Chiari malformation and tethered cord status post tethered cord release in 2005. New symptoms, including neck, back, arm pain and worsening headaches. History of Ehlers-Danlos/Postural Tachycardia Syndrome. MRI BRAIN: There is again 7-8 mm downward extension of relatively rounded cerebellar tonsils without peg-like appearance at this time. There is similar crowding at this level although with further effacement of the CSF space dorsal to the tonsils when comparing sagittal T2 cervical spine images back to 2011. CSF flow imaging again demonstrates decreased biphasic CSF flow through the dorsal foramen magnum.The ventricles, sulci and cisterns are within normal limits. There is no mass, mass effect or midline shift, extra-axial fluid collection, or restricted diffusion. There is again minimal nonspecific FLAIR hyperintensity along the right frontal horn. Normal flow voids are identified in the major intracranial vessels. There is a small right maxillary sinus mucosal retention cyst. There is scattered trace right mastoid fluid.MRI SPINE: The spine alignment is anatomic. The cord caliber and signal are normal. The conus medullaris terminates at the upper to mid L3 level. Filum terminale appears normal in caliber. There is apparent subtle linear T1 hyperintensity with respect to adjacent nerve roots and T2/STIR hypointensity within the distal thecal sac extending caudally from L5-S1, more conspicuous on the sagittal images, with a similar appearance when compared to prior images. Prone imaging again demonstrates ventral displacement of the conus and cauda equina nerve roots.The vertebral bodies, marrow, and disks demonstrate a normal MR appearance except for disk height loss and dessication at L5-S1. Mild scattered spondylotic changes are not significantly changed, although the C5-C6 posterior osteophyte disk complex is perhaps slightly more prominent along the right foraminal location, with slightly worsened foraminal narrowing, now moderate-severe right and moderate left in degree. There is also now increased prominence of a right paracentral disk protrusion with annular fissure at T9-10. Lumbar facet arthropathy is again noted.
1. Stable configuration and caudal extension of cerebellar tonsils through the crowded foramen magnum, with further decreased subarachnoid space dorsal to the tonsils compared back to 2011. Persistent reduced CSF flow through the dorsal foramen magnum. 2. No evidence of syrinx. 3. Abnormal low termination of the conus medullaris, but unchanged. Redemonstration of normal caliber filum with only mild intrinsic T1 hyperintensity with respect to adjacent nerve roots, with persistent normal ventral motion of distal cord/conus and cauda equina nerve roots on prone images.4. Mild scattered spondylotic changes, minimally progressed, with moderate-severe right foraminal narrowing at C5-C6.