Date : 00.00.00
Name of the Patient : Abc XyzMitlmn / F / 16 yrs.
Referred by : Dr. Abc Xyzl.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
C/O scoliosis of the spine with difficulty in walking since 4-5 years.
M.R.I of the dorso-lumbar spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
8 mm thick T1 Weighted and T2 Weighted axial images.
There is scoliosis of the dorso-lumbar spine with convexity to the right. Segmentation vertebral anomalies are noted in the upper dorsal region.
There is evidence of diastematomyelia extending over the D7 to D12 vertebral levels. A probable bony/fibrous spur is noted at the D10 vertebral level. A syrinx is noted at the D9 vertebral level, anteriorly and at the D3/D4 level.
The tip of the conus is noted at the L3 vertebral level.
The visualized dorso-lumbar vertebral bodies and intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The MRI features are suggestive of spinal dysraphism with :
1. Segmentation vertebral anomalies in the upper dorsal region.
2. Diastematomyelia extending over the D7 to D12 vertebral levels. A probable bony/fibrous spur at the D10 vertebral level.
3. A syrinx in the dorsal spinal cord at the D9 and D3/D4 level.
As compared to the previous MRI (Study No.0000) dated 00.00.00, there is no significant change noted.