History of an L4/L5 laminectomy, titanium rods, recently assaulted and now with back pain, RLE weakness, decreased rectal tone, and urinary incontinence. Redemonstrated are postoperative changes of a laminectomy and posterior spinal fusion at the L4-5 level with transpedicular screws. Additionally, there is a interbody anterior fusion of L4-5 vertebral bodies. There is no evidence of traumatic subluxation, fracture or hardware complication. The lumbar spine alignment remains within normal limits. The vertebral body and disc space heights are otherwise preserved. The vertebral bone marrow signal is unremarkable. There is no significant spinal canal stenosis. The spinal cord displays normal signal and morphology. A small CSF fluid collection is seen dorsal to the L4-5 thecal sac compatible with a small pseudomeningocele which is grossly unchanged compared to the prior exam and without mass effect on the thecal sac. No evidence of an epidural or paraspinous hematoma.T12-L1: There is no significant compromise to spinal canal or neural foramina.L1-L2: There is no significant compromise to spinal canal or neural foramina.L2-L3: There mild facet arthropathy but no significant compromise to spinal canal or neural foramina.L3-L4: There is mild facet arthropathy but no significant compromise to spinal canal or neural foramina. L4-5: There is mild facet arthropathy and postsurgical changes but no significant compromise to spinal canal or neural foramina.L5-S1: There is mild facet arthropathy but no significant compromise to spinal canal or neural foramina.
Remote postoperative changes of L4-5 spinal fusion. No significant spinal canal or neural foraminal stenosis at any level. No evidence of an epidural or paraspinous hematoma.