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hs/bv
Date : 00.00.00

Name of the Patient : Abc Xyzitsingh Gulmn / M / 3 yrs.
Referred by : Dr. Abc Xyzauhan.
Examination : M.R.I. of the Dorso-lumbar Spine.

CLINICAL PROFILE :

C/O meningocele for which patient was operated at the age of 3 months.
C/O paraplegia with bladder/bowel involvement since then.

EXAMINATION :

M.R.I of the dorso-lumbar spine was performed using the following parameters :

3 mm thick T1 Weighted and T2 Weighted sagittal images.

5 mm thick T1 Weighted and T2 Weighted axial images.

The brain was screened with 4 mm thick T1 Weighted sagittal images.

OBSERVATION :

There is an open spinal canal posteriorly in the lower dorsal and lumbar regions with segmentation anomalies of multiple dorsal vertebrae (confirmation with X-rays would be worthwhile). The thecal sac in the visualized dorso-lumbar region is seen to be capacious.

Areas which are near isointense to normal neural tissue are seen within the thecal sac over the L2 to L5 levels and this may represent a neural placode. The filum terminale appears to be inserting into this. Ventral myeloschisis is noted at the D6/D7 and D2/D3 vertebral levels. The spinal cord in the mid and lower dorsal regions appear to be of smaller calibre. However, the visualized dorsal spinal cord shows normal signal intensity.

The remaining visualized dorso-lumbar vertebral bodies and intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.

On screening the brain there is evidence of a large cervico-medullary kink with herniation of the cerebellar tonsils through the foramen magnum. Also seen is a bulbous/beaked tectum. There is dilatation of the third and both the lateral ventricles. The fourth ventricle is stretched in the supero-inferior direction.
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Rotational anomaly is seen of both the kidneys.

IMPRESSION :

The MRI features are suggestive of :

1. Post-operative status.

2. A probable neural placode over the L2 to L5 levels with insertion of the filum terminale.

3. The spinal cord in the mid and lower dorsal regions appears to be of smaller calibre ? atrophy.

4. Features of a Chiari II malformation in the brain with dilatation of the third and both the lateral ventricles.



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