Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

MRI of the Cervical and Lumbar Spine Radiology Sample Report

DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

INDICATIONS FOR STUDY:
1.  Spinal stenosis.
2.  Low back pain.
3.  Bilateral leg numbness.
4.  Weakness in hands.

CERVICAL AND LUMBAR SPINE MRI:

Due to the patient's body habitus and size, the patient could not be moved into the coil more and visualization of the upper lumbar spine is very limited.  The patient's head was also squeezed into the cervical spine coil and was very uncomfortable during the study.

MRI OF THE CERVICAL SPINE:

Sagittal and axial images were obtained.  The craniocervical junction is within normal limits.  Spinal cord is normal in location and signal intensity.  There is straightening of the normal curvature.  Marrow signal within the bony structures is unremarkable.

At C7-T1, there is no focal disk disease.

At C6-7, there is a disk bulge which causes mild flattening of the anterior CSF space and some neural foraminal narrowing, left greater than right.

At C5-6, there is a combination of disk bulge and posterior osteophytes, which narrows the neural foramina and flattens the anterior CSF space, more so than at the C6-7 level.

At C4-5, there is a disk bulge, which flattens the anterior CSF space and causes some bilateral neural foraminal narrowing, left greater than right.

At C3-4, there is a combination of bone and disk, which slightly flattens the anterior CSF space and narrows the neural foramina bilaterally.

IMPRESSION:
Some mild multilevel disk disease, as described above, with some disk bulges and posterior osteophytes.  There is no frank disk herniation.

MRI OF THE LUMBAR SPINE:

Sagittal and axial images were obtained.  The upper lumbar spine is not well visualized due to body habitus and positioning within the coil.  The conus appears grossly within normal limits, normal in location and signal intensity.  The marrow signal appears within normal limits.  There is marked narrowing at L5-S1 with some apparent fusion at this level to the left of midline.  There is some minimal scoliosis.  Marrow signal within the bony structures is unremarkable.

At L5-S1, the nerve roots exit normally.  There is some slight right neural foraminal narrowing on one image due to a combination of bone and disk; however, the neural foramina are patent on the next image.

At L4-5, there is a mild disk bulge and posterior facet degenerative changes.  Nerve roots are patent.

At L3-4, there are some mild posterior facet degenerative changes, thickening of the ligamentum flavum, and neural foraminal narrowing.  On the next image, the nerve roots exit normally.

IMPRESSION:
1.  There is some slight trilateral narrowing at L3-4.  The nerve roots exit more normally on the next image.
2.  At L4-5, there is a disk bulge and some posterior facet degenerative changes.
3.  At L5-S1, there is a bulging disk and narrowing on the right with slight right neural foraminal narrowing on one image.  On the next, the neural foramina are more patent.  There is no focal disk herniation.

More MRI Sample Reports and Examples           Right Elbow MRI Sample Report


MRI of the Right Knee Sample                            Abdominal MRI Sample Report