Date : 00.00.00
Name of the Patient : Abc XyzJ. Glmn / F / 11 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O swelling in the lumbo-sacral region since birth. Operated on 00.00.00. Histopathology s/o ? fibrolipoma, ? infundibular cyst.
Now C/O low backpain radiating to the LLE on sitting/standing or walking for a long time since 1 month.
M.R.I of the lumbo-sacral 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.
3 mm thick T2 Weighted coronal images.
There is seen an open lumbo-sacral canal over the L3 to S2 vertebral levels. Susceptibility artifacts at the S1 vertebral level to the left of the midline, may be the sequelae of previous surgery.
There is seen an approximately 2.1 x 2.2 x 3.2 cms sized well-defined mass lesion within the thecal sac, extending over the L4 and L5 vertebral levels. This lesion is slightly hyperintense to CSF on all the pulse sequences. Along the postero-superior margin of the lesion, there is a focal hyperintense lesion on the T1 Weighted images which appears relatively hypointense on the T2 Weighted images and may represent fatty tissue. The intrathecal nerve roots of the
conus-cauda region are draped around this lesion. The tip of the conus medullaris is not well identified separately from the lesion. The spinal cord is low-lying and is tethered to the mass lesion. Scalloping of the posterior margins of the lumbar vertebrae is noted with probable dural ectasia in the lower lumbar region.
The remaining lumbar vertebral bodies and the intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
1. Post-operative status.
2. An approximately 2.1 x 2.2 x 3.2 cms sized intradural mass lesion at the L4 and L5 vertebral levels as described is not specific for a single etiology. This may represent a dermoid/epidermoid cyst. A fat signal intensity lesion is noted along the postero-superior margin of the lesion. The spinal cord appears to be tethered to the mass lesion.
No previous investigations were available for comparison.