Normal Lumbar Spine MRI Report Template

Normal lumbar spine MRI report template with level-by-level wording, conus position, alignment and degenerative grading notes.

EXAMINATION: MRI lumbar spine without intravenous contrast.

CLINICAL HISTORY: [indication]

COMPARISON: None available.

TECHNIQUE: Sagittal and axial multisequence MR imaging of the lumbar
spine without intravenous contrast.

FINDINGS:
Alignment: Normal lumbar lordosis. No spondylolisthesis.
Vertebrae: Normal heights and marrow signal. No acute fracture.
Conus medullaris: Terminates normally at [level]. Normal signal.
L1-L2 through L5-S1: No disc herniation, spinal canal stenosis or
neural foraminal narrowing at any level.
Paraspinal soft tissues: Unremarkable.

IMPRESSION:
1. No disc herniation, spinal canal stenosis or significant neural
foraminal narrowing.

Dictation notes

• Use a consistent grading vocabulary (disc bulge vs protrusion vs extrusion; mild/moderate/severe stenosis) — mixed vocabularies read as different findings on follow-up.
• State the conus level on every lumbar MRI; a low conus changes the differential.

Frequently asked questions

What belongs in a normal lumbar spine MRI report?

A lumbar spine MRI report covers alignment, vertebral body heights and marrow signal, the conus medullaris level and signal, each disc level from L1-L2 through L5-S1 for herniation, spinal canal stenosis and neural foraminal narrowing, and the paraspinal soft tissues. The normal impression states no disc herniation, canal stenosis or significant foraminal narrowing.

Why should the conus medullaris level be stated on every lumbar MRI?

The conus level should be reported on every lumbar spine MRI because a low-lying conus changes the differential — it raises the question of a tethered cord — and because documenting the level confirms the cord termination was actually reviewed. The conus normally ends around L1-L2 in adults. Conus signal should be assessed at the same time, since the distal cord is included on every lumbar study.

What is the difference between a disc bulge, protrusion and extrusion?

A bulge is disc material extending beyond the vertebral margins over more than 90 degrees of the circumference; a protrusion is a focal herniation whose base is wider than its dome; an extrusion's dome is wider than its base or the material migrates away from the disc. Using one consistent vocabulary, with graded stenosis (mild/moderate/severe), matters because mixed terms read as different findings on follow-up studies.

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