EFTA00282969.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: BMANNA COMPANY: DATE: NOVEMBER 5, 20/5 FAX NUMBER: MO 350-0306 TOTAL NO. OF PAGES INCLUDING COVER: 5 PHONE NUMBER: SINDF.R'S REFERENCE NUMBER: YOUR REFERENC:E NUMBER: URGENT X FOR REVIEW ❑PLEASE COMMENT K PLEASE REPLY 0 PLEASE RECYCLE NCYtt.‘,./CO2.O4ENTS: Requested MRI results for Mr. Epstein. Thank you, Rrianna 523 EAST 72Kr4 STREET (2" FLOOR) NEW YORK, NY 16021 TEL: 212 606 1632 FAX 212 606 1726 EFTA00282969 NOV-04-2015 11:56 71BERNARDRAWLINSND F.Ud (mu cunt Raenrsai. atm tort, of the intandep rat.. • / I" HOSPITAL FOR SPECIAL SURGERY 535 East 70th Street New York, N.Y. 10021 DEPARTMENT OF RADIOLOGY AND IMAGING Check-in Date: 11/03/15 1514 Patient Name Location EPSTEIN,JEFFERY DIS Ordering Physician RAWLINS,BERNARD A Adm/Reg Physician Consulting Physician RAWLINS,BERNARD A Medical Record # Date of Birth Age 840411 01/20/53 62y 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 moderate left facet arthrosis is associated with thickening of the ligamenta £lava. Moderate central canal stenosis is identified and the stenosis is partially on a development basis. There is mild/moderate left neural foraminal stenosis and a small/moderate sized disc protrusion projects into and slightly lateral to the neural foramen and causes mild Page :1 , Report Continued on Next Page RAWLINS,BERNARD A FINAL FINAL HSS-523 EAST 72ND ST 2TH FL--SOUTH NEW YORK NY 10021 -252;;262;0533;4121712-0533- EFTA00282970 N00-04-2015 11:56 71BERMARDRRWLINSMD "t1.4 ASA Ldh a privileged 801 conttoential and for the sole unn of tka intended rent 2126061726 F.03 Mic HOSPITAL FOR Ma SPECIAL SURGERY 535 East 70th Street New York, N.Y. 10021 DEPARTMENT OF RADIOLOGY AND a< IMAGING Check-in Date: 11/03/15 1514 Checkin-Exam Code Summary 4121712-0533 Patient Name EPSTELN,JEFFERY Ordering Physician RAWLINS,BERNARD A Adm/Reg Physician Consulting Physician RAWLINS,BERNARD A Medical Record # Date of Birth 840411 01/20/53 Location DIS Age 62Y (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 ligamenta 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 is partially on a developmental basis. There is compression of the 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 HSS-523 EAST 72ND ST 2TH FL--SOUTH NEW YORK NY 10021 -262;;262;0533;4121712-0533- EFTA00282971 NOV-04-2015 F.U4 11:57 71BERNARDRAWLINSMD cu.° aim Lb Innislege° ano (manor:rand and fox ..e of thP intcrxich.1 rot: W HOSPITAL FOR SPECIAL SURGERY 535 East 70th Street New York, N.Y. 10021 DEPARTMENT OF RADIOLOGY AND • IMAGING Check-in Date: 11/03/15 1514 Checkin-Exam Code Summary 4121712-0533 Patient Name EPSTEIN,JEFFERY Ordering Physician RAWLINS,BERNARD A Adm/Reg Physician Consulting Physician RAWLINS,BERNARD A Medical Record # Date of Birth 840411 01/20/53 Location DIS Age 62Y (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 HSS-523 EAST 72ND ST 2TH FL--SOUTH NEW YORK NY 10021 -262;;262;0533;4121712-0533- EFTA00282972 NOV-04 -2015 11:57 . 71BERNARDRAWLINSMD • in L..Ileyeu WA, vvantliinli.iell SIM 7.0W P.05 of the• int ended rec. • / i• HOSPITAL FOR SPECIAL SURGERY 535 East 70th Street New York, N.V. 10021 DEPARTMENT OF RADIOLOGY AND IMAGING Check-in Date: 11/03/15 1514 Checkin-Exam Code Summary 4121712-0533 Patient Name EPSTEIN,JEFFERY Ordering Physician RAWLINS,BERNARD A Adm/Reg Physician Consulting Physician RAWLINS,BERNARD A Medical Record # Date of Birth Age 840411 01/20/53 62Y Location DIS (Continued) Page 4 right. Compression of the S1 nerve roots, more prominent on the right, between the facets and the disc. Mild/moderate central canal 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 HSS-523 EAST 72ND ST 2TH FL--SOUTH NEW YORK NY 10021 -262;;262;0532;4121712-0533- TOTAL P.05 EFTA00282973