Diagnosis: Other symptoms and signs involving the musculoskeletal systemClinical question: eval for tethered core, h/o of spinal bifidaSigns and Symptoms: inability to ambulate, BLE weakness Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall alignment and height. The spinal cord is tethered and there is a spina bifida defect present in the upper sacrum. There is a sinus tract which extends through the spina bifida defect to the skin surface. The distal spinal cord is attached to the sinus tract. There is a small fluid collection present at the sinus tract measuring 24 x 5 mm sagittal dimensions and 14 x 5 mm axial dimensions. This fluid collection is eccentric towards the left side as is the sinus tract. These findings are stable compared to the previous examAt L5-S1 there is no significant compromise to spinal canal or neural foramina.At L4-5 there is no significant compromise to spinal canal or neural foramina.At L3-4 there is no significant compromise to spinal canal or neural foramina.At L2-3 there is no significant compromise to spinal canal or neural foramina.At L1-2 there is no significant compromise to spinal canal or neural foramina.
1.The spinal cord is tethered and is associated with a sinus tract as detailed above. The patient is status post myelomeningocele repair. These findings appear stable compared to the previous exam from 1/2014.