Headache, Pain -- and Chiari I Malformation: Test your IQ

A 29-year-old man had a several year history of headache and constant, dull, neck pain that radiated up to the posterior scalp and down both shoulders. The headaches and neck pain increased in intensity with coughing, lifting, and exercising. On palpation, there was paraspinal and bony prominence tenderness.

On the visual analog scale, the patient reported a pain level of 6 on a scale of 0 to 10.

No abnormalities were seen on a flexion-extension radiograph of the cervical spine. Cervical MRI scan without contrast revealed a Chiari I malformation with herniation of the cerebellar tonsils measuring up to 2.7 cm (arrow) and extensive syringomyelia (arrowheads).