Report template

Report template — MRI of esqueleto axial

MRI report template for esqueleto axial — clinical body in pt-BR with [...] placeholders for exam-specific findings.

When to use

Spine MRI is the method of choice for radicular pain, suspected disc herniation, myelopathy, spondylodiscitis, cord lesions and staging of vertebral metastasis. Distinguish from CT, indicated for fractures and bony surgical planning.

What to evaluate

  • Alignment, disc height and disc signal (degeneration / desiccation).
  • Protrusions and herniations: location (central, paramedian, foraminal, extraforaminal), neural compression.
  • Spinal canal: stenosis, myelopathy signs.
  • Facet joints and ligamentum flavum.
  • Bone marrow signal, focal lesions, marrow edema.

Interactive template

Fill the blanks0/1

(CALOTA CRANIANA + COLUNAS CERVICAL, TORÁCICA E LOMBAR + BACIA) Técnica: Exame realizado pelas técnicas STIR, T1 e difusão, da cabeça à raiz das coxas para avaliação de lesões ósseas, sem uso de contraste endovenoso. Estudo realizado com protocolo direcionado à pesquisa de mieloma múltiplo. Análise: - Lesões ósseas: ausentes. - Demais achados: Comparação: Em relação ao exame de não se observam alterações significativas. Conclusão: Exame dentro dos limites da normalidade.
Template in Brazilian Portuguese (clinical reporting language). Adapt to your service protocol. Not medical advice — the physician reviews, edits and signs.

How to use

  • Replace each [...] with the exam's measurement or descriptor.
  • Adapt the conclusion to your service protocol before signing.
  • Use the template as a starting point — not a replacement for physician review.
  • In Laudos.AI, dictate findings in natural speech and the AI structures text in this format for review.

Frequently asked

Herniation vs disc protrusion — definitions?
Fardon/Milette (2014) standard: bulging = wide base (> 25% of circumference); protrusion = base ≥ length; extrusion = length > base; sequestration = disconnected fragment.
When contrast-enhanced spine MRI?
Post-op (fibrosis vs recurrent herniation), suspected infection (spondylodiscitis, epidural abscess), primary/metastatic tumor and active inflammatory lesion.
Acute lumbar pain — when MRI?
Only with red flags: progressive neurologic deficit, fever, significant trauma, suspected malignancy, cauda equina syndrome, or refractory pain > 4–6 weeks.

References

  • Fardon DF et al., Spine J 2014 (Lumbar Disc Nomenclature).

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