lateral recess stenosis. Moderate left and mild right foraminal stenosis. S1/2 evaluation is limited due to susceptibility artifact. There is mild disc bulge extending to bilateral foramina. The central canal is patent. Mild bilateral foraminal stenosis.