40 years Male (DOB:1/18/1976)Reason: rule out spinal cord abnormality History: CSF leak lumbar areaPROVIDER/ATTENDING NAME: ROBERT A MULLIKEN Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall alignment and height. The spinal cord is tethered and extends down to the level of S2 where there is a spina bifida defect present there is a surgical defect present at this level.Previously noted fluid collections behind the spinous processes of the L4 and L5 and behind the sacrum are smaller on the current. On sagittal imaging fluid collection currently measures approximately 28 x 15 mm sagittal dimensions with a second compartment measuring 42 x 3 mm. This previously measured 54 x 18 mm sagittal dimensions with a second compartment measuring 11 x 46 mm. There appears to be T2 signal hyperintensity extending up to the thecal sac resulting question this represent CSF leak.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is a disc bulge present at this level which is associated with some facet hypertrophy.At L4-5 there is no significant compromise to spinal canal or neural foramina.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.Tethered cord associated with sacral dysraphism. Findings are suggestive of surgically treated myelomeningocele.2.Fluid collections behind of the patient's thecal sac at the lumbosacral junction level have decreased in size. There are findings that suggest that these may represent CSF leak.