---

MRI Lumbar Spine - Structured Reporting Guide

How to Approach the Report

---

SECTION 1: CLINICAL INFORMATION & TECHNIQUE

• Indication (back pain, radiculopathy, post-op, red flags, etc.)
• Sequences performed: typically sagittal T1, sagittal T2, axial T2, STIR (±axial T1, ±contrast sequences)
• Field of view covered (e.g., T12 to sacrum)
• Comparison with prior imaging if available
• Contrast: if gadolinium was given, state dose and enhancement pattern

---

SECTION 2: VERTEBRAL BODIES

• Count vertebrae from the top - use the L1 level as anchor (opposite the conus)
• State the number of lumbar vertebrae (5 normal, 4 or 6 = transitional)
• Note any sacralization of L5 or lumbarization of S1 (Castellvi classification for lumbosacral transitional vertebrae - LSTV)
• Quantify spondylolisthesis by Meyerding grade (I: <25%, II: 25-50%, III: 50-75%, IV: >75%)

---

SECTION 3: INTERVERTEBRAL DISCS

A. Disc Degeneration

• Grade I: Homogeneous, bright white nucleus, normal height
• Grade II: Inhomogeneous, bright nucleus, possible horizontal cleft, normal height
• Grade III: Inhomogeneous, grey nucleus, unclear distinction from annulus, normal to slightly reduced height
• Grade IV: Inhomogeneous, dark nucleus, no distinction from annulus, reduced height
• Grade V: Collapsed disc, no distinction nucleus/annulus, markedly reduced height

B. Disc Morphology (Herniation Classification)

• Central
• Right/Left paracentral (subarticular zone) - most common, compresses traversing nerve root
• Right/Left foraminal - compresses exiting nerve root
• Right/Left extraforaminal (far lateral)

C. High-Intensity Zone (HIZ)

• Bright T2 signal within the posterior annulus
• Indicates annular tear and is associated with discogenic pain
• Best seen on sagittal T2

D. Endplate Changes (Modic Classification - T1 and T2 sagittal)

---

SECTION 4: SPINAL CANAL & CENTRAL STENOSIS

• Grade A: CSF visible around the cauda equina roots (normal)
• Grade B: CSF not visible but nerve roots distinguishable
• Grade C: Nerve roots not distinguishable, no CSF
• Grade D: No nerve roots visible (severe/critical)

• AP diameter of the spinal canal in mm (normal lumbar >15 mm; <10 mm = absolute stenosis)
• Congenital vs. acquired (degenerative) narrowing
• Epidural lipomatosis (excess epidural fat - measure on axial T1)
• Epidural hematoma or abscess (enhancing on post-contrast T1)

---

SECTION 5: NEURAL FORAMINA

• Grade 0: Normal - fat completely surrounds root
• Grade 1 (mild): Slight deformity of fat, fat still surrounds root
• Grade 2 (moderate): Marked deformity of fat, partial encirclement
• Grade 3 (severe): Obliteration of fat around root

• Normal lateral recess depth >5 mm
• Borderline: 3-5 mm
• Stenosed: <3 mm

---

SECTION 6: FACET JOINTS

• Grade 0: Normal joint space (2-4 mm)
• Grade 1: Narrowing (<2 mm) and/or small osteophytes
• Grade 2: Narrowing and/or moderate osteophytes ± mild hypertrophy
• Grade 3: Severe narrowing, large osteophytes, severe hypertrophy ± ankylosis

• Synovial cysts (hyperintense T2 para-articular cysts causing lateral recess/foraminal compression)
• Vacuum phenomenon (gas in facet joint on T1/GRE)
• Active synovitis (enhancing joint fluid on post-contrast T1)
• Facet effusion (T2 bright joint fluid)

---

SECTION 7: LIGAMENTUM FLAVUM

• Normal thickness: <4 mm
• Hypertrophy (>4 mm) contributes to central and lateral recess stenosis
• Calcification (low T1 and T2)
• Buckling into canal with disc height loss

---

SECTION 8: POSTERIOR ELEMENTS & BONY STRUCTURES

• Spinous processes: Fracture, kissing spine (Baastrup disease - T2 bright interspinous bursa)
• Laminae and pedicles: Erosion, fracture, asymmetry
• Sacroiliac joints (on coronal/axial): Erosion, sclerosis, marrow edema (STIR for sacroiliitis)
• Posterior longitudinal ligament (PLL) / Anterior longitudinal ligament (ALL): Ossification (OPLL), rupture

---

SECTION 9: CONUS MEDULLARIS & CAUDA EQUINA

• Position (level above L2 = normal)
• Signal (any T2 hyperintensity?)
• Enhancement (abnormal)
• Syrinx/hydromyelia (central canal dilatation)
• Tethering/lipoma of filum terminale

---

SECTION 10: PARASPINAL & SOFT TISSUES

• Paraspinal muscles: Fatty atrophy (multifidus, erector spinae) - grade by Goutallier classification (0 = no fat → 4 = >75% fat infiltration)
• Psoas muscles: Asymmetry, abscess, hematoma
• Iliopsoas: Bursitis
• Posterior paraspinal tissues: Post-surgical changes, seroma, hematoma
• Aorta and iliac vessels: Incidental aneurysm, atherosclerosis (visible on T1)
• Kidneys and retroperitoneum: Check on sagittal - renal lesions, lymphadenopathy
• Bowel: Occasionally visible incidental pathology

---

SECTION 11: POST-SURGICAL CHANGES (if applicable)

• Hardware: Position, loosening, adjacent level disease
• Fusion mass: Maturity, pseudoarthrosis
• Epidural fibrosis vs. residual/recurrent disc herniation - use gadolinium (fibrosis enhances early, disc does not)
• Post-laminectomy changes, seroma, hematoma

---

WHOLE SPINE SCREENING MRI - Structured Report

Sequences Used

• Sagittal T1 whole spine (C, T, L regions)
• Sagittal T2 whole spine (STIR preferred for marrow lesions)
• Targeted axial T2 at areas of clinical interest or abnormality
• Post-contrast T1 fat-sat if infection/malignancy/inflammation suspected

Reporting Structure for Whole Spine

1. Cervical Spine

• Vertebral alignment, C1/C2 relationship (dens-atlas interval, normal <3 mm adults)
• C2-C7 disc levels, cord signal at each level
• Foramen magnum - tonsillar herniation, craniocervical junction
• Cervical cord: signal, caliber, syrinx

2. Thoracic Spine

• Vertebral bodies: marrow signal (STIR for edema), height, alignment
• Disc levels T1-T12: herniation less common but more dangerous (smaller canal)
• Thoracic cord: signal abnormalities, demyelination, intramedullary lesions
• Costovertebral and costotransverse joints
• Paraspinal masses

3. Lumbar Spine

• As per full lumbar spine checklist above (Sections 2-10)

4. Sacrum and Coccyx

• Marrow signal, fractures (especially insufficiency fractures on STIR)
• Sacral nerve foramina on axial
• Sacroiliac joints - sclerosis, erosion, marrow edema

5. Global Assessment Across All Levels

---

IMPRESSION FORMAT - Best Practice

1. Lead with the most clinically significant finding
2. Address the clinical question directly
3. Use standardized language for disc pathology (avoid ambiguous terms like "mild degenerative changes" without specifics)
4. State the nerve root affected by herniation or stenosis
5. Provide graded severity for stenosis findings
6. Flag incidental findings separately
7. Suggest follow-up if needed (e.g., post-contrast for equivocal cord lesion)

1. L4/L5: Right paracentral disc extrusion with moderate right lateral recess 
   stenosis, contacting/displacing the right L5 traversing nerve root.

2. L5/S1: Disc protrusion, central, with mild central canal stenosis. 
   Pfirrmann grade IV disc degeneration.

3. L3/L4: Ligamentum flavum hypertrophy bilaterally (5 mm), contributing 
   to moderate central canal stenosis (Schizas grade B).

4. Conus medullaris: Normal position at T12/L1, homogeneous signal, 
   no syrinx or intramedullary lesion.

5. Incidental finding: 1.5 cm right renal upper pole cyst, Bosniak I.

---

Quick Reference Checklist

MRI LUMBAR SPINE - REPORTING CHECKLIST
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
□ TECHNIQUE: Sequences, FOV, contrast y/n
□ ALIGNMENT: Lordosis, spondylolisthesis (Meyerding), kyphosis
□ VERTEBRAL COUNT: Lumbar transitional anatomy (LSTV/Castellvi)
□ VERTEBRAL BODIES: Marrow signal, height, fractures, Modic changes
□ DISCS (level by level L1/L2 to L5/S1):
   □ Degeneration grade (Pfirrmann I-V)
   □ Morphology: Normal/Bulge/Protrusion/Extrusion/Sequestration
   □ Location: Central/Paracentral/Foraminal/Extraforaminal
   □ HIZ (annular tear)
   □ Disc height
□ ENDPLATES: Modic type (1/2/3), Schmorl's nodes
□ CENTRAL CANAL: Stenosis grade (Schizas A-D), AP diameter
□ LATERAL RECESS: Width in mm, side, cause
□ FORAMINA: Stenosis grade (Lee 0-3), level, side, cause
□ FACET JOINTS: Arthropathy grade, synovial cyst, effusion
□ LIGAMENTUM FLAVUM: Thickness, hypertrophy, calcification
□ CONUS: Level, signal, syrinx, tethering
□ CAUDA EQUINA: Clumping, enhancement, intradural lesions
□ PARASPINAL MUSCLES: Fatty atrophy (Goutallier), asymmetry
□ SOFT TISSUES: Psoas, retroperitoneum, vessels
□ SACRUM/SIJ: Signal, sacroiliitis, fracture
□ INCIDENTAL FINDINGS: Renal, vascular, bowel

---

Key Sequences and What Each Shows Best

---