sb/bv
Date : 00.00.00

Name of the Patient : Abc XyzJ. Glmn / F / 11 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 on 00.00.00. Histopathology s/o ? fibrolipoma, ? infundibular cyst.
On 00.00.00, excision of intradural lesion at L4 and L5 levels was done.
For follow up.

EXAMINATION :

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

5mm 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 seen 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 still seen an intermediate signal intensity mass lesion on the T1 Weighted images within the thecal sac at the L4 and L5 vertebral levels, along the posterior and right lateral margin of the spinal cord. This lesion appears relatively hypointense on the T2 Weighted images. Along the left lateral margin of the lesion, there is a focal hyperintense lesion on the T1 Weighted images which appears relatively hypointense on the T2 Weighted images and may represent fatty tissue. The intrathecal nerve roots of the conus-cauda region are clumped. The tip of the conus medullaris is not well identified separately from the
..2/.






lesion but may terminate at the L5 vertebral level. The spinal cord is low-lying. The distal spinal cord over L3 to L5 vertebral levels shows evidence of a deep ventral comissure.

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

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.

IMPRESSION :

As compared to the previous MRI dated 00.00.00 (study no.00002), there is significant reduction in the size of the intrathecal lesion though, minimal residual lesion is noted along the posterior and right lateral margin of the spinal cord.

The patient is status post-operative.