Findings
- 6 lumbar type vertebral bodies
- Surgical changes of L5-L6 posterior instrumented lumbar fusion
- Large, predominantly T2 signal hyperintense, T1 signal hypointense dorsal epidural collection spanning L3-L6 with largest component from L4-L5 through L5-L6 resulting in severe crowding of nerve roots in the thecal sac
- Possible communication between this collection and the left posterior paraspinal soft tissues at L5-L6
- Heterogeneous signal material in the ventral epidural space at L5-L6
- Collections containing fluid-fluid levels in the posterior paraspinal soft tissues bilaterally at the level of L4-L5
- Mild degenerative left neural foraminal stenosis at L5-L6
- Duplicated IVC
Diagnosis
Epidural hematoma
Sample Report
6 lumbar type vertebral bodies.
Surgical changes of L5-L6 posterior instrumented lumbar fusion. Large dorsal epidural hematoma spanning L3-L6 with largest component from L4-L5 through L5-L6 resulting in severe crowding of nerve roots in the thecal sac. Recommend urgent neurosurgical evaluation.
Possible communication between this collection and the left posterior paraspinal soft tissues at L5-L6.
Heterogeneous signal material in the ventral epidural space at L5-L6, which may represent postoperative tissue and/or residual native disc.
Collections containing fluid-fluid levels in the posterior paraspinal soft tissues bilaterally at the level of L4-L5, which are favored to represent hematomas. Recommend correlation with clinical signs of operative site soft tissue infection.
Discussion