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efta-efta00317344DOJ Data Set 9OtherWeill Cornell Imaging at New York-Presbyterian
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DOJ Data Set 9
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efta-efta00317344
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Weill Cornell Imaging at New York-Presbyterian
1105 York Avenue - 3rd Floor
dew York, NY 10021
Fax:
www.WCINYP.com
STRYBING, KRISTIN M, NP
525 East 68th Street- Starr 651 Box 99
Starr 651 Box 99
New York NY 10065
Exam: MRASPCANAL - MRA SPINAL CANAL W+WO CONTRAST
Exam Date and Time: 01/30/2018 18:01
Patient Name: EPSTEIN. JEFFREY
Pt. Location:
05 York Ave
MRN:
Visit Number:
Date of Birth:
Sex:
Request MD: STRYBING, KRISTIN M, NP
Accession: 6959326
EXAM:
MRA SPINAL CANAL W+W0 CONTRAST
CLINICAL HISTORY:
64 year old male with focus on the lower thoracic and entire lumbar
spine. Make sure he brings his imaging in to archive so we can
compare. Dorsalgia, unspecified
TECHNIQUE:
The lower cervical, thoracic, and lumbar spine was imaged with
sagittal T2, axial T2, coronal T2, 3D volume T2, gadolinium-enhanced
1st pass MRA. Delayed phase images of the MRA examination were also
performed. The MRA volume includes from the S2 level through mid T7.
Contrast: 8 cc Gadavist
COMPARISON:
No prior studies available for comparison at this time
FINDINGS:
The alignment of the spine is within normal limits. There is trace
anterolisthesis L4 on L5. The intervertebral disks are notable for
multilevel disc degenerative change with multilevel loss of thoracic
and lumbar intervertebral disc space height. There are multiple
Schmorl's nodes and mild endplate irregularity of the small ventral
and dorsal osteophytes.. The spinal cord is normal in appearance.
No abnormal cord signal intensity. No cord expansion or volume loss.
No evidence of syrinx. The MRA examination demonstrates normal
appearance of the thumb thoracic intercostal and lumbar arteries.
The aorta is normal in appearance. The proximal iliacs are likewise
normal. There is no evidence of abnormal intraspinal vascularity.
No enlarged arterial structures are prominent venous structures.
The appearance of the vertebral bodies is within normal limits. Mild
heterogeneous marrow signal intensity is evident. No evidence of
acute fracture. The prevertebral and posterior paraspinous soft
tissues demonstrate no significant abnormality.
There are disc bulges at T3-4, T4-5, T5-6, T6-7, T7-8, and T8-9
levels. There is no significant central canal stenosis at these
EFTA00317344
Weill Cornell Imaging at New York-Presbyterian
1305 York Avenue - 3rd Floor
New York, NY 10021
Fael
www.WCINYP.com
STRYBING, KRISTIN M, NP
525 East 68th Street- Starr 651 Box 99
Starr 651 Box 99
New York NY 10065
levels however.
Patient Name: EPSTEIN. JEFFREY
Pt. Location:
WGC- 1305 York Ave
MRN:
Visit Number:
Date of Birth:
Sex:
In the lumbar spine there is mild developmental canal stenosis with
short pedicles. There is acquired lumbar degenerative disease with a
diffuse disc bulge and facet degenerative change at the L2-3 and L3-4
levels. There is mild to moderate central canal stenosis at both of
these levels. There is a broad dorsal disc protrusion with marked
bilateral facet degenerative change at L4-5 resulting in severe
central canal stenosis and moderate to severe bilateral foraminal
stenosis. There is moderate bilateral facet degenerative change,
right greater than left at the L5-S1 level. No significant central
canal or foraminal stenosis however.
IMPRESSION:
No evidence of intraspinal arteriovenous malformation.
Mild multilevel thoracic degenerative change. Marked lumbar
degenerative disease with severe central canal stenosis at L4-5.
End of diagnostic report for accession: 6959326
Prepared by:
Study interpreted and report aooroved by. Phillips, C.Douglas. MD
01/31/20188:51 AM EST
EFTA00317345
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