Diagnosis: Other specified congenital anomaly of spinal cordClinical question: eval for possible lumbar infectionSigns and Symptoms: incision drainage Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall alignment and height.There thecal sac and spinal canal are large. There is a syrinx in the distal spinal cord. It previously measured 1.5x3.5 mm axial dimensions. This is enlarged since the prior exam. It now measures 3x5mm axial dimensions. The spinal cord is tethered and adheres to the posterior aspect of the spinal canal. There is a fluid collection with fluid-fluid levels redemonstrated in the perivertebral space surrounding spinous processes at the L3,L4 and L5 vertebral levels. It has ring enhancement with a thicker wall on the current exam. It previously measured 118x33 mm sagittal dimensions and now measures 71x18 mm sagittal dimensions. There is associated patchy enhancement in the adjacent musculature which was also previously present and some loculations. It is contiguous with the thecal sac at the laminectomy sites at the L5 level. There is some associated enhancement of the distal tethered cord and adjacent thecal sac which was also previously present.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.At L3-4 there is no significant compromise to spinal canal or neural foramina.At L2-3 there is no significant compromise to spinal canal or neural foramina.At L1-2 there is no significant compromise to spinal canal or neural foramina.
1.Since the prior exam the syrinx has enlarged.2.Since the prior exam the posterior perivertebral fluid collection has decreased in size and appears more organized. The possibility of infection cannot be excluded.3.Tethered cord with cord ending in the sacrum status post surgery.