Date : 00.00.00
Name of the Patient : Abc XyzKaplmn / F / 27 yrs.
Referred by : Dr. Abc Xyzlkaka.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
H/O spinal surgery in 0000 (details unavailable), (? dermoid).
C/O numbness in toes, ankles and fingers of BLE since 0000.
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 mm thick T1 Weighted and T2 Weighted axial images.
There is evidence of laminectomy over the L1 to L3 vertebral levels with post-operative changes in the soft tissues in the posterior lumbar region over these levels.
There is a well-marginated, hyperintense lesion on the T1 Weighted images within the thecal sac over the D12 to L2 vertebral levels. This lesion follows fat signal characteristics and appears relatively hypointense on the T2 Weighted images. The lesion is noted along the anterior and left lateral margin of the lower dorsal spinal cord. A smaller, similar signal intensity lesion is noted at the L5 vertebral level, in close relation to the intrathecal nerve roots at that level.
The intrathecal nerve roots at the L2 and L3 vertebral levels appear clumped, suggesting arachnoiditis.
Slight retroplacement of the thecal sac at the operative site is noted.
The lumbar vertebral bodies and the intervertebral discs reveal normal signal intensity. The left facet joint at the L2-L3 level appears slightly hypertrophied. The visualized pre and paravertebral soft tissues are unremarkable.
It is difficult to identify the conus medullaris separately from the lesion.
The visualized lower dorsal spinal cord appears atrophied without any change in signal intensity.
The thecal sac terminates at the S3 level.
1. Post-operative status.
2. Residual fat signal intensity lesion within the thecal sac over the D12 to L2 vertebral levels along the posterior and left lateral margin of the lower dorsal spinal cord as described is not specific for a single etiology. This may represent a dermoid or a lipoma.
3. Clumped intrathecal nerve roots at the L2 and L3 vertebral levels suggest arachnoiditis.
4. Atrophy of the visualized lower dorsal spinal cord.
As compared to the previous MRI dated 00.00.00, there is reduction in the size of the lesion.