Date : 00.00.00
Name of the Patient : Abc Xyz Shilmn / F / 17 days.
Referred by : Dr. Abc XyzMehta.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O swelling over the low back since birth with defect in BLE (right more than left).
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.
The L5 vertebral body is as marked on the film.
There is probable fusion and segmentation anomalies of the D9 to L1 vertebral bodies.
There is seen a fairly large, intermediate signal intensity lesion on the T1 Weighted images traversing the spinal canal, antero-posteriorly over the D10 to L1 vertebral levels. This lesion follows marrow signal intensity on all pulse sequences and represents a bony bar. The spinal cord is seen to split into the two hemi-cords over about the D7 to L5 vertebral levels. Separate thecal sac are noted at the levels corresponding to the bony bar. The left hemi-cord is slightly smaller than the right. Another, probable bony/fibrous band is noted at the L4-L5 level (scans 106.4, 107.4 & 107.5). The spinal cords probably unite distally at about the S1 vertebral level.
The thecal sac seems to extend upto the sacro-coccygeal junction and is open towards the skin surface at that level.
A small, intradural lipoma is noted at the tip of the thecal sac with the filum terminale, probably tethered to it (scans 102.4, 103.5, 103.6).
A syrinx is noted over the D4 to D6 vertebral levels.
The rest of the visualized dorso-lumbar vertebral bodies and the intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The MRI features suggests a diastematomyelia with hemi-cords extending over the D7 to L5 vertebral levels. A bony bar is noted over about the D10 to L1 vertebral levels with a another bony/fibrous bar at the L4-L5 level. A syrinx is noted over the D4 to D6 vertebral levels. An intradural lipoma is noted at the sacro-coccygeal junction with filum terminale probably tethered to a lipoma. Segmentation anomalies and fusion of the D9 to L1 vertebral bodies is noted.