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ke/hs/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzlmn / F / 38 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O limp in the right leg since 2 months.
H/O neurogenic bladder and saddle back anesthesia.

EXAMINATION :

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.

OBSERVATION :

Open sacral canal is noted with probable absence of the posterior appendages on the left side at the S2 and S3 vertebral levels. The left side of the sacral ala is seen to be deformed.

There is tethering of the spinal cord into a hyperintense lesion on the T1 Weighted images which is intradural in location at the S2 vertebral level and follows fat signal intensity characteristics and represents a lipoma. This lipoma is seen to have a large extradural component on the left side at the S2 and S3 vertebral levels. Syrnix (isointense to CSF) is noted within the spinal cord over the L4 to S2 vertebral levels.

The lumbar vertebral bodies and the intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
- 2 - Scan-00006



IMPRESSION :

The MRI features are suggestive of :

1. Spinal dysraphism with tethering of the spinal cord at the S2 vertebral level into a lipoma as described.

2. Syrinx within the spinal cord over the L4 to S2 vertebral levels.

As compared to the previous MRI dated 00.00.00 (study no.0000) a syrnix is now seen to extend upto the L4 vertebral level.
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