INFANT SPINE ULTRASOUND – RADIOLOGIST/SONOGRAPHER WORKSHEET Patient Name: ____________________________ Patient MRN: _____________________________ Date: ___________________________________ (Your Hospital Logo) INFANT SPINE ULTRASOUND – RADIOLOGIST/SONOGRAPHER WORKSHEET Indication: _____________________________ Comparison: ________ Age: ______Gestational Age at Birth_______ Cutaneous Stigmata (circle all that apply): Shallow Dimple Deep Dimple High Vascular Lesion Hairy Tuft Low-lying Cord Position (circle one): Symmetric Dependent Nondependent Normal Triangular/Tapered conus: Y N Normal Cord and Cauda Equina MOTION: Y N Nerve roots layer dependently without clumping/adherence: Y N Filum: Thickness: __________ Lesion: Y N Terminus of thecal sac (level, tapers, lesion, etc.): ________________________________________ Subarachnoid/Epidural Spaces: Sinus Tract: Y N Level__________ Vertebrae Intact Posterior Elements: Y N Segmentation Anomalies: Y N Paraspinal Soft Tissues Lesion (Masses/Fluid-Collection/Sinus Tract): Y N LEVEL OF CONUS ______________ S1 L5 Technique (circle all that apply): Static Cine Comments/Misc: ________________________________________________ ________________________________________________________________________________________________________________________________________________