History of tethered cord release, follow-up release. Worsening neck pain. Cervical: The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology. At C2-3 there is no significant compromise to the spinal canal or neural foramina.At C3-4 there is no significant compromise to the spinal canal or right neural foramen. There is mild left neural foraminal stenosis related to facet arthropathy and uncovertebral hypertrophy.At C4-5 there is no significant compromise to the spinal canal or neural foramina.At C5-6 there is a right paramedian disk protrusion associated with mild posterior ligamentous hypertrophy, endplate and uncovertebral osteophytes and effacement of CSF ventral and posterior to the spinal cord. Overall there is mild to moderate spinal stenosis at this level. Moderate right neural foraminal stenosis. No significant left neural foraminal narrowing.At C6-7 there is no significant compromise to the spinal canal. Small disc osteophyte complex, uncovertebral hypertrophy, and facet arthropathy result in moderate to severe left-sided neural foraminal stenosis. No significant right neural foraminal narrowing.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.Lumbar: For the purposes of numbering, the most inferior well-defined disc space is labeled L5-S1. There are postsurgical changes of tethered cord release via L4-L5 level with left sided laminoplasty. Conus terminates at the L4-L5 level as before and demonstrates abnormal contour. No new cord signal abnormality, syrinx, or fluid collections within the visualized distal cord or lumbar spinal canal are appreciated. Prone images demonstrate ventral motion of the conus compatible with deep tethering.Vertebral body heights and alignment are maintained. Mild dysplasia/bifid appearance involving the L5 spinous process again seen. Bone marrow signal is benign with scattered foci of T1 hyperintensity compatible with hemangioma. Mild degenerative changes are seen including mild lower lumbar facet arthropathy without significant spinal canal or neural foraminal stenosis at any level. There is minimal epidural fluid at the dorsal L4-L5 level without mass effect. There is edema involving the posterior paraspinous soft tissues also consistent with postsurgical change.
1. Expected postsurgical changes of tethered cord release. Prone images demonstrate ventral motion of the distal cord compatible with the tethering.2. Degenerative changes in the cervical spine with mild to moderate spinal canal stenosis at the C5-C6 level. There is also right C5-C6 and left C6-C7 neural foraminal stenosis. These findings are not significantly changed since 7/18/2015. 