Followup of spinal cord injury with re-tethered spinal cord at the site of his gunshot wound, status post surgery. There are postoperative findings related to multilevel lower thoracic posterior element resection, with fluid collections in the paraspinal soft tissues, along the incision plane. There is severe atrophy of the spinal cord at the T10 level. There are also areas of high signal in the spinal cord at the T11 level, where the spinal cord abuts the anterior aspect of the thecal sac. In addition, there is persistent clumping of the cauda equina nerve roots at T11-T12. There are bilateral pars interarticularis defects at L5 without spondylolisthesis. The vertebral column alignment is otherwise within normal limits. The vertebral body heights are preserved. The vertebral bone marrow signal is unremarkable. There is multilevel degenerative spondylosis, but no significant spinal canal or neural foraminal stenosis. There are small bilateral pleural effusions. There is a probable right renal cyst.
Recent postoperative findings in the lower thoracic spine with stigmata of gunshot wound injury, including severe atrophy of the spinal cord at the T10 level and areas of encephalomalacia in the spinal cord at the T11 level, where the spinal cord abuts the anterior aspect of the thecal sac, which is suggestive of persistent tethering. In addition, persistent clumping of the cauda equina nerve roots at T11-T12 also suggests the presence of adhesions. 