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Suspected Spine Infection

Variant: 1   Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new or worsening back or neck pain, with or without fever, who may have one or more of the following red flags (diabetes mellitus, IV drug use, cancer, HIV, or dialysis) or abnormal lab values. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI spine area of interest without and with IV contrast Usually Appropriate O
MRI spine area of interest without IV contrast Usually Appropriate O
Radiography spine area of interest May Be Appropriate Varies
3-phase bone scan complete spine May Be Appropriate ☢☢☢
Gallium scan whole body May Be Appropriate ☢☢☢☢
CT spine area of interest with IV contrast May Be Appropriate Varies
CT spine area of interest without IV contrast May Be Appropriate Varies
MRI spine area of interest with IV contrast Usually Not Appropriate O
FDG-PET/CT whole body Usually Not Appropriate ☢☢☢☢
WBC scan and sulfur colloid scan complete spine Usually Not Appropriate ☢☢☢☢
CT spine area of interest without and with IV contrast Usually Not Appropriate Varies

Variant: 2   Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with recent intervention (such as surgery with or without hardware, pain injection, or stimulator implantation). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI spine area of interest without and with IV contrast Usually Appropriate O
MRI spine area of interest without IV contrast Usually Appropriate O
Radiography spine area of interest May Be Appropriate Varies
3-phase bone scan complete spine May Be Appropriate ☢☢☢
Gallium scan whole body May Be Appropriate ☢☢☢☢
CT spine area of interest with IV contrast May Be Appropriate Varies
CT spine area of interest without IV contrast May Be Appropriate Varies
MRI spine area of interest with IV contrast Usually Not Appropriate O
FDG-PET/CT whole body Usually Not Appropriate ☢☢☢☢
WBC scan and sulfur colloid scan complete spine Usually Not Appropriate ☢☢☢☢
CT spine area of interest without and with IV contrast Usually Not Appropriate Varies

Variant: 3   Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new neurologic deficit or cauda equina syndrome. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI spine area of interest without and with IV contrast Usually Appropriate O
MRI spine area of interest without IV contrast Usually Appropriate O
CT spine area of interest with IV contrast May Be Appropriate Varies
CT spine area of interest without IV contrast May Be Appropriate Varies
Radiography spine area of interest Usually Not Appropriate Varies
MRI spine area of interest with IV contrast Usually Not Appropriate O
3-phase bone scan complete spine Usually Not Appropriate ☢☢☢
FDG-PET/CT whole body Usually Not Appropriate ☢☢☢☢
Gallium scan whole body Usually Not Appropriate ☢☢☢☢
WBC scan and sulfur colloid scan complete spine Usually Not Appropriate ☢☢☢☢
CT spine area of interest without and with IV contrast Usually Not Appropriate Varies

Variant: 4   Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with decubitus ulcer or wound overlying spine. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI spine area of interest without and with IV contrast Usually Appropriate O
MRI spine area of interest without IV contrast Usually Appropriate O
Radiography spine area of interest May Be Appropriate Varies
3-phase bone scan complete spine May Be Appropriate ☢☢☢
Gallium scan whole body May Be Appropriate ☢☢☢☢
CT spine area of interest with IV contrast May Be Appropriate Varies
CT spine area of interest without IV contrast May Be Appropriate Varies
MRI spine area of interest with IV contrast Usually Not Appropriate O
FDG-PET/CT whole body Usually Not Appropriate ☢☢☢☢
WBC scan and sulfur colloid scan complete spine Usually Not Appropriate ☢☢☢☢
CT spine area of interest without and with IV contrast Usually Not Appropriate Varies

Variant: 5   Suspected spine infection (such as epidural abscess or discitis osteomyelitis). Abnormal radiographs or CT findings. Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
MRI spine area of interest without and with IV contrast Usually Appropriate O
MRI spine area of interest without IV contrast Usually Appropriate O
3-phase bone scan complete spine May Be Appropriate ☢☢☢
FDG-PET/CT whole body May Be Appropriate ☢☢☢☢
Gallium scan whole body May Be Appropriate ☢☢☢☢
MRI spine area of interest with IV contrast Usually Not Appropriate O
WBC scan and sulfur colloid scan complete spine Usually Not Appropriate ☢☢☢☢

Panel Members
A. Orlando Ortiz, MD, MBAa; Alex Levitt, MDb; Lubdha M. Shah, MDc; Matthew S. Parsons, MDd; Vikas Agarwal, MDe; Keith Baldwin, MDf; Shamik Bhattacharyya, MD, MSg; Daniel J. Boulter, MDh; Judah Burns, MDi; Kathleen R. Fink, MDj; Christopher H. Hunt, MDk; Troy A. Hutchins, MDl; Lillian S. Kao, MDm; Majid A. Khan, MBBS, MDn; Bruce M. Lo, MD, RDMS, MBAo; Toshio Moritani, MD, PhDp; Charles Reitman, MDq; Michael D. Repplinger, MD, PhDr; Vinil N. Shah, MDs; Simranjit Singh, MDt; Vincent M. Timpone, MDu; Amanda S. Corey, MDv.
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (ie, only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (ie, more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new or worsening back or neck pain, with or without fever, who may have one or more of the following red flags (diabetes mellitus, IV drug use, cancer, HIV, or dialysis) or abnormal lab values. Initial imaging.
Variant 1: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new or worsening back or neck pain, with or without fever, who may have one or more of the following red flags (diabetes mellitus, IV drug use, cancer, HIV, or dialysis) or abnormal lab values. Initial imaging.
A. CT Spine Area of Interest
Variant 1: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new or worsening back or neck pain, with or without fever, who may have one or more of the following red flags (diabetes mellitus, IV drug use, cancer, HIV, or dialysis) or abnormal lab values. Initial imaging.
B. MRI Spine Area of Interest
Variant 1: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new or worsening back or neck pain, with or without fever, who may have one or more of the following red flags (diabetes mellitus, IV drug use, cancer, HIV, or dialysis) or abnormal lab values. Initial imaging.
C. Radiography Spine Area of Interest
Variant 1: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new or worsening back or neck pain, with or without fever, who may have one or more of the following red flags (diabetes mellitus, IV drug use, cancer, HIV, or dialysis) or abnormal lab values. Initial imaging.
D. 3-Phase Bone Scan Complete Spine
Variant 1: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new or worsening back or neck pain, with or without fever, who may have one or more of the following red flags (diabetes mellitus, IV drug use, cancer, HIV, or dialysis) or abnormal lab values. Initial imaging.
E. Gallium Scan Whole Body
Variant 1: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new or worsening back or neck pain, with or without fever, who may have one or more of the following red flags (diabetes mellitus, IV drug use, cancer, HIV, or dialysis) or abnormal lab values. Initial imaging.
F. WBC Scan and Sulfur Colloid Scan Complete Spine
Variant 1: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new or worsening back or neck pain, with or without fever, who may have one or more of the following red flags (diabetes mellitus, IV drug use, cancer, HIV, or dialysis) or abnormal lab values. Initial imaging.
G. FDG-PET/CT Whole Body
Variant 2: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with recent intervention (such as surgery with or without hardware, pain injection, or stimulator implantation). Initial imaging.
Variant 2: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with recent intervention (such as surgery with or without hardware, pain injection, or stimulator implantation). Initial imaging.
A. CT Spine Area of Interest
Variant 2: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with recent intervention (such as surgery with or without hardware, pain injection, or stimulator implantation). Initial imaging.
B. MRI Spine Area of Interest
Variant 2: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with recent intervention (such as surgery with or without hardware, pain injection, or stimulator implantation). Initial imaging.
C. Radiography Spine Area of Interest
Variant 2: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with recent intervention (such as surgery with or without hardware, pain injection, or stimulator implantation). Initial imaging.
D. 3-Phase Bone Scan
Variant 2: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with recent intervention (such as surgery with or without hardware, pain injection, or stimulator implantation). Initial imaging.
E. Gallium Scan Whole Body
Variant 2: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with recent intervention (such as surgery with or without hardware, pain injection, or stimulator implantation). Initial imaging.
F. WBC Scan and Sulfur Colloid Scan Complete Spine
Variant 2: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with recent intervention (such as surgery with or without hardware, pain injection, or stimulator implantation). Initial imaging.
G. FDG-PET/CT Whole Body
Variant 3: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new neurologic deficit or cauda equina syndrome. Initial imaging.
Variant 3: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new neurologic deficit or cauda equina syndrome. Initial imaging.
A. CT Spine Area of Interest
Variant 3: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new neurologic deficit or cauda equina syndrome. Initial imaging.
B. MRI Spine Area of Interest
Variant 3: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new neurologic deficit or cauda equina syndrome. Initial imaging.
C. Radiography Spine Area of Interest
Variant 3: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new neurologic deficit or cauda equina syndrome. Initial imaging.
D. 3-Phase Bone Scan
Variant 3: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new neurologic deficit or cauda equina syndrome. Initial imaging.
E. WBC Scan and Sulfur Colloid Scan Complete Spine
Variant 3: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new neurologic deficit or cauda equina syndrome. Initial imaging.
F. Gallium Scan Whole Body
Variant 3: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with new neurologic deficit or cauda equina syndrome. Initial imaging.
G. FDG-PET/CT Whole Body
Variant 4: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with decubitus ulcer or wound overlying spine. Initial imaging.
Variant 4: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with decubitus ulcer or wound overlying spine. Initial imaging.
A. CT Spine Area of Interest
Variant 4: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with decubitus ulcer or wound overlying spine. Initial imaging.
B. MRI Spine Area of Interest
Variant 4: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with decubitus ulcer or wound overlying spine. Initial imaging.
C. Radiography Spine Area of Interest
Variant 4: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with decubitus ulcer or wound overlying spine. Initial imaging.
D. 3-Phase Bone Scan
Variant 4: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with decubitus ulcer or wound overlying spine. Initial imaging.
E. Gallium Scan Whole Body
Variant 4: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with decubitus ulcer or wound overlying spine. Initial imaging.
F. WBC Scan and Sulfur Colloid Scan Complete Spine
Variant 4: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with decubitus ulcer or wound overlying spine. Initial imaging.
G. FDG-PET/CT Whole Body
Variant 5: Suspected spine infection (such as epidural abscess or discitis osteomyelitis). Abnormal radiographs or CT findings. Next imaging study.
Variant 5: Suspected spine infection (such as epidural abscess or discitis osteomyelitis). Abnormal radiographs or CT findings. Next imaging study.
A. MRI Spine Area of Interest
Variant 5: Suspected spine infection (such as epidural abscess or discitis osteomyelitis). Abnormal radiographs or CT findings. Next imaging study.
B. 3-Phase Bone Scan
Variant 5: Suspected spine infection (such as epidural abscess or discitis osteomyelitis). Abnormal radiographs or CT findings. Next imaging study.
C. Gallium Scan Whole Body
Variant 5: Suspected spine infection (such as epidural abscess or discitis osteomyelitis). Abnormal radiographs or CT findings. Next imaging study.
D. WBC Scan and Sulfur Colloid Scan Complete Spine
Variant 5: Suspected spine infection (such as epidural abscess or discitis osteomyelitis). Abnormal radiographs or CT findings. Next imaging study.
E. FDG-PET/CT Whole Body
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.