Patient History: low back 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 laminectomies at L3, L4 and L5 with a posterior fusion at L3, L4, L5 and S1 with pedicle screws and interconnecting rods as well as bone graft. There is a cross bar present centered at L4-5. There is mild anterior subluxation of L4 on L5.There is a septated fluid collection present at the laminectomy sites of L3, L4 and L5 which surrounds the posterior crossbar. This associated with the peripheral contrast enhancement and appearance of infiltrating margins.At L5-S1 there is no significant compromise to spinal canal or neural foramina.At L4-5 there is no significant compromise to spinal canal or neural foramina. There is anterior subluxation of L4 and L5 by approximately 4 mm.At L3-4 there is no significant compromise to spinal canal or neural foramina. There are some endplate reactive changes present at L3-4At L2-3 there is no significant compromise to spinal canal or neural foramina. There is mild disc bulge at this level associated with disc desiccation and facet hypertrophy. There is narrowing of the neural foramina bilaterally with encroachment of the exiting nerve roots within the right neural foramen.At L1-2 there is no significant compromise to spinal canal or neural foramina.There is a 16 mm right parapelvic cyst of the right kidney and a 12 mm cortical cyst along the superior aspect of the left kidney.
1.The patient is status post posterior fusion and laminectomies. There is a fluid collection present at the surgical site which abuts the thecal sac. Differential considerations may include seroma as well as CSF leak and even infection in the appropriate clinical circumstances. Please correlate with the timing of surgery.2.There is no significant compromise to spinal canal or neural foramina.3.There is mild subluxation of L4 and L5.4.There is some encroachment of the exiting nerve roots at the right L4-5 neural foramen due to facet hypertrophy