Presentation
History withheld.
Patient Data
Dorsal upper sacral defect associated with enlargement of the thecal sac without definite protrusion through the sacral defect. This area contains a lipomatous mass to which an elongated spinal cord is tethered at the L5/S1 level. The placode-lipoma interface is within the spinal canal (lipomyelocele). Minor posterior scalloping of the L5 and S1 vertebrae. No other cord signal abnormality. A slightly prominent cord central canal at C5/C6 is not large enough for a syrinx. No visible Chiari malformaiton.
Laminectomy of the L5 and posterior defect of the entire sacrum are noted, associated with a low-lying cord terminating in a fatty mass. The thecal sac is expanded at this level, protruding through the posterior defect. Features consistent with repaired lipomyelomeningocele. Note is made of bilateral L5 pars defects with only minimal (grade 1) spondylolisthesis.
Case Discussion
This patient had a lipomyelomeningocele diagnosed at birth, which was repaired shortly thereafter.
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