Radiology and Imaging Specialist-Vorlage
MRI L Spine Detailed Report
Eine professionelle Radiology and Imaging Specialist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Effortlessly generate comprehensive and accurate MRI L Spine detailed reports with this specialised template, perfect for radiologists and imaging specialists. Designed for clarity and precision, it captures essential findings from vertebral alignment to level-by-level anomalies, ensuring no critical detail is missed. This template streamlines the reporting process, providing structured sections for disc signal, vertebral marrow, cord termination, and paravertebral soft tissues. When used with Heidi, this template intelligently highlights contradictions and ensures all relevant clinical information is captured, producing a professional and consistent output. Enhance your diagnostic reporting with a tool that understands the nuances of spinal imaging.
Vorlagenvorschau
Specialty: Radiology and Imaging Specialist
MRI L Spine Detailed Report
Scan Date: 11 2024
Clinical Information
- Low back pain radiating to the left leg for 3 months.
- Suspected L5/S1 disc herniation.
- Neurological examination revealed weakness in the left extensor hallucis longus.
Findings
Vertebral Alignment:
Normal lumbar lordosis is maintained. No evidence of spondylolisthesis or retrolisthesis.
Disc Signal And Height:
L1/L2:
Disc signal and height are normal.
L2/L3:
Disc signal and height are normal.
L3/L4:
Disc signal is reduced, indicating mild desiccation. Disc height is preserved.
L4/L5:
Disc signal is significantly reduced, indicating moderate desiccation. Disc height is mildly reduced.
L5/S1:
Disc signal is markedly reduced, indicating severe desiccation. Disc height is significantly reduced.
Vertebral Marrow Signal:
L1:
Vertebral marrow signal is normal.
L2:
Vertebral marrow signal is normal.
L3:
Vertebral marrow signal is normal.
L4:
Vertebral marrow signal is normal.
L5:
Vertebral marrow signal is normal.
Cord Termination:
The spinal cord terminates at the T12/L1 level.
Level-By-Level Findings:
L1/L2:
No disc bulge or protrusion. No nerve root impingement. Facet joints demonstrate no degenerative changes. Ligamentum flavum normal.
L2/L3:
No disc bulge or protrusion. No nerve root impingement. Facet joints demonstrate no degenerative changes. Ligamentum flavum normal.
L3/L4:
Broad-based disc protrusion, causing mild effacement of the thecal sac. Left and right nerve roots are not compressed. Facet joints show mild degenerative changes. Ligamentum flavum is mildly hypertrophied.
L4/L5:
Central and paracentral disc extrusion measuring 6 x 8 mm, indenting the thecal sac and impinging on the traversing left L5 nerve root. Right L5 nerve root is normal. Facet joints show moderate degenerative changes with mild osteophytes. Ligamentum flavum is moderately hypertrophied.
L5/S1:
Posterior disc bulge with a small central annular tear. No significant nerve root compression. Facet joints show severe degenerative changes with prominent osteophytes and subchondral sclerosis. Ligamentum flavum is severely hypertrophied.
Paravertebral Soft Tissues:
No abnormal soft tissue masses or fluid collections are identified in the paravertebral regions.
Conclusion
- moderate disc desiccation and mild height loss at L4/L5 with central and paracentral disc extrusion, impinging on the traversing left L5 nerve root.
- severe degenerative changes at L5/S1 facet joints.
- neither cauda equina nor cord compression.
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