52 years Male (DOB:5/18/1963)Reason: schwannoma removed. 6 month follow up History: 6 month follow upReferring Attending: EDWIN RAMOS 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 status post right-sided hemilaminectomy at the L3 vertebral body level for removal of an intrathecal mass. There is some central and to lesser degree peripheral clumping of nerve roots present at the L3-4 disc space level at the prior location of the patient's intrathecal mass. There is a fluid collection present at the hemilaminectomy site currently measuring 20 x 27 mm axial dimensions and previously measuring approximately 16 x 11 mm axial dimensions. It currently measures 27 x 47 mm sagittal dimensions. It has a thin enhancing wall. Previously noted fluid in the subcutaneous tissues superficial to the paravertebral muscles at the incision site has resolved.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is disc desiccation, loss of disc space height and a disc bulge at this level.At L4-5 there is no significant compromise to spinal canal or neural foramina. There is disc desiccation, loss of disc space height and a disc bulge at this level.At L3-4 there is no significant compromise to spinal canal or neural foramina.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.A previously noted 27 x 28 mm axial dimension mass at the inferior pole of the left kidney which also be identified on the recent abdomen CT from 10/29/2015 is not included on the current exam.
1.Since the prior exam, a fluid collection at the right hemilaminectomy site at L3 has enlarged. It is not clear based on this exam whether this communicates with the thecal sac.2.Some clumping of nerve roots at the level of the mass is concerning for potential arachnoiditis. Please correlate with clinical symptoms. 