Reason: epidural abscess History: LBP There is no abnormal enhancement to suggest an epidural abscess. The vertebral column alignment is within normal limits. The vertebral body and disc space heights are preserved. The vertebral bone marrow signal is unremarkable. There is mild disc bulging at L2-3, L3-4 and L4-5 without significant stenoses. There is mild left L4-5 neural foraminal narrowing. There is mild facet joint hypertrophy at the lower levels. Scattered perineural root sleeve cysts are seen, including in the sacral region. The spinal cord displays normal signal and morphology. There is edema and enhancement involving the posterior paraspinal muscles, right greater than left. There is also involvement of the right iliopsoas muscle. No discrete fluid collection is seen.
1. There is no abnormal enhancement to suggest an epidural abscess.2. There is edema and enhancement involving the posterior paraspinal muscles, as well as the right iliopsoas muscle. These findings may reflect an underlying myositis or some other inflammatory process. No discrete fluid collection.Findings were discussed with Dr. Mulliken, attending physician in the emergency room, on 5/11/2016 at 9:40am.