62-year-old male status post C3, C4, C5, C6, and partial C7 laminectomy as well as bilateral C3, C4, C5, and C6 lateral mass fusion exhibiting drainage at wound. Surgery performed 12/4/2015 There has been interval laminectomy at C3, C4, C5, and C6. Bilateral pedicle screws are now present at C3, C4, C5, and C6. Posterior to the resection site, within the operative tract, underlying the skin, there is a 4 cm craniocaudal by 1.5 cm AP x 2.5 cm transverse fluid collection demonstrating peripheral enhancement.Craniovertebral junction appears within normal limits. Redemonstrated is osseous fusion involving the C3-C4 vertebral bodies and the C5-C6 vertebral bodies. There is minimal retrolisthesis of C5 on C6. Alignment is otherwise grossly maintained. Bone marrow signal is benign.C2-3: There is mild right neural foraminal narrowing related to uncovertebral hypertrophy and facet arthropathy. No significant compromise to the spinal canal or left neural foramen. These findings are unchanged.C3-4: Secondary to laminectomy, the central canal has been decompressed and central stenosis is no longer evident. As before, there Is questionable subtle T2 hyperintensity within the cord at this level.C4-5: Fusion at the intervertebral discs level is again noted. Secondary to laminectomy, the central canal has been decompressed and central stenosis is no longer evident. Mild left and minimal right neural foraminal narrowing is unchanged.C5-6: Secondary to laminectomy, the central canal has been decompressed and central stenosis is no longer evident. There is persistent deformity of the cord particularly in its right aspect. Redemonstrated is T2 hyperintensity in the cord and volume loss consistent with myelomalacia. There is severe right and moderate left neural foraminal stenosis related to uncovertebral hypertrophy and to a lesser degree facet arthropathy, unchanged.C6-7: Secondary to laminectomy, the central canal has been decompressed. As before, there is no significant spinal canal stenosis. There is mild left and minimal right neural foraminal stenosis, unchanged. C7-T1: There is a disc osteophyte complex and bilateral uncovertebral hypertrophy. There is mild spinal canal stenosis at this level. There is mild to moderate bilateral neural foraminal stenosis. These findings are unchanged.The vertebral artery flow voids appear to be intact. Paraspinous soft tissue structures appear within normal limits.
There has been interval laminectomy at C3, C4, C5, and C6. Bilateral pedicle screws are now present at C3, C4, C5, and C6. Posterior to the resection site, within the operative tract, underlying the skin, there is a 4 cm craniocaudal by 1.5 cm AP x 2.5 cm transverse fluid collection demonstrating peripheral enhancement. Given the length of time since surgery, and the clinical provided history of drainage occurring at the wound site, these findings are most suggestive of abscess.