sb/hs/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyzt lmn / M / 3 1/2 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
C/O weakness of the RLE.
H/O VP shunt done at the age of 2 months and spinal surgery 3 1/2 years back. (Exact details not available).
EXAMINATION :
M.R.I of the dorso-lumbar 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.
OBSERVATION :
There is evidence of spina bifida over the D11 to atleast the S1 vertebral level with a resultant open lumbo-sacral canal, posteriorly.
There is evidence of a subcutaneous lipoma in the lumbo-sacral region, posteriorly, extending over the L2 to atleast S4 vertebral levels. Minimal lipomatous tissue is noted, intradurally, along the posterior margin of the thecal sac at the L5 and S1 vertebral levels. An ill-defined hypointense signal on all the pulse sequences deep to the subcutaneous lipoma at the L4 vertebral level may represent fibrous/scar tissue (or ?? a dorsal dermal sinus).
The tip of the conus medullaris is noted at the L4-L5 disc level. A syrinx (isointense to CSF) is noted in the spinal cord at the D6 and D7 vertebral levels and the D11 and D12 vertebral levels. The spinal cord appears atrophied at the L1 and L1-L2 disc levels. There is a suggestion of diastematomyelia at the L2, L2-L3 and at the D12-L1 levels. There is however, no obvious fibrous/bony bar noted at these levels.
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 thecal sac terminates at the S2 level.
IMPRESSION :
1. Spina bifida over the D11 to atleast the S1 vertebral level with a resultant open lumbo-sacral canal, posteriorly.
2. Subcutaneous lipoma in the lumbo-sacral region, posteriorly, extending over the L2 to atleast S4 vertebral levels with minimal extension intradurally, at the L5 and S1 vertebral levels.
3. Fibrous/scar tissue (or ?? a dorsal dermal sinus) deep to the subcutaneous lipoma at the L4 vertebral level.
4. A syrinx in the spinal cord at the D6 and D7 vertebral levels and the D11 and D12 vertebral levels.
5. Atrophied spinal cord at the L1 and L1-L2 disc levels.
6. Probable diastematomyelia at the L2, L2-L3 and at the D12-L1 levels without an obvious fibrous/bony bar.