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Radiology and Imaging Specialist Template

MRI lumbar spine detailed

A professional Radiology and Imaging Specialist template for healthcare professionals.
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About this template

Need to document the findings of a lumbar spine MRI? This MRI L spine detailed template is perfect for radiology and imaging specialists. It provides a structured format to record scan dates, detailed findings on vertebral alignment, disc desiccation, marrow signal, cord termination, and specific lumbar level observations. This template helps ensure comprehensive reporting of the MRI, including conclusions on cauda equina and cord compression. With Heidi, this template can be quickly populated from a medical visit transcript, saving valuable time and improving documentation accuracy. Get your MRI reports done efficiently and accurately with this template.

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Scan Date 1 November 2024. Findings The L5/S1 disc level is taken as the first fully formed disc above the sacrum Vertebral Alignment: Mild levoscoliosis noted. Disc Desiccation and Thickness: L4/L5: Mild disc desiccation. L5/S1: Moderate disc desiccation with reduced disc height. Vertebral Marrow Signal: L3: Normal marrow signal. L4: Mildly decreased marrow signal. Cord Termination: Conus medullaris terminates at the L1/L2 level. Lumbar Level Findings: L3: No significant findings. L4: Mild disc bulge with possible mild left foraminal stenosis. No significant nerve root compression. L5: Moderate disc bulge with mild bilateral foraminal stenosis. Possible mild compression of the left S1 nerve root. L5/S1: Moderate disc herniation with severe left foraminal stenosis and compression of the left S1 nerve root. Mild right foraminal stenosis. Facet Joints and Ligamentum Flavum: Mild degenerative changes in facet joints at L4/L5 and L5/S1 levels. Ligamentum flavum appears mildly thickened at L5/S1. Paravertebral Soft Tissues: No significant abnormalities. Conclusion - Moderate disc herniation at L5/S1 with severe left foraminal stenosis and compression of the left S1 nerve root. - Mild to moderate degenerative changes noted at multiple levels. - No cauda equina or cord compression identified. - Survey and planning images are non-diagnostic.
Scan Date [Date]. [Findings] The L5/S1 disc level is taken as the first fully formed disc above the sacrum (If vertebral alignment mentioned, report it here) (If disc desiccation and/or disc thickness mentioned, report it here. Use separate headings for each level mentioned) (Mention the levels of vertebral marrow signal findings - report on each level separately) (Mention the levels cord termination) (Please mention the findings at each lumbar level mentioned. There might be comment on the disc, nerve roots left and right. If there is contrast used then there might be comments on areas of enhancement. Mention facet joints in terms of degenerative disease severity if mentioned. Please keep the findings grouped by lumbar level. The lumbosacral level or L5/S1 is also considered to be a level to comment upon if mentioned) (There may be a more general summary about facet joints, ligamentum flava findings, if so, report here) (If there is a comment about paravertebral soft tissues then mention it here) Conclusion - (Please conclude here. Important features should be the absence or presence of cauda equina compression or cord compression. If absent, or not mentioned, then a statement to say that there is neither cauda equina nor cord compression can go here. Use bullet points) - (Please conclude upon any non-diagnostic imaging. Please mention any use of survey images or planning images. State that survey and planning images are non-diagnostic) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
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Specialty

Radiology and Imaging Specialist

Used

7 times

Type

Document

Last edited

15/07/2025

Created by

Heshan Panditaratne

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