Low back pain, evaluate for infection at the operative site Compared to 8/21/2015, previously seen epidural hematoma extending from L4-L5 to L5-S1 level has been evacuated. Current study demonstrates a fluid collection dorsal to the thecal sac at the L4-L5 level extending to the L5-S1 level with moderate to severe degree of mass effect on the thecal sac right greater than left. This collection measures approximately 2.7 x 2.7 x 2.3 cm in the AP, transverse, and craniocaudal dimensions.There is peripheral enhancement associated with this collection, with susceptibility artifact slightly limiting evaluation. Also noted is enhancement involving the epidural space along the right lateral aspect of the spinal canal in the epidural space along the right L5 to S1 levels. This enhancement is increased since prior postoperative study from 8/21/2015 and may represent granulation tissue.Small more superficial fluid collection is also seen in the midline posteriorly along the surgical tract. Enhancement of the paraspinous soft tissues is also increased since prior which may reflect postsurgical change.Again seen are earlier postsurgical changes of L4-L5 bilateral laminectomy with placement of bone graft material and an interspinous clamp. There is minimal anterolisthesis at L4-L5, otherwise alignment is anatomic. Vertebral body heights are intact. Multilevel disc desiccation with degenerative disc disease, most severe at L4-L5. Endplate degenerative changes at L4-L5. Normal signal within the distal cord and conus which ends at L1-L2. Again seen is mild clumping of the cauda equina below L2-L3 which likely reflects arachnoiditis.Degenerative changes including mild bilateral neural foraminal stenosis at L3-L4 as well as moderate to severe right and mild to moderate left L4-L5 neural foraminal stenosis are again seen related to disc bulge and facet arthropathy.Numerous bilateral renal cysts.
Again seen are prior postsurgical changes of L4-L5 laminectomy and interspinous fusion with interval evacuation of epidural hematoma since MRI from 8/21/2015. Current study demonstrates a fluid collection dorsal to the thecal sac extending from L4-L5 to L5-S1 at the level of the laminectomy/facetectomies with mass effect on the thecal sac resulting in moderate to severe spinal canal stenosis, right worse than left. There is mild peripheral enhancement associated with this collection as well as enhancement involving the epidural space particularly on the right L5 to S1 levels. This enhancement is nonspecific and may reflect granulation tissue, with infection not excluded. The fluid collection may represent a pseudomeningocele, with superimposed infection again not excluded.Moderate to severe right L4-L5 neural foraminal stenosis which may be impinging on the L4 nerve root again seen and similar to prior.