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Current study

MR Lumbar SpineDe-identified synthetic case

Template

MRI Lumbar Spine

Format

Full structured reportNumbered impression
2:14
Preliminary
Template appliedSections orderedAustralian English

Exam

MRI lumbar spine.

Technique

Multiplanar multisequence non-contrast MRI of the lumbar spine.

Clinical details

Right-sided low back pain with L5 radicular symptoms.

Comparison

No prior imaging available for comparison.

Findings

Lumbar lordosis is maintained. Vertebral body heights are preserved. Mild Modic type 1 endplate change at L4/5. The conus terminates at L1 and has normal signal.

L1/2: No significant disc bulge, spinal canal or foraminal stenosis.

L2/3: Mild disc desiccation with a shallow central protrusion. No spinal canal or foraminal stenosis.

L3/4: Broad-based disc bulge with mild bilateral foraminal narrowing. No spinal canal stenosis.

L4/5: Disc desiccation with a 4 mm right paracentral protrusion narrowing the right subarticular recess and contacting the descending right L5 nerve root. Moderate right and mild left foraminal stenosis.

L5/S1: Mild disc desiccation and bilateral facet arthropathy. No spinal canal or foraminal stenosis.

Paravertebral musculature is preserved. The partially visualised sacroiliac joints are unremarkable.

Impression

1 L4/5 right paracentral disc protrusion contacts the descending right L5 nerve root.

2 Moderate right L4/5 foraminal stenosis may irritate the exiting right L4 nerve root.

3 Mild Modic type 1 endplate change at L4/5.

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Natural dictation · de-identified

“At L4/5 there is disc desiccation with a 4 mm right paracentral protrusion contacting the descending right L5 nerve root. Moderate right and mild left foraminal stenosis. L2/3 has a shallow central protrusion without stenosis. Lumbar lordosis and vertebral body heights are maintained. The conus is normal. At L3/4 there is a broad disc bulge with mild foraminal narrowing. L5/S1 has mild disc desiccation and facet arthropathy without stenosis. There is mild Modic type 1 change at L4/5.”

Your MRI lumbar spine template
HeadingsAnatomical orderNumbered impression

EXAM

MRI lumbar spine.

TECHNIQUE

Multiplanar multisequence non-contrast MRI.

CLINICAL DETAILS

Right-sided low back pain with L5 radicular symptoms.

COMPARISON

No prior imaging available.

FINDINGS

Lumbar lordosis and vertebral body heights are maintained. The conus is normal.

L1/2: No stenosis.
L2/3: Shallow central protrusion without stenosis.
L3/4: Broad disc bulge with mild bilateral foraminal narrowing.
L4/5: 4 mm right paracentral protrusion contacts the descending right L5 nerve root. Moderate right foraminal stenosis.
L5/S1: Mild disc and facet degeneration without stenosis.

IMPRESSION

1. L4/5 right paracentral disc protrusion contacts the descending right L5 nerve root.
2. Moderate right L4/5 foraminal stenosis may irritate the exiting right L4 nerve root.
3. Mild Modic type 1 endplate change at L4/5.

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Reporting preferencesSaved
SpellingUse Australian clinical spelling
Australian English⌄
MeasurementsKeep units consistent
mm⌄
Impression formatShort numbered conclusions
Voice correctionsRemember repeated vocabulary fixes
Preview

1. Small knee joint effusion.
2. No meniscal or ligament tear.

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