epidural fluid collection, follow up. Back pain. For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. Previously identified epidural or extradural fluid collection at the level of T12-L1 is again shown. The MR signal characteristics as well as size (20mm x 11mm) of the lesion do not show any significant interval change since prior exam. Therefore, the possibility of epidural hematoma might be relatively lower.Instead, since the content of the lesion well follows those of CSF, this lesion could be extradural CSF leakage or epidural arachnoid cyst. On axial T2 weighted images (series 1601, image 10/20), the left side of dural lining appears to be thinned out. Most frequent extradural CSF collection is related to prior trauma including lumbar puncture. Diagnosis could be made through CT myelography with delayed CT scan, although differentiation from arachnoid cyst is often difficult.There is normal lumbar lordosis. The spine alignment is anatomic. The vertebral body height is preserved. The bone marrow and end plates demonstrate a normal MR appearance. The signal of the visualized cord is normal. The epidural space, thecal sac, and spinal cord are preserved with no evidence of spinal canal/neural foraminal narrowing. The conus medullaris terminates at the L1-L2 level. The paraspinal soft tissues are unremarkable.There is no evidence of abnormal enhancement, cord compression or mass. Degenerative changes are specified by the intervertebral level as follows: T12-L1: no neuroforaminal narrowing or spinal stenosis. L1-L2: no neuroforaminal narrowing or spinal stenosis. L2-L3: no neuroforaminal narrowing or spinal stenosis. L3-L4: no neuroforaminal narrowing or spinal stenosis. L4-L5: disc dessication with minimal to mild diffuse disc bulging, no change since prior exam. L5-S1: no neuroforaminal narrowing or spinal stenosis.
1. No change of T12-L1 extradural/epidural fluid collection since prior exam. Diagnostic possibility include extradural CSF leakage or arachnoid cyst, CT myelography with delayed scan is recommended for further investigation.2. Disc dessication with mild disc bulging, no change since prior exam.