1. 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: ________________________________________________
________________________________________________________________________________________________________________________________________________