Male, 52 years old, with left leg pain and swelling, history of lumbar laminectomy complicated by CSF leaking. Postoperative findings are demonstrated compatible with recent laminotomy and facetectomy on the left at L4-5 and L5-S1. The overlying paraspinal soft tissues are edematous and show diffuse ill-defined enhancement compatible with recent surgery. Within the laminotomy bed at L5-S1, a fluid collection is evident measuring 20 x 16 x 11 mm. No encroachment on the spinal canal is seen. No epidural collections are detected. Thickening and mild anterior displacement of the left posterolateral dura at this level is likely postoperative.Enhancement of at least the left S2 nerve root and perhaps several other left-sided nerve roots is seen extending from the conus down to the operative region.Edema and enhancement within the sacrum is partially visualized along with engorgement of the presacral venous plexus.Elsewhere vertebral body signal characteristics are unremarkable. Vertebral body height and morphology are within normal limits.L1-2: Facet arthropathy. No significant spinal canal or foraminal stenosis. No interval changes. L2-3: Facet arthropathy. Minimal disc bulging. No significant spinal canal or foraminal stenosis. No interval changes. L3-4: Facet arthropathy. Minimal disc bulging asymmetric to the left. No significant spinal canal stenosis. Minimal left foraminal narrowing. No interval changes. L4-5: Facet arthropathy. Mild disc bulging with a central annular fissure and small central protrusion. No significant spinal canal stenosis. Postoperative changes as above. Moderate right and mild left foraminal narrowing. L5-S1: Facet arthropathy. Minimal disc bulging. No significant spinal canal stenosis. Postoperative changes as above. No significant foraminal narrowing. Hydronephrosis and hydroureter is evident on the left. The left renal parenchyma is atrophic.
1.Findings are demonstrated compatible with recent left L4-5 and L5-S1 laminotomy and facetectomy. A small fluid collection within the L5-S1 laminotomy bed is compatible with a pseudomeningocele. Edema and enhancement in the overlying paraspinal soft tissues are likely within expected limits given recent surgery.2.Diffuse enhancement of at least the left S2 nerve root and perhaps of several other intrathecal nerve roots is seen. This could represent a reactive arachnoiditis related to surgery. Alternately, radiculitis from chronic nerve root impingement can also occasionally produce enhancement.3.Edema and enhancement are partially visualized within the sacrum. This is of uncertain etiology but could reflect an occult sacral insufficiency fracture. Pelvic CT can be considered as an initial follow-up exam. This finding was communicated to Dr. Ramos via email at 11:00 AM on 7/1/16. 4.Left hydronephrosis and hydroureter are redemonstrated with associated renal atrophy.