This report was compiled by Frank M. Painter, D.C. Send all comments or additions to:Frankp@chiro.org
You are welcome to download a
Word template version (36 KB) of this document for use in your office. Individuals may copy and file this document for personal use, however, you may not sell, or reproduce it in any group or commercial venture, without written permission from the copyright holder.
DATE OF BIRTH:
PATIENT'S FILE #:
VIEWS SUBMITTED: A routine
cervical/thoracic/lumbar series was accomplished on x-x-x
at Westgate Orthopaedics/West Suburban Hospital.
RADIOLOGICAL FINDINGS: In the cervical
series, the A-P view revealed mild/moderate right/left
rotatory curvature of the cervical spine, with left/right spinous
process rotation from C- to C/T-, and with left/right lateral
translation of the head of -". NOTE: Add comments about
any sclerotic changes on the lateral aspects of the discs,
vertebral bodies, pedicles, or facets.
The neutral lateral view demonstrated a
mildly/moderately hypolordotic cervical spine with a -- cm. curve
(normal for this patient would be a 17-22 cm. curve). There is --
cm. of anterior head/spine placement. The disc spaces are
mildly/moderately reduced at C-, with mild/moderate anterior/posterior 0
osteophytes present/ OR are well preserved. The Atlas
Plane line is -- (normal is
18-24o ) and the Whitehorn's (Axis)
angle is -- (normal is 0o ).
The flexion view revealed in/adequate
anterior sagittal translation of the spine with the -- segments
moving as a unit and/or hypermobile translation at the C--
segment(s) was observed.
The extension view demonstrated
in/adequate posterior sagittal translation of the spine with the
-- segments failing to extend, and/or paradoxic motion evident at the
-- segment(s), and paradoxic motion evident at the -- segment(s).
Cervical rotation views demonstrate
loss of axial rotation and lateral bending (reduced coupled
motion patterns) in right/left rotation, with minimal spinous
rotation from C-- to C-T--.
Cervical oblique views
The APOM view revealed equal and
adequate/slightly/moderately reduced atlantoaxial joint spaces,
with right/left posterior rotation of the C1 segment, and
right/left spinous rotation at C2.
Flexion locks are present at occiput,
C1, C2, C3, C4, C5, C6, C7
Extension locks are present at occiput,
C1, C2, C3, C4, C5, C6, C7, T1
Rotational locks are present at C7, T1,
T2, T3, T4 on the left/right
Potential cervical listings are PR/PL
at C2, C3, C4, C5, C6, C7
The Lumbar series reveals in the AP
view a mild/moderate right/left rotatory curvature of the
lumbar spine, with left/right spinous process rotation from T- to
L-. There is a --mm. leg length iniquity on the left/right. There
is anterior/posterior rotation of the bilateral/left/right ilia
on sacrum. Sacrum is inferior on the left/right --mm OR is
rotated to the right/left.
The lateral lumbar view demonstrates a
mildly/moderately hypolordotic lumbar spine with a --cm. curve
(normal for this patient would be a 20-24 cm. curve) The disc
spaces are mildly/moderately reduced at L-, with mild/moderate
anterior osteophytes present OR are within normal limits
for this patient's age.
The lateral bending lumbar views
reveals adequate motion to the -- and inadequate coupled motion
patterns in -- lateral bending, with a loss of axial rotation of
the T12, L1, L2, L3, L4, L5 spinous processes, which fail to
rotate adequately towards the side of bending.
Lumbar oblique views
The AP cephalic view demonstrates leg
length iniquity on the left/right and sacral inferiority/body
OR body rotation to the right/left.
The ilia listings are Right/Left PI AS
The sacral listings are BL BR, Inferior
on the right/left
Rotational locks are present at L1, L2,
L3, L4, L5 on the right/left
The potential lumbar listings are PR/PL
at L1, L2, L3, L4, L5
The Thoracic series revealed in the AP
The lateral thoracic view
RECOMMENDATIONS: List here any
additional tests that may shed more light on the patient's