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Normal Lumbar Spine CT Report Template
Normal lumbar spine CT report template: alignment, vertebral heights, posterior elements, disc levels, pars and the visualized paraspinal soft tissues, with notes on fracture classification and when MRI follows.
EXAMINATION: CT lumbar spine without intravenous contrast. CLINICAL HISTORY: [indication, e.g. “Low back pain”] COMPARISON: None available. TECHNIQUE: Axial helical images through the lumbar spine without intravenous contrast, with coronal and sagittal reformats in bone and soft tissue algorithms. Dose reduction techniques were used. FINDINGS: Alignment: Normal lumbar lordosis. No listhesis. The anterior and posterior vertebral lines and spinolaminar line are maintained. Vertebral bodies: Five non-rib-bearing lumbar-type vertebrae. Normal heights. No acute fracture. Normal bone density for age. Posterior elements: The pedicles, pars interarticularis, laminae, facets and spinous processes are intact at all levels. No pars defect. Discs: Disc heights are preserved. No significant disc bulge or herniation on this CT examination. Central canal: No significant central canal stenosis at any level. Neural foramina: Patent bilaterally at all levels. Facet joints: No significant facet arthropathy. Sacrum and sacroiliac joints: Intact. The sacroiliac joints are unremarkable. Paraspinal soft tissues: Normal. No paraspinal hematoma or collection. Visualized abdomen and pelvis: Unremarkable on this limited examination. IMPRESSION: 1. No acute fracture or malalignment of the lumbar spine. 2. No significant degenerative change.
Dictation notes
- Count the vertebrae from the sagittal reformat and state the numbering convention used when there is a transitional segment — a level-off error here becomes a wrong-level surgery.
- Classify a thoracolumbar fracture by morphology (compression, burst, distraction, translation) and say whether the posterior ligamentous complex is involved — that is the AO/TLICS language the spine surgeon uses to decide on bracing versus fixation.
- Report the percent height loss and the amount of retropulsion into the canal for any compression deformity; “mild compression fracture” cannot be followed.
- CT does not clear the cord or ligaments — when there is a burst fracture, a neurologic deficit or an unexplained posterior element injury, the impression should recommend MRI explicitly.
- Describe the pars on the sagittal reformat at L5 in every young patient with low back pain; an incomplete stress reaction is a fine lucency, not a frank defect.
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