Case 30 - Unstable Fracture, Two Column Injury

Dr. Yousem has provided the following report as a sample report for your reference. It does not match the case reviewed in the video.

Epidural hematoma post-op lumbar spine

Indication: Postop lumbar spondylosis surgery

TECHNIQUE: Axial CT scan images were performed through the lumbar spine with
multiplanar reconstructions of the axial CT data.

FINDINGS:

Postoperative changes are present with fusion from the L2 level to the S1 level with multiple pedicle screws in place. There are surgical drains placed with their tips at the L4-5 level. Laminectomy defect is seen from the L2-3 level to the L5-S1 level.

At the T12-L1 level there is posterior osteophyte to the right of midline indenting the thecal sac. There is degenerative facet joint disease.

At the L1-2 level there is degenerative posterior ossifying to the left of midline with degenerative facet joint disease, right greater than left. Bilateral pedicle screws are in place at L2. There is surgical air
posterior to the thecal sac in the epidural space with slight displacement of the thecal sac anteriorly.

At L2-3 there are bilateral L2 and L3 pedicles screws in place. There is posterior soft tissue at the L2-3 level with narrowing of the AP diameter spinal canal to approximately 6.5 mm.The thecal sac appears to be flattened by this soft tissue posterior to the thecal sac as seen best on series 4 image 53.

At the L3-4 level there is disc space narrowing. There is posterior osteophyte formation. Bilateral pedicle screws are present in good positioning. Posterior bony prominence is seen along the inferior margin
of the L4 vertebra.

At the L4-5 level there is posterior osteophyte formation with degenerative facet joint disease. There is laminectomy defect. There is neural foraminal narrowing bilaterally, right greater than left. A drain is placed in the posterior epidural space.

At the L5-S1 level there is degenerative posterior ossifying this is worse on the left side than the right side with severe left foraminal narrowing. S1 and L5 pedicle screws are appropriately located.

There is scoliosis convex to the left side centered at the L3 level.


IMPRESSION:

Soft tissue indenting the thecal sac from posteriorly at the L2-3 and L3-4 levels worrisome for postoperative hematoma with narrowing of the AP diameter spinal canal to 6 mm at this level.

Postoperative changes after L2-S1 fusion with laminectomy defects and appropriate location of the hardware.

Severe foraminal narrowing on the left side at L5-S1.