Date : 00.00.00
Name of the Patient : Abc Xyzl Qlmn / M / 18 mnths.
Referred by : Dr. Abc Xyzapadia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O retention of urine.
M.R.I of the lumbo-sacral spine was performed using the following parameters :
3 mm thick T1 Weighted and T2 Weighted sagittal images.
6 mm thick T1 Weighted and T2 Weighted axial images.
There is evidence of an open lumbo-sacral canal from the L4 level to the S2 level.
There is outpouching of the thecal sac at the L4 and L5 levels. The spinal cord is tethered at the L4 level to a neural placode at the L4 vertebral level.
A syrinx is seen within the lower dorsal and lumbar spinal cord and is multi-septate.
The remaining 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 cervico-dorsal spine screened with 4 mm thick T1 Weighted sagittal images and the brain was screened with 5 mm thick T1 Weighted axial images and which shows moderate dilatation of both the lateral and third ventricles. The fourth ventricle is small. There is beaking of the cerebllar tonsils and the tip is seen to lie below the foramen magnum level. A syrinx is noted in the lower cervical and dorsal regions.
A Chiari malformation with meningocele at the L4 and L5 vertebral levels with tethering of the spinal cord at the L4 level to a neural placode at the L4 vertebral level with other changes of a Chiari malformation as described above.