Proposal and clinical application of a structured standardized report for lumbosacral MRI integrated with a...

Creation and evaluation of a structured report (SR) for lumbar spine magnetic resonance imaging (MRI), with the implementation of a previously clinically validated grading system that differentiates lumbar stenosis based on the location and underlying causes, with particular attention to the often underestimated aspect of spinal epidural lipomatosis (SEL).

This prospective single-center study enrolled all the MRIs of the lumbar spine performed at our institution within one month. A (SR) was created using the RSNA's platform "RadReport.org" and submitted to radiologists of our center. Both free-text reports and SR were then evaluated by referring clinicians. The radiologists' intra- (after 2 months) and inter-operator agreement on the new grading system in a SR was assessed using Cohen's Kappa index. Subsequently, an evaluation survey was carried out among the 12 radiologists and 16 clinicians in our hospital, using a five-point Likert scale.

In a period of 1 month, a total of 150 structured reports were generated (86 women, average age 58 ± 22 years). An almost perfect intra-operator (Kc = 0.955) and inter-operator (Kc = 0.838) agreement was detected. The survey showed almost complete satisfaction (89%) and perception of ease of use (83%) of the SR. The new grading system was preferred over the previous ones by 96% of clinicians and 81% of radiologists.

An MRI SR of the lumbar spine could be a valid and appreciated tool to improve communication between specialists, allowing a better multidisciplinary evaluation.