Low back pain and fever. History of endocarditis. The study is limited by patient motion, at least moderately.Sagittal alignment is notable for 7 mm of anterior subluxation of L5 relative to S1, likely spondylolytic and degenerative. There is moderate-to-severe lumbar disc height loss, sparing L1-L2. There is T2-hyperintensity in the L4-L5 disc and to a lesser extent L5-S1, while the other discs show desiccation. There is also abnormal signal in the posterior aspect of L5 vertebral body associated suggestion of erosion of the posterior cortex and possibly mild posterior height loss (versus physiologic wedging). Milder marrow edema is also present in the posterior part of L4 vertebral body and perhaps L3 as well. There is inflammatory change in the adjacent anterior epidural fat and the L3-L4, L4-L5 and L5-S1 neural foramina bilaterally. There is an abnormal anterior epidural fluid collection with rim enhancement that extends from the upper L3 level to the second sacral segment level. The collection is largest at the mid L4 level, where it has an anterior-posterior diameter of 1.3 cm and does posteriorly displace and severely compress the thecal sac. It measures in transverse 2 cm. There is inflammatory change also in the paraspinal soft tissues including the medial aspect of the left iliacus and psoas muscles. This is most pronounced at L5 level, where there multiple small fluid locules medial to the psoas muscle. The largest discrete locule measures up to 2 cm.Faint contrast enhancement within the thecal sac extending from mid L2 through mid S1 level may relate to venous congestion from the severe spinal canal stenosis or may reflect associated arachnoiditis. This is associated with circumferential tumoral contrast enhancement and thickening that is most pronounced at L5 and S1 levels.L1-L2: No spinal canal or neural foraminal stenosis.L2-L3: Disc bulge and mild ligamentum flavum thickening and facet arthropathy cause moderate spinal canal and bilateral neuroforaminal stenoses.L3-S1: Severe thecal sac compression by the epidural abscess. The neural foramina are involved by the inflammatory.
1.Limited examination, because of patient motion.2.Osteomyelitis involving L5 vertebral body and perhaps L4 and L3 vertebral bodies in addition to discitis involving L4-L5 and perhaps L5-S1 discs. Relatively large epidural abscess extending from L3 through S2 level which severely compresses the thecal sac and involve the respective neural foramina bilaterally.3.There is also paravertebral soft tissue involvement with small left paraspinal abscesses at L5 level.4.Associated intrathecal contrast enhancement may reflect reaction to the epidural inflammatory process and the severe canal stenosis or may represent associated arachnoiditis.Dr. Monther Qandeel discussed the above findings and recommendations with Neuro ICU Fellow Dr. Mojumder over the phone on 3/4/2016 11:42 AM. The epidural abscess has significantly increased in size compared to the limited noncontrast-enhanced lumbar spine MRI from Methodist SouthLake dated February 29, 2016 and March 1, 2016 and CT scan from February 28, 2016. Then, the collection was limited to the L4 level and caused only mild-to-moderate mass-effect on the thecal sac. The osseous and paravertebral soft tissue abnormalities were also less pronounced.