Status post spinal cord untethering and lipoma. History of VACTERL syndrome. There are postsurgical changes of recent spinal cord untethering with foci of air within the lower lumbar epidural space and posterior paraspinous soft tissues as well as laminotomy defects involving the lower lumbar spine. Intradural blood products are evident with low T2 signal in the distal thecal sac. There are also postoperative fluid and blood products in the dorsal epidural space from the L3 level to the lumbosacral junction with associated severe effacement of the thecal sac and mass effect on the conus, which is low-lying, as well as the cauda equina nerve roots. Filar lipoma is again evident with decrease in amount of fat since the preoperative study consistent with resection. Precise conus position is difficult to discern due to the diminutive appearance of the lumbar thecal sac. Conus is anteriorly displaced related to the epidural fluid which also limits the utility of the prone sequence. Vertebral body heights and alignment are maintained. Neural foramina are patent.
Interval postoperative changes of spinal cord untethering. There is severe effacement of the distal thecal sac from the L3 to the S1 levels related to epidural fluid and blood products.Dr. Ali discussed above findings with Amanda Johnson at 12:30 PM on 8/24/2016.