Date : 00.00.00
Name of the Patient : Abc Xyzer B. Plmn / M / 27 days.
Referred by : Dr. Abc Xyzwant.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
M.R.I of the lumbo-sacral spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and T2 Weighted axial images.
3 mm thick T1 Weighted coronal images.
There is an open sacral canal from the L5 level downwards .
There is outpouching of the thecal sac at the L5 level extending upto the surface of the skin and would represent a meningocele. There is tethering of the spinal cord at the L4-L5 level which appears to be tethered to a neural placode at the L4 level. There is a suspicious hypointense area within the spinal cord at the L3 and L4 vertebral levels suggestive of a syrinx.
The remaining lumbar vertebral bodies and the intervertebral discs show normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The brain was screened with 5 mm thick T1 Weighted sagittal images and T2 Weighted axial images which shows severe dilatation of both the lateral and third ventricles. The fourth ventricle appears normal. There is resultant thinning of the corpus callosum. There is beaking of the tectal plate.
The MRI features are suggestive of spinal dysraphism with meningomyelocele and tethering of the spinal cord with hydrocephalus and beaking of the tectal plate.
The diagnosis of a Chiari malformation should be considered.