History of tethered cord, new worsening symptoms, leg weakness. There are postoperative findings related to posterior lumbar spine surgery for attempted dethetering. There is a fluid collection in the posterior lumbar paraspinal soft tissues that measure up to 75 mm in length. The conus medullaris is bulbous and terminates at L3-4, where it is posteriorly deviated alongside the duraplasty. In addition, the cauda equina nerve rots appear to be clumped and deviated peripherally to the overlying dura. Posterior fusion hardware is present in the upper thoracic, lower thoracic, and at L2-L4, with associated metallic artifact. There is thoracolumbar dextroscoliosis. The bone marrow signal is unremarkable. The vertebral body heights are preserved.
1. Postoperative findings related to posterior lumbar spine surgery for attempted dethetering, with a fluid collection in the posterior lumbar paraspinal soft tissues that measure up to 75 mm in length, which may represent cerebrospinal fluid leakage or seroma. In addition, there are persistent signs of tethered cord and suggestion of arachnoiditis involving the cauda equina.2. Thoracolumbar dextroscoliosis with fixation hardware in position. Discussed with Dr. Frim at 2:10 PM on 6/11/16.