EFTA00622056.pdf

NOV-04-2015 11:56 71BERNARDAMLINSMD P.01 BERNARD A. RAWLINS, MD HOSPITAL FOR SPECIAL SURGERY ADULT AND PEDIATRIC SPINE SURGERY FACSIMILE. TRANSMITTAL SHEET TO: LESLEY CiROFF FROM: BR] ANNA COMPANY: DATE: NOVEMBER 5, 20/5 FAX NUMBER: TOTAL NO. OF PAGES INCLUDING COVER: 5 PHONE NUMBER: SINDF.R'S REFERENCE NUMBER: YOUR REFERENC:E NUMBER: URGENT X FOR REVIEW ❑PLEASE COMMENT ❑ PLEASE REPLY 0 PLEASE RECYCLE MYtt.S./CO2.O4ENTS: Requested MRI results for Mr. Epstein. Thank you, Rrianna 523 EAST 72" STREET (2" FLOOR) NEW YORK, NY 10021 EFTA00622056 NOV-04-2015 11:56 71BERNARDRAWLINSND FAld oim cwweennai and tor the sole use of the into eat% •/ HOSPITAL FOR Patient Name Location EPSTEIN,JEFFERY I" SPECIAL SURGERY Ordering Physician DIS RAWLINS,BERNARD A 535 East 70th Street Adm/Reg Physician New York, N.Y. 10021 DEPARTMENT Consulting Physician OF RAWLINs,BERNARD A Medical Record # Date of Birth Age RADIOLOGY 840411 01/20/53 62y AND IMAGING Check-in Date: 11/03/15 1514 Chk-in # Order Exam 4121712 0001 0533 MRI LUMBAR SPINE Ord Diag: M48.06 -SPINAL STENOSIS, LUMBAR Page :1 MRI lumbar spine: Spin-echo sagittal, axial and coronal sequences were obtained and a STIR sagittal sequence. Patient history: Leg weakness and numb sensation in the legs. The lower thoracic spinal cord and conus medullaris are normal. T12-L1: There is no stenosis. L1-2: Disc degeneration is identified. There is moderate right and mild left facet arthrosis and no stenosis. L2-3: Disc degeneration is present and a minimal retrolisthesis. There is mild/moderate right and mild left facet arthrosis along with mild thickening of the ligamenta flava. Mild/moderate central canal stenosis is identified and the stenosis is partially on a developmental basis. There is mild left and mild/moderate right neural foraminal stenosis. A small/moderate sized disc protrusion projects into and slightly lateral to the right neural foramen and causes minimal impingement of the right L2 nerve root immediately lateral to the neural foramen. L3-4: Disc degeneration is present. Moderate/severe right and left facet arthrosis is associated with thickening of the moderate ligamenta £lava. Moderate central canal stenosis is identified and the stenosis is partially on a development basis. There is mild/moderate left foraminal stenosis and a small/moderate sized disc protrusion neural projects into and slightly lateral to the neural foramen and causes mild Page :1 , Report Continued on Next Page RAWLINS BE NARD A FINAL FINAL -262;:262;0533:4121712-0533- EFTA00622057 N00-04-2015 11:56 „__ _. 71BERNARD LICN Sn RAWLINSMD F. k1.5 Ldh y9 privileged aim cnntlitentia l and tor the role urn of tha intended tern. Mic HOSPITAL FOR Patient Name Location EPSTEIN,JEFFERY Ma SPECIAL SURGERY Ordering Physician DIS RAWLINS,BERNARD A 535 East 70th Street Adm/Reg Physician New York, N.Y. 10021 DEPARTMENT Consulting Physician OF RAWLINB,SERNARD A Medical Record # Date of Birth RADIOLOGY 840411 01/20/53 Age 62Y AND a< IMAGING Check-in Date: 11/03/15 1514 Checkin-Exam Code Summary 4121712-0533 (Continued) Page 2 impingement of the left L3 nerve root at the exit zone and slightly lateral to the neural foramen. There is mild/moderate right neural foraminal stenosis and a small/moderate sized disc protrusion projects into and slightly lateral to the right neural foramen and causes minimal impingement of the right L3 nerve root at the exit zone of the neural foramen. L4-5: Disc degeneration is present and mild posterior bulge of the disc. There is a prominent fissure in the outer annulus adjacent to the left neural foramen. Severe facet arthrosis is associated with an approximate 2 mm anterolisthesis. There is thickening of the ligament a flava and severe stenosis of the central canal and the subarticular recesses. The stenosis is partially on a developmental basis. There is a small collection of fluid located subjacent to the left ligamentum flavum, medial to the left facet joint, and possibly a very small collection of fluid in the right ligamentum flavum. The L5 nerve roots exit the thecal sac approximately 7 mm caudad to the disc space. Severe left neural foraminal stenosis causes impingement of the left L4 nerve root. There is moderate right neural foraminal stenosis and a small/moderate sized disc protrusion projects into the neural foramen and impinges the right L4 nerve root. LS-S1: Disc degeneration is present. Severe right and mild left facet arthrosis is detected and mild/moderate central canal stenosis, that partially on a developmental basis. There is compression of the is S1 nerve roots, more prominent on the right, between the facets and the disc, depicted in axial images 13-14 in series 6. Mild left and moderate right neural foraminal stenosis is detected. Page :2 , Report Continued on Next Page RAWLINS BERNARD A FINAL FINAL -262;;262;0533;4121712-0533- EFTA00622058 NOV-04-2015 11:57 71BERNARDRAWL INSMD F.U4 Lu aim Lb Innislege° ano contado.ntia1 and fin the sole uncr of thP intondch1 rot: W HOSPITAL FOR SPECIAL SURGERY Patient Name EPSTEIN,JEFFERY Ordering Physician RAWLINS,BERNARD A Location DIS 535 East 70th Street Adm/Reg Physician New York, N.Y. 10021 DEPARTMENT Consulting Physician RAWLINS,BERNARD A OF Medical Record # Date of Birth RADIOLOGY 840411 01/20/53 Age 62Y AND • IMAGING Check-in Date: 11/03/15 1514 Checkin-Exam Code Summary 4121712-0533 (Continued) Page 3 There is partial ankylosis of the anterosuperior compartment of the SI joints. Impression: 1. L1-2: Disc degeneration. Facet arthrosis. 2. L2-3: Disc degeneration. Mild/moderate central canal stenosis. Small/moderate sized disc protrusion projects into and slightly lateral to the right neural foramen and causes minimal impingement of the right L2 nerve root immediately lateral to the neural foramen. 3. L3-4: Disc degeneration. Facet arthrosis. Moderate central canal stenosis. Small/moderate sized disc protrusion projects into and slightly lateral to the left neural foramen and causes mild impingement of the left L3 nerve root at the exit zone and slightly lateral to the neural foramen. Small/moderate sized disc protrusion projects into and slightly lateral to the right neural foramen and causes minimal impingement of the right L3 nerve root at the exit zone of the neural foramen. 4. L4-5: Disc degeneration. Grade 1 degenerative anterolisthesis. Severe stenosis of the central canal and the subarticular recesses. Severe left neural foraminal stenosis causes impingement of the left L4 nerve root. Moderate right neural foraminal stenosis and a small/moderate sized disc protrusion projects into the neural foramen and impinges the right L4 nerve root. 5. L5-91: Disc degeneration. Facet arthrosis, more prominent on the Page :3 , Report Continued on Next Page RAWLINS,BERNARD A FINAL FINAL -262;;262;0533;4121712-0533- EFTA00622059 NOV-04-2015 11:57 71BERWRDRAWL I NSMD P.05 I.SA • V. Ylleytm WA, wmaucnutll ana tor Lae Cole us• oi tar, intended rec. •/ HOSPITAL FOR Patient Name Location EPSTEIN,JEFFERY i• SPECIAL SURGERY Ordering Physician DIS RAWLINS,BERNARD A 535 East 70th Street Adm/Reg Physician New York, N.V. 10021 DEPARTMENT Consulting Physician RAWLINS,BERNARD A OF Medical Record # Date of Birth Age RADIOLOGY 840411 01/20/53 62Y AND IMAGING Check-in Date: 11/03/15 1514 Checkin-Exam Code Summary 4121712-0533 (Continued) Page 4 right. Compression of the S1 nerve roots, more prominent on the between the facets and the disc. Mild/moderate central canal right, stenosis. 6. The results of the MRI exam were reported to Dr. Rawlins on 11/4/2015. Ordering Diagnosis ICD 10: M48.06: SPINAL STENOSIS, LUMBAR REGION Dictated By- RICHARD HERZOG M.D. Personally Viewed- RICHARD HERZOG M.D. Agreed with- RICHARD HERZOG M.D. Released Date Time- 11/05/15 0748 Page :4 , End of Report RAWLINS,BERNARD A FINAL FINAL -262;;262;0532;4121712-0533- TOTAL P.05 EFTA00622060