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Date : 00.00.0000

Name of the Patient : Abc XyzJ. Glmn / F / 12 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O swelling in the lumbo-sacral region since birth. Operated upon on 00.00.00. Histopathology s/o ? fibrolipoma, ? infundibular cyst.
On 00.00.00, excision of an intradural lesion at the L4 and L5 levels was done.
For follow-up.

EXAMINATION :

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.
5 mm thick T1 Weighted coronal images.

OBSERVATION :

There is evidence of an open lumbo-sacral canal over the L2 to S2 vertebral levels. Susceptibility artifacts at the S1 vertebral level to the left of the midline, may be the sequelae of previous surgery. There is slight hypertrophy of the laminae at the L4 and L5 vertebral levels which may also be the sequelae of previous surgery.

There is seen an intradural fat signal intensity lesion on all pulse sequences along the left lateral and posterior margin of the lower spinal cord over the L3-L4 disc level upto the L5 vertebral level. This lesion represents an intradural lipoma. The posterior margin of the spinal cord is most likely adhered to this lipoma.

The lower spinal cord appears slightly irregular and the intrathecal nerve roots appear clumped. The tip of the conus medullaris terminates at about the L5-S1 disc level. ..2/.





The distal spinal cord over the L3 to L5 vertebral levels shows evidence of a deep ventral commissure.

Scalloping of the posterior margins of the lumbar vertebrae is noted with probable dural ectasia in the lower lumbar region.

The lumbar vertebral bodies and intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.

IMPRESSION :

The patient is a known C/O spinal dysraphism with an open lumbo-sacral canal, intradural lipoma and a tethered cord as described. The patient is status post-operative for an intradural epidermoid tumor.

As compared to the previous MRI dated 00.00.00 (study no.00001), the previously identified residual intradural epidermoid tumor is not identified on the present study. Slight irregularity of the lower spinal cord is noted over L3 to L5 levels as described.



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