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Cervical Pain or Cervical Radiculopathy

Variant: 1   Adult. Acute or increasing cervical pain without radiculopathy. No trauma or “red flags.” Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography cervical spine May Be Appropriate ☢☢
Discography cervical spine Usually Not Appropriate ☢☢
Radiography cervical spine flexion extension lateral views Usually Not Appropriate ☢☢
Radiographic myelography cervical spine Usually Not Appropriate ☢☢☢
MRA neck with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI cervical spine with IV contrast Usually Not Appropriate O
MRI cervical spine without and with IV contrast Usually Not Appropriate O
MRI cervical spine without IV contrast Usually Not Appropriate O
Bone scan whole body with SPECT or SPECT/CT cervical spine Usually Not Appropriate ☢☢☢
CT cervical spine with IV contrast Usually Not Appropriate ☢☢☢
CT cervical spine without and with IV contrast Usually Not Appropriate ☢☢☢
CT cervical spine without IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CT myelography cervical spine Usually Not Appropriate ☢☢☢☢

Variant: 2   Adult. Acute or increasing cervical pain with radiculopathy. No trauma or “red flags.” Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography cervical spine May Be Appropriate ☢☢
MRI cervical spine without IV contrast May Be Appropriate O
Radiography cervical spine flexion extension lateral views Usually Not Appropriate ☢☢
Radiographic myelography cervical spine Usually Not Appropriate ☢☢☢
MRA neck with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI cervical spine with IV contrast Usually Not Appropriate O
MRI cervical spine without and with IV contrast Usually Not Appropriate O
Bone scan whole body with SPECT or SPECT/CT cervical spine Usually Not Appropriate ☢☢☢
CT cervical spine with IV contrast Usually Not Appropriate ☢☢☢
CT cervical spine without and with IV contrast Usually Not Appropriate ☢☢☢
CT cervical spine without IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CT myelography cervical spine Usually Not Appropriate ☢☢☢☢

Variant: 3   Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or “red flags.” Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography cervical spine Usually Appropriate ☢☢
Radiography cervical spine flexion extension lateral views Usually Appropriate ☢☢
MRI cervical spine without IV contrast Usually Appropriate O
CT cervical spine without IV contrast Usually Appropriate ☢☢☢
MRI cervical spine without and with IV contrast May Be Appropriate O
CT myelography cervical spine May Be Appropriate ☢☢☢☢
Discography cervical spine Usually Not Appropriate ☢☢
Radiographic myelography cervical spine Usually Not Appropriate ☢☢☢
MRA neck with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI cervical spine with IV contrast Usually Not Appropriate O
Bone scan whole body with SPECT or SPECT/CT cervical spine Usually Not Appropriate ☢☢☢
CT cervical spine with IV contrast Usually Not Appropriate ☢☢☢
CT cervical spine without and with IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢

Variant: 4   Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI cervical spine without and with IV contrast Usually Appropriate O
MRI cervical spine without IV contrast May Be Appropriate O
CT cervical spine with IV contrast May Be Appropriate ☢☢☢
CT cervical spine without IV contrast May Be Appropriate ☢☢☢
Discography cervical spine Usually Not Appropriate ☢☢
Radiography cervical spine Usually Not Appropriate ☢☢
Radiography cervical spine flexion extension lateral views Usually Not Appropriate ☢☢
Radiographic myelography cervical spine Usually Not Appropriate ☢☢☢
MRA neck with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI cervical spine with IV contrast Usually Not Appropriate O
Bone scan whole body with SPECT or SPECT/CT cervical spine Usually Not Appropriate ☢☢☢
CT cervical spine without and with IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CT myelography cervical spine Usually Not Appropriate ☢☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢
Gallium scan whole body Usually Not Appropriate ☢☢☢☢
WBC scan whole body Usually Not Appropriate ☢☢☢☢

Variant: 5   Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI cervical spine without and with IV contrast Usually Appropriate O
MRI cervical spine without IV contrast May Be Appropriate O
CT cervical spine with IV contrast May Be Appropriate (Disagreement) ☢☢☢
CT cervical spine without IV contrast May Be Appropriate (Disagreement) ☢☢☢
FDG-PET/CT whole body May Be Appropriate ☢☢☢☢
Discography cervical spine Usually Not Appropriate ☢☢
Radiography cervical spine Usually Not Appropriate ☢☢
Radiography cervical spine flexion extension lateral views Usually Not Appropriate ☢☢
Radiographic myelography cervical spine Usually Not Appropriate ☢☢☢
MRA neck with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI cervical spine with IV contrast Usually Not Appropriate O
Bone scan whole body with SPECT or SPECT/CT cervical spine Usually Not Appropriate ☢☢☢
CT cervical spine without and with IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/MRI skull base to mid-thigh Usually Not Appropriate ☢☢☢
FDG-PET/MRI whole body Usually Not Appropriate ☢☢☢
CT myelography cervical spine Usually Not Appropriate ☢☢☢☢
Fluoride PET/CT whole body Usually Not Appropriate ☢☢☢☢

Variant: 6   Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI cervical spine without IV contrast May Be Appropriate (Disagreement) O
Radiography cervical spine Usually Not Appropriate ☢☢
Radiography cervical spine flexion extension lateral views Usually Not Appropriate ☢☢
Radiographic myelography cervical spine Usually Not Appropriate ☢☢☢
MRA neck with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI cervical spine with IV contrast Usually Not Appropriate O
MRI cervical spine without and with IV contrast Usually Not Appropriate O
Bone scan whole body with SPECT or SPECT/CT cervical spine Usually Not Appropriate ☢☢☢
CT cervical spine with IV contrast Usually Not Appropriate ☢☢☢
CT cervical spine without and with IV contrast Usually Not Appropriate ☢☢☢
CT cervical spine without IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CT myelography cervical spine Usually Not Appropriate ☢☢☢☢

Variant: 7   Adult. Chronic cervical pain without radiculopathy. No trauma or “red flags.” Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography cervical spine May Be Appropriate ☢☢
MRI cervical spine without IV contrast May Be Appropriate O
Discography cervical spine Usually Not Appropriate ☢☢
Radiography cervical spine flexion extension lateral views Usually Not Appropriate ☢☢
Radiographic myelography cervical spine Usually Not Appropriate ☢☢☢
MRA neck with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI cervical spine with IV contrast Usually Not Appropriate O
MRI cervical spine without and with IV contrast Usually Not Appropriate O
Bone scan whole body with SPECT or SPECT/CT cervical spine Usually Not Appropriate ☢☢☢
CT cervical spine with IV contrast Usually Not Appropriate ☢☢☢
CT cervical spine without and with IV contrast Usually Not Appropriate ☢☢☢
CT cervical spine without IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CT myelography cervical spine Usually Not Appropriate ☢☢☢☢

Variant: 8   Adult. Chronic cervical pain with radiculopathy. No trauma or “red flags.” Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI cervical spine without IV contrast Usually Appropriate O
Radiography cervical spine May Be Appropriate (Disagreement) ☢☢
CT cervical spine without IV contrast May Be Appropriate ☢☢☢
Discography cervical spine Usually Not Appropriate ☢☢
Radiography cervical spine flexion extension lateral views Usually Not Appropriate ☢☢
Radiographic myelography cervical spine Usually Not Appropriate ☢☢☢
MRA neck with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI cervical spine with IV contrast Usually Not Appropriate O
MRI cervical spine without and with IV contrast Usually Not Appropriate O
Bone scan whole body with SPECT or SPECT/CT cervical spine Usually Not Appropriate ☢☢☢
CT cervical spine with IV contrast Usually Not Appropriate ☢☢☢
CT cervical spine without and with IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢
CT myelography cervical spine Usually Not Appropriate ☢☢☢☢

Panel Members
Rami W. Eldaya, MDa; Matthew S. Parsons, MDb; Troy A. Hutchins, MDc; Ryan Avery, MDd; Judah Burns, MDe; Brent Griffith, MDf; Alvand Hassankhani, MDg; Majid A. Khan, MDh; Henry Ng, MD, MPHi; Noah M. Raizman, MDj; Charles Reitman, MDk; Vinil N. Shah, MDl; Clint W. Sliker, MDm; Hesham Soliman, MDn; Vincent M. Timpone, MDo; Christian A. Tomaszewski, MD, MS, MBAp; Noushin Yahyavi-Firouz-Abadi, MD, MBAq; Bruno Policeni, MD, MBAr.
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 (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (i.e., 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: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT cervical spine
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
B. CT cervical spine with IV contrast
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
C. CT cervical spine without and with IV contrast
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
D. CT cervical spine without IV contrast
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
E. CT myelography cervical spine
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
F. CTA neck with IV contrast
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
G. Discography cervical spine
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
H. MRA neck with IV contrast
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
I. MRA neck without and with IV contrast
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
J. MRA neck without IV contrast
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
K. MRI cervical spine with IV contrast
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
L. MRI cervical spine without and with IV contrast
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
M. MRI cervical spine without IV contrast
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
N. Radiographic myelography cervical spine
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
O. Radiography cervical spine
Variant 1: Adult. Acute or increasing cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
P. Radiography cervical spine flexion extension lateral views
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT cervical spine
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
B. CT cervical spine with IV contrast
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
C. CT cervical spine without and with IV contrast
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
D. CT cervical spine without IV contrast
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
E. CT myelography cervical spine
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
F. CTA neck with IV contrast
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
G. MRA neck with IV contrast
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
H. MRA neck without and with IV contrast
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
I. MRA neck without IV contrast
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
J. MRI cervical spine with IV contrast
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
K. MRI cervical spine without and with IV contrast
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
L. MRI cervical spine without IV contrast
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
M. Radiographic myelography cervical spine
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
N. Radiography cervical spine
Variant 2: Adult. Acute or increasing cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
O. Radiography cervical spine flexion extension lateral views
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT cervical spine
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
B. CT cervical spine with IV contrast
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
C. CT cervical spine without and with IV contrast
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
D. CT cervical spine without IV contrast
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
E. CT myelography cervical spine
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
F. CTA neck with IV contrast
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
G. Discography cervical spine
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
H. MRA neck with IV contrast
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
I. MRA neck without and with IV contrast
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
J. MRA neck without IV contrast
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
K. MRI cervical spine with IV contrast
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
L. MRI cervical spine without and with IV contrast
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
M. MRI cervical spine without IV contrast
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
N. Radiographic myelography cervical spine
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
O. Radiography cervical spine
Variant 3: Adult. Prior cervical spine surgery. Acute or increasing mechanical cervical pain or radiculopathy. No trauma or "red flags.” Initial imaging.
P. Radiography cervical spine flexion extension lateral views
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT cervical spine
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
B. CT cervical spine with IV contrast
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
C. CT cervical spine without and with IV contrast
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
D. CT cervical spine without IV contrast
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
E. CT myelography cervical spine
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
F. CTA neck with IV contrast
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
G. Discography cervical spine
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
H. FDG-PET/CT skull base to mid-thigh
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
I. Gallium scan whole body
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
J. MRA neck with IV contrast
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
K. MRA neck without and with IV contrast
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
L. MRA neck without IV contrast
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
M. MRI cervical spine with IV contrast
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
N. MRI cervical spine without and with IV contrast
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
O. MRI cervical spine without IV contrast
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
P. Radiographic myelography cervical spine
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
Q. Radiography cervical spine
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
R. Radiography cervical spine flexion extension lateral views
Variant 4: Adult. Suspected or known infection with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
S. WBC scan whole body
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT cervical spine
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
B. CT cervical spine with IV contrast
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
C. CT cervical spine without and with IV contrast
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
D. CT cervical spine without IV contrast
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
E. CT myelography cervical spine
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
F. CTA neck with IV contrast
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
G. Discography cervical spine
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
H. FDG-PET/CT whole body
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
I. FDG-PET/MRI skull base to mid-thigh
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
J. FDG-PET/MRI whole body
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
K. Fluoride PET/CT whole body
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
L. MRA neck with IV contrast
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
M. MRA neck without and with IV contrast
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
N. MRA neck without IV contrast
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
O. MRI cervical spine with IV contrast
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
P. MRI cervical spine without and with IV contrast
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
Q. MRI cervical spine without IV contrast
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
R. Radiographic myelography cervical spine
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
S. Radiography cervical spine
Variant 5: Adult. Diagnosis of malignancy with acute or increasing cervical pain or radiculopathy. No trauma. Initial imaging.
T. Radiography cervical spine flexion extension lateral views
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT cervical spine
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
B. CT cervical spine with IV contrast
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
C. CT cervical spine without and with IV contrast
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
D. CT cervical spine without IV contrast
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
E. CT myelography cervical spine
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
F. CTA neck with IV contrast
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
G. MRA neck with IV contrast
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
H. MRA neck without and with IV contrast
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
I. MRA neck without IV contrast
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
J. MRI cervical spine with IV contrast
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
K. MRI cervical spine without and with IV contrast
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
L. MRI cervical spine without IV contrast
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
M. Radiographic myelography cervical spine
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
N. Radiography cervical spine
Variant 6: Adult. Suspected cervicogenic headache. No neurologic deficit. Initial imaging.
O. Radiography cervical spine flexion extension lateral views
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT cervical spine
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
B. CT cervical spine with IV contrast
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
C. CT cervical spine without and with IV contrast
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
D. CT cervical spine without IV contrast
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
E. CT myelography cervical spine
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
F. CTA neck with IV contrast
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
G. Discography cervical spine
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
H. MRA neck with IV contrast
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
I. MRA neck without and with IV contrast
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
J. MRA neck without IV contrast
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
K. MRI cervical spine with IV contrast
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
L. MRI cervical spine without and with IV contrast
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
M. MRI cervical spine without IV contrast
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
N. Radiographic myelography cervical spine
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
O. Radiography cervical spine
Variant 7: Adult. Chronic cervical pain without radiculopathy. No trauma or "red flags.” Initial imaging.
P. Radiography cervical spine flexion extension lateral views
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT cervical spine
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
B. CT cervical spine with IV contrast
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
C. CT cervical spine without and with IV contrast
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
D. CT cervical spine without IV contrast
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
E. CT myelography cervical spine
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
F. CTA neck with IV contrast
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
G. Discography cervical spine
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
H. MRA neck with IV contrast
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
I. MRA neck without and with IV contrast
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
J. MRA neck without IV contrast
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
K. MRI cervical spine with IV contrast
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
L. MRI cervical spine without and with IV contrast
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
M. MRI cervical spine without IV contrast
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
N. Radiographic myelography cervical spine
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
O. Radiography cervical spine
Variant 8: Adult. Chronic cervical pain with radiculopathy. No trauma or "red flags.” Initial imaging.
P. Radiography cervical spine flexion extension lateral views
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.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

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.