51 years Male (DOB:3/12/1965)Reason: r/o cord compression History: right lower extremity weaknessPROVIDER/ATTENDING NAME: DAVID A HARTER DAVID A HARTER Cord compression protocol:The vertebral bodies are appropriate in the overall alignment and height. The spinal cord has normal signal characteristics and overall morphology. There is no compromise of the spinal cord.The patient is status post laminectomies at L3, L4 and L5 and there is soft tissue swelling and fluid collections at the surgical site.MRI lumbar spine:Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall alignment and height. The conus medullaris on sagittal imaging is grossly intact.The patient is status post laminectomies at L3, L4 and L5 and discectomy at L4-5 and L5-S1.. There is a fluid collection present measuring 92 mm superior-inferior length extending at the laminectomy sites which bulges into the spinal canal. It measures 12 mm in thickness. It is associated with effacement of the spinal fluid surrounding the nerve roots within the thecal sac extending from L3 down to the L4-5 disc space. Below that level there is fluid surrounding the thecal sac extending down to the L5-S1 level. There is soft tissue swelling present along the left and right hemicanal at the L5-S1 level extending into the disc space and also bilaterally at L4-5 extending into the disc space. There are blood products present along the right hemicanal at L5-S1. This is associated with some encroachment of the nerve roots at the right lateral recess at L5-S1 and some partial effacement of the thecal sac at this level.There is an additional fluid collection present in the subcutaneous tissues adjacent to the perivertebral space which measures 43 x 19 mm axial dimensions and approximately 104 mm superior-inferior length.There is heterogeneous signal within the medial and posterior paravertebral musculature at the surgical sites.There is narrowing of the neural foramina due to disc bulge at L3-4 and L4-5 and to a lesser degree L5-S1 bilaterally. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat.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.
1.This is a limited exam specific for the exclusion of cord compression only and does not exclude more subtle lesions such as intrinsic cord abnormalities. No cord compression is identified. However, the cauda equina does appear to be potentially compressed. Please note that the postsurgical findings may mimic compression of the cauda equina, however, clinical correlation is needed to confirm this.2.The patient is status post laminectomies at L3, L4 and L5 with discectomy at L4-5 and L5-S1. 3.There is fluid collection at the laminectomy sites at L3 and L4 associated with findings suspicious for compression of the cauda equina. Please correlate clinical symptoms.4.There is soft tissue swelling surrounding the thecal sac at the L4-5 and L5-S1 levels extending from the L4-5 disc space down to the sacral spinal canal associated with some blood products in the right hemicanal at L5-S1. This results in some circumferential narrowing of the thecal sac and affects the nerve roots at the lateral recesses sees at these levels.5.Due to the screening nature of this protocol details are not as evident on imaging as dedicated protocols of the spine.6.Findings were discussed with Dr Constantine.