Female, 47 years old, with spinal stenosis status post C3-4 fusion with significant wound drainage. Assess for CSF leak versus epidural hematoma. Redemonstrated are findings related to recent anterior cervical discectomy and fusion. Fusion instruments are seen from C3 through C7.Prevertebral edema and/or fluid spans from C2 through C4. At the C4 and C5 prevertebral levels, there is a fluid collection which extends superficially through the surgical tract to the skin surface (see image 22 series 14). The margins of this collection and fluid filled tract show enhancement but this degree of enhancement is very likely within expected postoperative limits. Fluid from this collection seems to communicate with the C5-6 disc space. The posterior annulus bulges mildly causing slight effacement of the left ventral thecal sac. No definite evidence of any pathologic epidural collection or hemorrhage is seen. Image quality, including artifact from the orthopedic instruments, does not permit reliable localization of any potential dural defect.There is a mild reversal of the normal cervical lordosis. Only the C2 vertebral body and the upper thoracic vertebral bodies are adequately visualized to assess for marrow signal and these levels appear within normal limits.A small area of mild T2 hyperintensity is evident within the cervical spinal cord at the C3-4 level which may reflect myelomalacia from prior cord impingement. No other areas of concerning spinal cord signal abnormality are detected.C2-3: Right facet hypertrophy. No significant spinal canal or foraminal stenosis. C3-4: Bilateral facet hypertrophy. Minimal posterior disc-osteophyte complex formation. No significant spinal canal stenosis. Moderate left foraminal narrowing. C4-5: Postoperative artifact. Minimal disc bulging. Mild spinal canal narrowing. No significant foraminal narrowing. C5-6: Postoperative artifact. Left paracentral disc bulging as above. Mild generalized spinal canal narrowing. Moderate left foraminal narrowing. C6-7: Postoperative artifact. No significant spinal canal or foraminal stenosis. C7-T1: Postoperative artifact. No significant spinal canal or foraminal stenosis.
A small fluid collection is evident within the prevertebral space at the C4 and C5 levels which extends superficially through the left neck surgical tract to the skin surface. Fluid from this collection appears to communicate with the adjacent C5-6 disc space and there is mild posterior bulging of the C5-6 annulus which causes mild effacement of the left ventral thecal sac, a finding which is likely within expected postoperative limits. Given the imaging findings and timeframe after surgery, a CSF leak is felt to be likely. Image quality is not adequate to accurately identify potential dural defects. Superinfection of the above-described fluid collection and tract is not highly suspected. No evidence of any significant epidural collection or hematoma is seen.