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ke/sb/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzeep M. Balmn / M / 9 yrs.
Referred by : Dr. Abc Xyzankhla.
Examination : M.R.I. of the Dorso-lumbar Spine.

CLINICAL PROFILE :

C/O weakness of BLE and no control over bowel since birth.
Release of tethered cord with excision of lipoma on 00.00.0000.

EXAMINATION :

M.R.I of the dorso-lumbar spine was performed using the following parameters :

5 mm thick T1 Weighted and T2 Weighted sagittal images.

6 mm thick T1 Weighted and T2 Weighted axial images.

OBSERVATION :

There are post-operative changes in the posterior soft tissues over the L3 to S1 levels. Open lumbo-sacral canal is noted at the L3, L4 and L5 levels. Segmentation anomaly of the L4 vertebral body and posterior elements of the L4 and L5 vertebrae is noted.

There is tethering of the spinal cord to an intradural lipoma at the L2 and L3 vertebral levels and its tip is seen to lie at the L4-L5 level with thickened filum terminale extending upto the L5-S1 level.










A hypointense signal is seen in the spinal cord extending over the D12-L1 level upwards into the dorsal spine upto about D9 vertebral level, with few septae following CSF signal characteristics and would represent a syrinx.

Dural ectasia is seen in the lower lumbar region.

The visualized dorso-lumbar vertebral bodies and the intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

IMPRESSION :

The MRI features are suggestive of :

1. Post-operated study.

2. Spinal dysraphism with an intradural lipoma at the L2 and L3 levels, tethering the spinal cord with its the tip lying at the L4-L5 level with thickened filum terminale extending upto the L5-S1 level. A syrinx in the lower dorsal spinal cord extending over the D12-L1 level upwards into the dorsal spine upto about the D9 level, with few septae.

As compared to the previous MRI dated 00.00.00, there is still seen a residual intradural lipoma at the L2/L3 level, tethering the cord. A syrinx is not noted in the lower dorsal region.








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