ke/sb/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzni A. Klmn / F / 9 months.
Referred by : Dr. Abc Xyzthure.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O purulent discharge from low back since 1 month with fever.

EXAMINATION :

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

3 mm thick T1 Weighted and T2 Weighted sagittal images.

4 mm thick T1 Weighted coronal images.

4 mm thick T1 Weighted and T2 Weighted axial images.

OBSERVATION :

The L5 vertebral body is as marked on the film.

There is seen an obliquely oriented linear, hypointense signal on all pulse sequences in the subcutaneous fat in the midline, in the posterior lumbo-sacral region at the S3 vertebral level. This lesion extends from the surface of the skin upto the posterior paraspinal muscle layer. Spina bifida is noted at S3 level. There is extension of this tract upto the lamina of the S3 vertebra (suspicious soft tissue/fibrous/bony spur is noted in the right postero-lateral epidural space at S2/S3 level).

The tip of the conus medullaris is noted at the L2-L3 level. No intraspinal lipoma/tethering of the cord is noted.

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.
- 2 - scan-00003


IMPRESSION :

The MRI features suggest a dorsal dermal sinus at about the S3 vertebral level as described. A probable S3 spina bifida is noted. There is no evidence of tethering.