Date : 00.00.00
Name of the Patient : Abc Xyza P. Vallmn / F / 9 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
H/O spinal surgery for an extradural dermoid in April 0000.
C/O backache with pain radiating to the RLE since 2 months.
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.
There are post-operative changes in the posterior soft tissues in the lumbar region and laminectomy of the lumbar vertebrae.
The thecal sac in the lower dorsal and the lumbar region appears capacious with scalloping of the posterior aspect of the L2, L3 and L4 vertebral bodies.
The tip of the spinal cord is seen to lie at the L3 vertebral level.
A hyperintense intradural lesion is seen on the T1 Weighted images, along the posterior margin of the spinal cord at the L2 vertebral level which is seen to follow fat signal characteristics. This represents an intradural lipoma.
There is a suggestion of a syrinx over the D6 to D8 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.
The hip joints were screened with 5 mm thick T1 Weighted coronal images which shows superior dislocation of the right femur with inflammatory changes (probably infective) around the right hip joint, the right iliac bone and around the right thigh.
1. Post-operative status.
2. Tethering of the spinal cord with the tip lying at the L3 vertebral level.
3. Intradural lipoma along the posterior margin of the spinal cord at the L2 vertebral level (?? residual dermoid).
4. A suggestion of a syrinx over the D6 to D8 vertebral levels.
5. Superior dislocation of the right femur with inflammatory changes (probably infective) around the right hip joint, the right iliac bone and right thigh.