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Normal Thoracic Spine MRI Report Template
Normal thoracic spine MRI report template: alignment, vertebral marrow, cord signal and caliber, disc levels T1-2 through T12-L1 and the conus, with notes on level counting, cord signal change and compression fracture wording.
EXAMINATION: MRI thoracic spine without intravenous contrast. CLINICAL HISTORY: [indication, e.g. “Mid back pain”] COMPARISON: None available. TECHNIQUE: Sagittal T1, T2 and STIR and axial T2 images of the thoracic spine without intravenous contrast. Levels were numbered from [the C2 vertebra on the sagittal localizer / the lumbosacral junction, assuming five lumbar-type vertebrae]. FINDINGS: Alignment: Normal thoracic kyphosis. No listhesis or scoliosis. Vertebral bodies: Normal height and marrow signal. No compression deformity, marrow edema, focal marrow replacing lesion or endplate change. Spinal cord: Normal caliber and signal from the cervicothoracic junction to the conus medullaris. The conus terminates at [L1]. No syrinx or intramedullary lesion. Discs: Normal disc height and signal at every level from T1-2 through T12-L1. No disc protrusion, extrusion or significant bulge. Spinal canal and foramina: The spinal canal is capacious at every level. No central canal or neural foraminal stenosis. Facet joints and posterior elements: Unremarkable. No facet arthropathy or ligamentum flavum thickening. Epidural space and thecal sac: No epidural collection or mass. The cerebrospinal fluid signal is normal. Paraspinal soft tissues: Unremarkable. The visualized posterior mediastinum, lungs and retrocrural region are unremarkable. IMPRESSION: 1. Normal MRI of the thoracic spine. No disc herniation, canal stenosis, cord signal abnormality or compression fracture.
Dictation notes
- State how the levels were counted (from C2 down or from the sacrum up) and whether a transitional vertebra is present — a thoracic level that is one off from the surgeon's count is the classic wrong-level surgery setup, and the method in the TECHNIQUE line is the defense.
- Cord signal change is described by length in vertebral segments, cross-sectional extent (central, dorsal columns, lateral columns) and whether it enhances or expands the cord — demyelination, ischemia and compressive myelopathy have different footprints.
- A compression fracture needs height loss as a percentage, the STIR marrow signal (acute versus chronic), posterior cortex integrity and any retropulsion — benign and pathologic fractures are separated by the convex posterior border, pedicle involvement and marrow replacement, not by height loss alone.
- Thoracic disc herniations are frequently calcified and the cord has no room: describe the cord deformity and any signal change rather than reporting the herniation size in isolation.
- The visualized posterior mediastinum, lungs, aorta and kidneys are part of the read; a posterior mediastinal mass or aortic aneurysm on a spine MRI is a reportable incidental finding.
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