Yearly follow for lumbar syrinx. There is absence of posterior elements in the L4-L5 spine and sacrum, consistent with spinal dysraphism. There is partial fusion of the L3 and L4 vertebrae, consistent with segmentation anomaly. There is unchanged exaggerated lordosis of the lumbar spine and kyphosis of the thoracic spine, as well as mild rotatory scoliotic deformity. There is an unchanged low lying conus medullaris that terminates at the L3 level associated with an elongated morphology of the spinal cord, which contains long-segment syringohydromyelia that measures up to 2 mm in width. There is an ectatic thecal sac in the lumbosacral region, which contains nerve roots and a portion of the conus that herniate through the dysraphism into the posterior soft tissues of the lower back consistent with myelomeningocele. There are unchanged foci of T2 hypointensity and T1 hyperintensity in the region of the conus, which may represent residual postoperative blood products. There is anterior lumbosacral lipomatosis. There is no significant spinal canal stenosis. The paraspinal soft tissues are unchanged. There is partly imaged left hip joint dislocation and effusion.
1. Unchanged appearance of the spinal dysraphism with myelomeningocele with tethered cord configuration and syringohydromyelia.2. Partly imaged left hip joint dislocation and effusion.