Spina bifida with hydrocephalus, unspecified region [741.00], Reason for Study: ^Reason: eval for pathology s/p Chiari decompression, LUE weakness History: LUE weakness, parenthesis There is evidence of decompressive suboccipital craniectomy.There is evidence of buckling of operation site dura indicating postoperative status.Focal acute hemorrhage on the lower medulla extended toward cervical medullary junction with the surrounding edema is seen.Central canal from C5 to T1 shows prominency and there is overt central canal dilatation from T6 to T9. Therefore, both C5 to T1 and T6 to T9 might represent syringomyelia. There is normal cervical lordosis. The cervical spine alignment is anatomic. The vertebral body height is preserved. The bone marrow and end plates demonstrate a normal MR appearance. The signal of the visualized cord is normal .There are minimal bulging of discs at the level of C45 and C56 without imaging evidence of spinal stenosis.
1. Left posterior lower medullary hemorrhage which extends toward left cervicomedullary junction with surrounding edema as described above.2. Syringomyelia from lower cervical and mid thoracic level as described above.3. Minimal disc bulging at the level of C45 and C56.4. Unremarkable thoracic discs and spinal canal.