 There are postoperative findings related to T2-L1 posterior spinal fusion with residual mild scoliosis with a leftward apex at T2-T3 and a rightward apex at T8-T9. There is a slightly heterogeneous T1 and T2 hyperintense posterior epidural fluid collection extending from C4 through T1 that measures up to 1 mm in thickness, previously 4 mm, with mild residual spinal canal stenosis mainly secondary to reversed lordosis and mild disc-osteophyte complexes superimposed on a congenitally narrow spinal canal. The associated abnormal T2 hyperintensity within the cervical spinal cord has progressed and now involves the entire circumference of the cord extending from the C4-C5 level to the C6-C7 level. Artifact from the patient's spinal hardware limits thoracic evaluation. There are grossly unchanged scattered thoracic epidural blood products without spinal cord compression. The vertebral body and disc space heights are preserved. There is mild paranasal sinus mucosal thickening and minimal fluid within the mastoid air cells. There is T2 hyperintensity within the left lung base and a small right pleural effusion.
1.Progression of cervical spinal cord t2 hyperintensity centered at C5-C6; the adjacent epidural hematoma has redistributed and no longer results in significant spinal canal or cord compression. 2.Scattered additional epidural blood products throughout the thoracic spinal canal without cord compression. 3.Worsened right pleural effusion and unchanged left lower lobe atelectasis or pneumonia. 