{"id":"69a232c8efd4f1d91750420c","name":"Cervical Spine CT Without Contrast","slug":"cervical-spine-ct-without-contrast","description":"Structured template for cervical spine CT imaging without intravenous contrast, including assessment of vertebral alignment, spinal canal, neural foramina, and intervertebral discs from skull base through thoracic inlet.","category":{"modality":"CT","system":"Spine"},"tags":["cervical spine","non-contrast","trauma protocol","alignment","stenosis","fracture"],"sections":{"title":{"defaultText":"Cervical Spine CT Without Intravenous Contrast","aiInstructions":"Use this standard title format unless the source report specifies a different examination name."},"clinicalHistory":{"defaultText":"[Patient-specific — populated at report time]","aiInstructions":"Ask the user for: patient age, sex, presenting complaint, relevant clinical history, and reason for the exam. This section contextualizes the entire report. Always include it."},"comparison":{"defaultText":"Prior spine CT study dated [DATE].","aiInstructions":"If a prior study date is mentioned in the source report, insert the specific date. If no prior studies are available, replace with 'No prior studies available for comparison.'"},"technique":{"defaultText":"Multiple contiguous 2 x 1 mm axial images were obtained from the skull base through the thoracic inlet without administration of intravenous contrast. Reformatted images in the coronal and sagittal planes were generated. Images were reviewed in soft tissue and bone windows.","aiInstructions":"Preserve the technical parameters from the source report. Include slice thickness, spacing, anatomical coverage, and reconstruction planes. If radiation dose parameters (DLP, CTDI) are available in the source, add them as supplementary technical information."},"findings":{"defaultText":"The cervical spine is evaluated for alignment, fracture, stenosis, and degenerative changes.","aiInstructions":"Organize findings by anatomical region and pathologic process. Begin with overall alignment assessment, then address specific structures and disc levels in sequential order.","fields":[{"name":"Cervical Alignment and Lordosis","defaultText":"Preservation of normal cervical lordosis. Cervical alignment is maintained without vertebral body subluxation. No facet subluxation or dislocation is identified.","aiInstructions":"Document the presence or absence of normal lordosis, any kyphosis or loss of alignment, and specifically state whether subluxation or dislocation is present. Reference specific vertebral levels if abnormalities are noted."},{"name":"Prevertebral Soft Tissues","defaultText":"No significant prevertebral soft tissue swelling is identified.","aiInstructions":"Assess for edema, hemorrhage, or abnormal soft tissue enlargement anterior to the vertebral bodies. Note if swelling is present and estimate its extent."},{"name":"Atlas (C1) and Axis (C2)","defaultText":"The odontoid process appears intact. The atlanto-occipital articulation is unremarkable. The atlanto-dental articulation is unremarkable. The lateral atlanto-axial articulations appear unremarkable bilaterally.","aiInstructions":"Specifically assess the odontoid process for fracture or abnormality, the atlanto-occipital joint alignment, the atlanto-dental interval, and bilateral lateral atlanto-axial articulations. Document any abnormalities in detail."},{"name":"Vertebral Bodies and Fractures","defaultText":"No acute fracture is identified. The vertebral body and disc space heights are grossly preserved.","aiInstructions":"Assess all cervical vertebral bodies from C3 through C7 for acute or chronic fractures, compression, or height loss. Include the thoracic inlet region if visualized. Document specific levels if abnormalities are present."},{"name":"Spinal Canal and Neural Foramina","defaultText":"There is no significant spinal canal stenosis or neural foraminal narrowing.","aiInstructions":"Assess the central spinal canal diameter and the bilateral neural foramina at each disc level. Grade stenosis as none, mild, moderate, or severe if present. Note any limitations in evaluation (e.g., beam hardening artifact from shoulders)."},{"name":"C2-C3 Disc Level","defaultText":"At the C2-C3 level, there is no significant posterior disc bulge, disc herniation, or significant spinal canal stenosis. There is no significant neural foraminal narrowing.","aiInstructions":"Document disc morphology, presence or absence of bulge or herniation, degree of spinal canal involvement, and foraminal patency. If abnormalities exist, specify their location and severity."},{"name":"C3-C4 Disc Level","defaultText":"At the C3-C4 level, no significant abnormality is identified.","aiInstructions":"Assess the intervertebral disc for bulge, herniation, extrusion, or migration. Evaluate spinal canal stenosis and bilateral neural foraminal narrowing. Document specific findings or confirm normalcy."},{"name":"C4-C5 Disc Level","defaultText":"At the C4-C5 level, no significant abnormality is identified.","aiInstructions":"Assess the intervertebral disc for bulge, herniation, extrusion, or migration. Evaluate spinal canal stenosis and bilateral neural foraminal narrowing. Document specific findings or confirm normalcy."},{"name":"C5-C6 Disc Level","defaultText":"At the C5-C6 level, no significant abnormality is identified.","aiInstructions":"Assess the intervertebral disc for bulge, herniation, extrusion, or migration. Evaluate spinal canal stenosis and bilateral neural foraminal narrowing. Document specific findings or confirm normalcy."},{"name":"C6-C7 Disc Level","defaultText":"At the C6-C7 level, no significant abnormality is identified.","aiInstructions":"Assess the intervertebral disc for bulge, herniation, extrusion, or migration. Evaluate spinal canal stenosis and bilateral neural foraminal narrowing. Document specific findings or confirm normalcy."},{"name":"C7-T1 Disc Level","defaultText":"At the C7-T1 level, no significant abnormality is identified.","aiInstructions":"Assess the intervertebral disc for bulge, herniation, extrusion, or migration. Evaluate spinal canal stenosis and bilateral neural foraminal narrowing. Document specific findings or confirm normalcy."},{"name":"Technical Limitations","defaultText":"The evaluation of the spinal canal and its contents below the level of [SPECIFIC LEVEL] is limited secondary to beam hardening artifact related to shoulders.","aiInstructions":"Document any technical limitations affecting diagnostic quality, such as beam hardening artifact, motion artifact, or limited field of view. Specify the anatomical levels affected."}]},"impression":{"defaultText":"1. No evidence of acute fracture or subluxation.\n2. No significant foraminal or central spinal canal stenosis.","aiInstructions":"Synthesize key findings into concise, numbered impressions. Address fracture status, alignment, stenosis, and any significant degenerative or pathologic changes. Correlate with clinical history and recommend follow-up imaging or clinical correlation if indicated."}},"aiUsageInstructions":{"summary":"Use this template to generate a complete Cervical Spine CT Without Contrast radiology report.","steps":["1. Collect patient clinical history from the user (age, sex, clinical indication).","2. Confirm whether prior studies are available for comparison.","3. For the Technique section, use defaultText or adapt based on actual acquisition parameters.","4. For each field in sections.findings.fields: ask the user for the finding or infer from clinical context. Use defaultText if the structure is normal.","5. Generate the Impression by summarizing the most significant findings from step 4.","6. Use the aiInstructions for each section to guide the depth and format of the content.","7. Maintain formal radiology report language throughout. Passive voice preferred.","8. If any finding is abnormal, quantify it with measurements and describe its imaging characteristics."],"language":"Formal radiology report language. Passive voice preferred. Avoid first-person pronouns.","format":"Numbered impression list. Prose findings paragraphs or structured field-by-field format both acceptable.","units":"Report measurements in centimeters (cm) for masses, millimeters (mm) for small structures."},"meta":{"canonicalUrl":"https://radiluxreports.com/templates/cervical-spine-ct-without-contrast","claudeApiUrl":"https://radiluxreports.com/templates/api/claude/cervical-spine-ct-without-contrast","useInDashboardUrl":"https://radiluxreports.com/?templateId=69a232c8efd4f1d91750420c","apiUrl":"https://radiluxreports.com/templates/api/cervical-spine-ct-without-contrast","updatedAt":"2026-03-01T00:12:17.379Z","license":"Free for clinical and educational use. Attribution appreciated."}}