Writing a Radiology Report
Patient Name/DOB/Age/Gender/Date of Study/Date of Report/Referring Dr.
Examination Type: (Conventional Radiograph/MRI/CT) + Body Part (Upright Thoracic Spine)
View: AP/Lateral/Oblique (cervical/thoracic/lumbar)
Findings:
Paragraph 1:
A: Alignment:
 Coronal plane curves: List/Lean/Shift; Pelvic unleveling; Scoliosis. Scoliosis should be
measured. Convexity points to the side you call it. And Mention rotation.
 Sagittal plane curves: Lordosis/Kyphosis= increased, decreased, focal changes.
Mild/Moderate/Severe
 Listhesis: 4 items
1. Level
2. Direction: Antero/Retro/Latero
3. Degree: Grade 1, 6mm
4. Due to: Spondylolytic, degeneragive
 Measurements: pertinent to the area being evaluated
o Every cervical should have the ADI measured (>3mm Adult/>5mm Child)
o For non-standard measurements include if + (Ex. McGregor’s Line)
Anomalies:
 Extra/Missing parts; Check at transitional areas!
o Ex. Lumbosacral Transitional Segments
o Castellvi 1: Spatulation without articulation
o Castellvi 2: Spatulation with articulation
 2A: Unilateral accessory joint
 2B: Bilateral accessory joint
o Castellvi 3: Complete Fusion
 3A: Unilateral
 3B:Bilateral
o Castellvi 4: Combined fusion and accessory joint
 Missing Psoas shadow: Ascites
Paragraph 2:
Bone/Cartilage:
 Overall bone density: Normal/Increased/Decreased; Grade- Mild/Moderate/Severe
 Generalized/Localized?
 “Cortical margins intact, trabecular patterns are normal”
 Check all cortical margins, patterns and PEDICLES!
 Disruptions: Alignment, apposition, rotation
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Sclerosis, lysis, missing structures, shapes/sizes of vertebra (anterior wedging,
trapezoidal shape, endplate abnormalities)
Talk about all major joint spaces in the view!
o In Cervical Spine: Discs, facets, uncinates
o Lumbar: Discs, facets, SI joints, Hips
Always grade changes: Mild/Moderate/Severe Joint Space Loss
Spondylophyte formation (especially if posterior)
Spondylophyte vs. syndesmophyte
Facet Joints: Sclerosis, Hypertrophy, Osteophyte formation
Uncinates: sclerosis, hypertrophy, osteophytes; might need oblique view
Costovertebral/Costotransverse: Rib DJD
SI Joints: Cortical margins, irregularity, sacroilitis, sclerosis, might need AP angulated
spot view
Extra Axial- Grade changes Mild/Moderate/Severe
o Evaluate: joint spaces, subchondrial sclerosing, osteophytes, erosions, loose
bodies
Measurements:
o AC joint space for impingment
o Anterior Humeral Line: supracondylar Fx
o Scapholunate Space, VISI/DISI in wrist
o 3 Joint spaces of the hip
o Boehler’s Angle for calcaneal Fx
Paragraph 3:
Soft Tissues:
Cervical:
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Adenoidal hypertrophy, prevertebral soft tissues (2’s 6’s) Midline trachea, Lung Apices,
Calcifications of carotids
“No distension of the prevertebral soft tissues is noted. The trachea is in midline. The lung
apices are clear of gross pathology.”
Thoracic:
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Trachea midline, cardiomedialstinal silhouette, lung fields, hili, clear spaces,
paravertebral soft tissue stripe hemidiaphragms, upper abdomen: magenblasse, liver,
spleen
“No distension of the paravertebral soft tissue stripe is noted. The visualized lung fields are
clear of gross consolidation, mass, or interstitial disease. The trachea is in midline. The
cardiomediastinal silhouette is unremarkable.”
Lumbar:
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Hemidiaphragms, lung bases, psoas shadow (ascites) solid organ pattern (presence,
laterality- situs inversus) Organomegally, ectopia, Bowel (contents/contour) Presacral
space (lateral view); Bladder, Vascular (abdominal aorta)
“The psoas shadows are symmetric. The bowel is normal in contents and contour. No
abdominal masses, pelvic masses, or organomegaly is seen.”
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Look For: Masses, Calcifications, Displacement if fascial planes, Organ Shadows
Extremities: Capsular fat pads: Scaphoid, posterior elbow, hip; Joint effusion (supra
patellar pouch, FBI sign) Tendon/ligament/muscle/ misc calcifications. HADD-myositis
ossificans/HPT or diabetic vascular calcinosis
Impressions:
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Numbered List that goes with every finding.
Worst first!!
Give a diagnosis or differential list; do not exceed 3
Example:
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Expansile, geographic, lytic lesion in right ilium.
o Differential possibilities include: ABC, GCT, and eosinophilic granuloma. See
recommendation #1.
Mild loss of intervertebral disc space with spondylophyte formation is seen at L4-S1.
o Mild degenerative disc disease, L4-S1
Multipule foci of dense sclerosis are noted thoughout the lumbar spine, sacrum, and
ilium. These foci are not expansile, demonstrate a wide zone of transition.
o Findings suggestive of blastic metastasis. See recommendation #1.
Recommendations:
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ONLY if: additional imaging, Lab tests, or Referrals are needed.
Tell specific views needed, tests to be run or specific Dr. that needs to be seen.
Example:
o An MRI of the lumbar spine and a bone scan is recommended in order to further
evaluate the possibility of blastic metastasis. Laboratory evaluation to include
ESR, PSA, and chemistry panel.
o An MRI of the distal radius is recommended for more thorough evaluation of this
lesion.
Additional Issues:
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If the films suck: explain what’s wrong with them @ beginning of “Findings” section
If you don’t know:
o Describe is, differential it, then have films read by a radiologist.
If there are previous radiographs: First sentence of “Findings” comment on comparison.
o “Comparison is made with [insert exam and views] performed on [insert date of
exam] at [facility].