Wk 6, Case 5 - Review

Patient History
32-year-old male with a history of complex thoracolumbar spinal issue including history of thoracolumbarstenosis, for which he underwent thoracic-L4 fusion in 2007. He complains primarily of low back pain and right lateral leg pain. On examination, he is neurologically intact.

Findings
These images demonstrate a post myelogram CT scan with faint contrast in the spinal canal. There is reversal of the normal cervical spine lordosis with a kyphotic and scoliotic angulation convex to the left side in the cervical region. Axial scans of the cervical spine show uncovertebral joint degenerative change, left greater than right at the C3-4 level leading to mild to moderate left foraminal narrowing. At the C5-6 level there is uncovertebral joint degenerative changes well with mild right foraminal narrowing. Otherwise there is simply the impact of the scoliosis and kyphosis.

There is a bony lesion in the junction of the left lamina and spinous process at the T1 level which shows both lytic and sclerotic components and measures approximately 7 mm. There is bony reaction associated with the lesion. Just below this there is the beginning of a rod for scoliosis treatment. The thoracic spine shows a leftward scoliotic angle centered at the T5-6 level and a rightward scoliotic angle centered at the T10-T12 level. There appears to be a hemivertebra on the left side at the leftward scoliotic angle.

Rods are present on the left side beginning at T2 and on the right side beginning at T4. There is foraminal stenosis at the T4-5 level on the right side. The rods lead to pedicle screws at the L2 level, L3 level, L4 level, L5 level and left S1 level with an anterior screw at the sacral level. There is a split in the spinal cord beginning at the L2 level and lasting approximately one vertebral bodies segment. It reconnects at the L3-4 disc level and there is a low conus medullaris with tethered cord ending at approximately the L5-S1 level. The thecal sac appears empty in the sacrum. A crossing sacroiliac joint screw is present on the left side. Degenerative facet joint disease is present at multiple levels in the lumbar spine with fusion present posteriorly with bone grafting.

Impressions
Scoliosis of the cervical and thoracic spine with what appears to be a hemivertebra in the mid thoracic region, probably T6 at the apex of the leftward scoliosis. Diastematomyelia with split cord from L2 to the L3-4 level reconnecting in a tethered cord. Empty thecal sac suggestive of arachnoidal adhesions in the lumbar level. Mild degenerative changes in the cervical spine with scoliosis convex to the left side.