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Normal Cervical Spine MRI Report Template
Normal cervical spine MRI report template: alignment, marrow, cord signal and caliber, craniocervical junction, then level-by-level C2-3 through C7-T1 disc, canal and foraminal wording, with myelopathy and grading notes.
EXAMINATION: MRI cervical spine without intravenous contrast. CLINICAL HISTORY: [indication, e.g. “Neck pain with radiculopathy”] COMPARISON: None available. TECHNIQUE: Sagittal T1, T2 and STIR and axial T2 (and gradient echo) images of the cervical spine without intravenous contrast. FINDINGS: Alignment: Normal cervical lordosis. No listhesis. Craniocervical junction: Normal. The cerebellar tonsils are above the foramen magnum. Vertebral bodies and marrow: Normal heights and marrow signal. No fracture, marrow edema or focal lesion. Spinal cord: Normal caliber and signal throughout the visualized cervical and upper thoracic cord. No cord compression, edema or syrinx. Posterior fossa and visualized brain: Unremarkable. Prevertebral and paraspinal soft tissues: Normal. Disc levels: C2-3: Normal disc. No canal or foraminal stenosis. C3-4: Normal disc. No canal or foraminal stenosis. C4-5: Normal disc. No canal or foraminal stenosis. C5-6: Normal disc. No canal or foraminal stenosis. C6-7: Normal disc. No canal or foraminal stenosis. C7-T1: Normal disc. No canal or foraminal stenosis. IMPRESSION: 1. Normal MRI of the cervical spine. No disc herniation, spinal canal stenosis or cord signal abnormality.
Dictation notes
- Report canal stenosis by its effect on the cord — CSF effaced, cord contacted, cord flattened, cord with T2 signal change — rather than as “moderate”; the surgeon operates on the cord, not on the disc.
- Foraminal stenosis is graded on the axial gradient echo or T2 series and localized by side and the exiting root (a C5-6 foraminal disc compresses the C6 root) — write the root, not just the level, when the indication is radiculopathy.
- Cord T2 hyperintensity without a compressive cause is a differential (demyelination, infarct, inflammatory myelitis, compressive myelopathy at a different level) and the impression should recommend contrast or a brain MRI rather than stop at “signal change”.
- Describe a disc as protrusion versus extrusion and give its position (central, paracentral, foraminal) — this is the consensus nomenclature and the only wording that is reproducible between readers.
- The sagittal STIR is where the marrow edema, ligamentous injury and the compression fracture that CT missed live — read it separately rather than as a confirmation of T2.
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