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sb/hs/nl/rg
Date : 00.00.00

Name of the Patient : Abc Xyzik Trilmn / M / 9 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

Operated for intraspinal dermoid in August 0000.
For follow-up.

EXAMINATION :

M.R.I of the lumbo-sacral spine was performed using the following parameters :

4 mm thick T1 Weighted and T2 Weighted sagittal images.

5 mm thick T1 Weighted and T2 Weighted axial images.

OBSERVATION :

There is evidence of laminotomy at the L4 and L5 vertebral levels with post-operative changes in the soft tissues in the posterior lumbar region at these levels.

There is slight widening of the spinal canal over the L3 to S2 vertebral levels. A small portion of the previously identified lesion is seen posterior to the L3 vertebral body in proximity to the conus. The intrathecal nerve roots are splayed peripherally, probably as a result of arachnoiditis. The tip of the conus medullaris appears slightly irregular and is displaced anteriorly.

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 conus medullaris terminates at the L3 level and the thecal sac terminates at the S3 level.

The lower dorsal spinal cord shows normal signal intensity.

IMPRESSION :

1. Post-operative status.

2. An intrathecal lesion extending posterior to the L3
vertebra as described represents a residual dermoid/epidermoid cyst. The intrathecal nerve roots are splayed peripherally, probably as a result of arachnoiditis.

As compared to the previous MRI scan 0000, dated 1.08.98, the patient is now status post-operative. There is near complete excision of the previously identified tumor. The intrathecal nerve roots are also better defined on the present study.

A contrast enhanced scan would be worthwhile, if clinically indicated.

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