Date : 00.00.00
Name of the Patient : Abc Xyzra M. Jlmn / F / 30 yrs.
Referred by : Dr. Abc Xyzgla.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O radicular pain in BLE (left more than right) with tingling.
H/O TP Shunt with tethering of cord - repair and excision of meningocele sac done 00.00.00.
M.R.I of the lumbo-sacral spine was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
5 and 8 mm thick T1 Weighted and T2 Weighted axial images.
There are post-operative changes in the posterior soft tissues in the lumbo-sacral region.
There is an open sacral canal over the S2 level downwards with outpouching of the thecal sac which would represent a meningocele. A probable neural placode is noted along the right lateral margin of the meningocele sac (sacns 106.3-4).
The spinal cord is low lying and its tip is seen to lie at the L3 vertebral level. Probable thickened filum terminale is noted.
The lumbar vertebral bodies and the intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
- 2 -
The dorsal spine was screened with help of 5 mm thick T2 Weighted sagittal images which shows a syrinx in the dorsal spinal cord over the D8 to the D10 vertebral levels. The cervico-dorsal spine was screened with the help of 5 mm thick T1 Weighted sagittal images and which shows atrophy of the upper dorsal spinal cord.
1. Post-operative status.
2. A meningocele sac with low lying spinal cord as described.
3. A syrinx in the dorsal spinal cord over the D8 to the D10 vertebral levels, with atrophy of the upper dorsal spinal cord.
As compared to the previous MRI dated 00.00.00, there is slight decrease in size of the meningocele sac. The size and extent of the dorsal syrinx is unchanged.