Female, 56 years old, with back pain status post lumbar instrument fusion, status post epidural hematoma evacuation. Evaluate for hematoma. Evidence of posterior instrumented fusion is again seen with pedicle screws on the right at L4-S1, and on the left at L5 and S1. Interbody devices have also been placed at L4-5 and L5-S1. Evidence of laminectomy/facetectomy is also seen on the right at L4-5 and on the left at L5-S1.Since the prior examination, the previously seen large fluid collection within the superficial soft tissues of the lumbar region has resolved. A fluid collection which was evident more deeply within the right L4-5 operative bed, extending to the epidural space, has also significantly improved with only a small amount of residual fluid or edema present. Previous encroachment upon the thecal sac has improved as well.Marrow signal abnormality compatible with edema is seen involving nearly the entirety of the L4 and L5 vertebral bodies, a finding which has progressed from the prior examination. There may be some edema in the prevertebral soft tissues, but this is equivocal. No definite evidence of any new epidural or paraspinal fluid collection is seen. Edema persists within the right psoas musculature.Straightening of the cervical lordosis is again seen. Vertebral body heights are largely preserved with the exception of postoperative change at L4 and L5. No other areas of marrow signal abnormality are seen.At L3-4, facet arthropathy, ligamentum flavum thickening, and a disc bulge with central annular fissure contribute to mild spinal canal narrowing. The foramina are not significantly compromised.At L5-S1, posterior element hypertrophy and bulging disc material resulting in a moderate narrowing of the spinal canal, but improved from the prior examination. Moderate right and mild left foraminal narrowing is seen.At L5-S1, posterior element hypertrophy and disc bulging asymmetric to the left lateral recess is seen. No significant generalized spinal canal stenosis is seen. The neural foramina are mildly narrowed.
1.Since the prior examination, the previously demonstrated subcutaneous and epidural fluid collections within the operative region have resolved or nearly completely resolved. No findings are seen to suggest new or progressive bleeding. The thecal sac remains narrowed at the L4-5 level though this is improved relative to the prior study.2.Progressive edema is seen within the L4 and L5 vertebral bodies when compared to the prior examination. There may be mild edema within the prevertebral soft tissues but this is equivocal. No new fluid collections are seen. In the absence of leukocytosis or an abnormal ESR, these findings may simply represent edema reactive to surgical instrumentation. Infection is considered less likely but cannot be eliminated as a possibility based on imaging. At least one follow-up MRI can be considered if the patient's symptoms do not improve.