ke/sb/rg.
Date : 00.00.00
Name of the Patient : Abc XyzMitlmn / F / 16 yrs.
Referred by : Dr. Abc Xyzl.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
C/O scoliosis of the spine with difficulty in walking since 4-5 years.
EXAMINATION :
M.R.I of the dorso-lumbar spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
8 mm thick T1 Weighted and T2 Weighted axial images.
OBSERVATION :
There is scoliosis of the dorso-lumbar spine with convexity to the right. Segmentation vertebral anomalies are noted in the upper dorsal region.
There is evidence of diastematomyelia extending over the D7 to D12 vertebral levels. A probable bony/fibrous spur is noted at the D10 vertebral level. A syrinx is noted at the D9 vertebral level, anteriorly and at the D3/D4 level.
The tip of the conus is noted at the L3 vertebral level.
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.
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IMPRESSION :
The MRI features are suggestive of spinal dysraphism with :
1. Segmentation vertebral anomalies in the upper dorsal region.
2. Diastematomyelia extending over the D7 to D12 vertebral levels. A probable bony/fibrous spur at the D10 vertebral level.
3. A syrinx in the dorsal spinal cord at the D9 and D3/D4 level.
As compared to the previous MRI (Study No.0000) dated 00.00.00, there is no significant change noted.