Reason: hx failed back syndrome. s/p epidural injection: c/o pain down leg and weakness/ back pain. r/o abnormality History: back and leg pain Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall height. The conus medullaris on sagittal imaging is grossly intact. The patient is status post instrumentation with posterior effusion with a pedicle screws at L3, L4 and L5 bilaterally, laminectomies at L3, L4 and L5 and disk spacer at L4-5. There is epidural fat accumulation in the lower lumbosacral canal.There is mild ill-defined dural enhancement present at L4, L5 and S1.At L5-S1 there is no significant compromise to spinal canal or neural foramina. L5 is minimally posteriorly subluxed relative to S1. There is a disk bulge present at this level associated with the signal hyperintensity on T2 within the posterior aspect of the annulus fibrosis. This is stable when compared to the prior examAt L4-5 there is no significant compromise to spinal canal or neural foramina. There is mild intra-subluxation of L4 on L5 which is unchanged when compared to the prior exam.At L3-4 there is no significant compromise to spinal canal or neural foramina.At L2-3 there is no significant compromise to spinal canal or neural foramina.At L1-2 there is no significant compromise to spinal canal or neural foramina.
1.Findings suggest an inflammatory reaction in the lower lumbar spinal canal. It is possible this represents reaction to epidural injection, given the clinical history, although any inflammatory process including early infection may have a similar appearance.2.Status post lumbar spine surgery with instrumentation for fusion and laminectomies from L3 through L5 .3.There is mild anterior subluxation of L4 on L5 which is stable.4.There is no significant compromise of spinal canal or exiting nerve roots appreciated.5.Findings suggest epidural lipomatosis in the lower lumbosacral canal. This is not changed substantially the prior exam