Date : 00.00.00
Name of the Patient : Abc Xyzkant Adiplmn / M / 10 yrs.
Referred by : Dr. Abc Xyzdar / Dr. Abc Xyzidya.
Examination : M.R.I. of the Dorso-lumbo-sacral
CLINICAL PROFILE :
Diagnosed C/O congenital hydrocephalus with delayed milestones.
H/O surgery for meningomyelocele at the age of 3 days.
M.R.I of the dorso-lumbo-sacral 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.
3 mm thick T1 Weighted coronal images.
There is scoliosis of the mid dorsal spine with convexity to the right.
The distal sacral segments are not well visualized. There is an open lower lumbar and sacral canal.
There is evidence of a diastematomyelia with two hemicords extending over about D10 to L5-S1 levels. A bony bar is noted at the L1 level, separating the two hemicords. A syrinx is seen in the hemicord on the left at the level of the bony bar. Another focal syrinx is noted in the mid dorsal region.
The conus medullaris terminates at the S1 vertebral level. An intradural lipoma is noted at the L5/S1 vertebral level along the postero-lateral margin of the thecal sac. There is however, no obvious tethering of the left hemicord to the intradural lipoma.
The visualized dorso-lumbar vertebral bodies and the intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The right kidney is not identified in the right renal fossa, ? ectopic kidney, ?? agenesis of the right kidney.
The MRI features suggest spinal dysraphism with a diastematomyelia extending over about D10 to L5-S1 levels, with a bony bar at the L1 level, separating the two hemicords. A syrinx is seen in the hemicord on the left at the level of the bony bar and another focal syrinx in the mid dorsal region.
An intradural lipoma is noted at the L5/S1 level.
Non-visualization of the right kidney in the right renal fossa, ? ectopic kidney, ?? agenesis of the right kidney.