The patient came to the clinic 24-October-2012 complaining of fainting attacks with neck pain and pain both upper limbs for 18 months. She is also complaining of LBP and numbness both feet.

MRI brain done 17-October-2012 showing Arnold-Chiari malformation. Cervical MRI showed the same tonsilar herniation reaching the level of mid of C2 and several disci, the most prominent was C6-7. MRI lumbar spine showed extruded disc L4-5 more to the left with secondary stenosis with old wedge fracture L2 of no clinical significance.

On examination: the patient is limping with preserved sensori-motor status of the upper limbs, but exaggerated deep reflexes. There is weak dorsiflexion both feet 3/5 with weak quadriceps right -4/5 and left 4/5.

The patient was sent for MRI of the dorsal spine and dynamic studies, which were performed 25-October-2012 and they were uneventful.

Decompressive laminectomy C1 and C2 with drilling of the posterior rim of the foramen magnum with exposure of the dura over both cerebellar hemispheres. The dura was opened in Y-shape fashion to expose the tonsils and the spinal cord with the running vermian branches of PICA  both sides. The arteries were full of calcification. Using microscopic facilities, dissection of the arachnoidal bans tethering the tonsils were bisected with preservation of all the minor arterioles and veins. Using dural graft, adopted to the dural defect, it was stitched to obtain water-tight closure of the dura, using 6 zero nylon.

Routine closure of the wounds. Smooth postoperative recovery. The power of both feet became normal.

The patient has several problems: Arnold-Chiari malformation and PLD L4-5 and small cervical disci. The first 2 conditions require surgery, but precedence must be paid to the Arnold-Chiari malformation.

The patient has no syringomyelia, for what no attempt was done, intentionally to reach the obex.