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Appropriateness Criteria

Variant 1: Age greater than or equal to 16 years and less than 65 years. Acute cervical spine blunt trauma; imaging not indicated by CCR or NEXUS clinical criteria. Low-risk criteria. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography cervical spine Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 3 0 2 0 1 0 1
References Study Quality
4 (10891516) 3
5 (11597285) 3
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 21 1 0 0 0 0 0 0 0
MRA neck with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 21 1 0 0 0 0 0 0 0
MRA neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 21 1 0 0 0 0 0 0 0
MRA neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 21 1 0 0 0 0 0 0 0
MRI cervical spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 21 1 0 0 0 0 0 0 0
MRI cervical spine without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 21 1 0 0 0 0 0 0 0
MRI cervical spine without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 20 2 0 0 0 0 0 0 0
CT cervical spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 20 1 1 0 0 0 0 0 0
CT cervical spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 2 1 0 0 0 0 0 0
CT cervical spine without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 2 3 1 0 0 0 0
References Study Quality
4 (10891516) 3
5 (11597285) 3
CTA head and neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 21 1 0 0 0 0 0 0 0
CT myelography cervical spine Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 21 1 0 0 0 0 0 0 0
Variant 2: Age 16 years or older. Acute cervical spine blunt trauma. Imaging indicated by CCR or NEXUS clinical criteria. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT cervical spine without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 1 1 1 0 1 3 15
References Study Quality
29 (19509621) 2
32 (15920400) M
31 (27602907) 4
30 (25757133) 4
9 (27438681) 2
Radiography cervical spine Usually not appropriate Strong ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 16 1 3 0 0 1 1 0 0
References Study Quality
41 (24139671) 3
40 (23404352) 3
39 (22663912) 4
37 (21085024) 2
29 (19509621) 2
38 (21265348) 3
36 (20583514) 3
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 20 1 1 0 0 0 0 0 0
MRA neck with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 20 1 1 0 0 0 0 0 0
MRA neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 20 1 1 0 0 0 0 0 0
MRA neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 20 1 1 0 0 0 0 0 0
MRI cervical spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 20 1 1 0 0 0 0 0 0
MRI cervical spine without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 20 1 1 0 0 0 0 0 0
MRI cervical spine without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 1 2 0 1 0 1 0 0
CT cervical spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 20 1 1 0 0 0 0 0 0
CT cervical spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 2 1 0 0 0 0 0 0
CTA head and neck with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 5 1 1 0 0 0 0
References Study Quality
35 (32195997) 2
34 (36101794) 4
33 (32520898) 2
CT myelography cervical spine Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 20 1 1 0 0 0 0 0 0
Variant 3: Age 16 years or older. Acute cervical spine blunt trauma. No unstable injury demonstrated initially, but kept in collar for neck pain. No new neurologic symptoms. Follow-up imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT cervical spine without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 1 0 0 0 6 1 3 4 7
References Study Quality
9 (27438681) 2
31 (27602907) 4
30 (25757133) 4
29 (19509621) 2
Radiography cervical spine May be appropriate (Disagreement) Expert Opinion ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 12 2 2 0 0 4 1 0 1
References Study Quality
41 (24139671) 3
38 (21265348) 3
70 (27984030) Good
68 (22310029) 3
MRI cervical spine without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 2 14 5 1 0 0
References Study Quality
60 (23075855) 2
48 (22187629) 1
68 (22310029) 3
59 (18188119) M
69 (19912072) 4
47 (19672633) 3
67 (15853463) 2
66 (24269913) 2
65 (34850316) 1
64 (35690715) 4
63 (21619408) M
62 (27893647) 2
61 (24033302) 3
58 (18469647) 3
57 (20065765) M
56 (25997715) 4
55 (20336892) 4
54 (18404054) 4
53 (34480416) 2
52 (16374279) 2
51 (18073599) 4
9 (27438681) 2
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 20 2 0 0 0 0 0 0 0
MRA neck with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 20 1 1 0 0 0 0 0 0
MRA neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 20 1 1 0 0 0 0 0 0
MRA neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 20 1 0 1 0 0 0 0 0
MRI cervical spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 20 1 0 0 1 0 0 0 0
MRI cervical spine without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 20 1 1 0 0 0 0 0 0
CT cervical spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 20 1 1 0 0 0 0 0 0
CT cervical spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 20 2 0 0 0 0 0 0 0
CTA head and neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 1 2 0 0 0 0 0 0
CT myelography cervical spine Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 19 1 2 0 0 0 0 0 0
Variant 4: Age 16 years or older. Acute cervical spine blunt trauma. Suspected arterial injury with or without positive cervical spine CT. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CTA head and neck with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 2 4 16
References Study Quality
92 (24355656) 3
93 (22695428) 3
87 (24458034) 3
99 (37191023) 2
98 (27015579) 2
97 (28799874) 2
96 (25794340) 2
95 (16688051) 3
94 (34854931) 4
91 (12435934) 1
88 (17893500) 2
83 (19537053) 4
34 (36101794) 4
33 (32520898) 2
Arteriography cervicocerebral Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 2 2 0 0 0 1 0 0
References Study Quality
87 (24458034) 3
90 (11981216) 2
89 (24157089) 4
88 (17893500) 2
78 (23574813) 2
76 (21494192) 3
74 (22990630) 3
MRA neck with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 4 3 0 0 0 1 0 0
MRA neck without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 14 4 3 1 0 0 0 0 0
References Study Quality
100 (28759887) 4
MRA neck without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 12 5 2 2 1 0 0 0 0
References Study Quality
93 (22695428) 3
103 (18635617) 2
102 (22929690) 4
101 (7839986) 2
Variant 5: Age 16 years or older. Acute cervical, thoracic or lumbar spine blunt trauma. Suspected or confirmed ligamentous, spinal cord or nerve root injury, with or without trauma identified on CT. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI spine area of interest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 0 5 1 15
References Study Quality
129 (31405713) 4
128 (20388006) 4
127 (36705382) 2
126 (33309644) 2
125 (27417396) 4
124 (27404215) 4
123 (25769487) 3
122 (17108836) 4
121 (16307197) 4
120 (32298957) 4
119 (30007757) 4
118 (29530277) 2
117 (27334017) 4
116 (29229178) 4
115 (28826754) 3
114 (28803621) 4
113 (29450715) 4
112 (27235527) 4
111 (24731570) 3
110 (23025962) 3
109 (22614795) 2
108 (22407141) 4
107 (19523626) 4
106 (19486558) 4
105 (16103286) 4
66 (24269913) 2
61 (24033302) 3
56 (25997715) 4
55 (20336892) 4
36 (20583514) 3
21 (31440893) 4
12 (23114489) 4
9 (27438681) 2
59 (18188119) M
Arteriography spine area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 19 1 2 0 0 0 0 0 0
MRA spine area of interest with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 1 0 1 1 0 0 0 0
MRA spine area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 1 1 2 0 0 0 0 0
MRA spine area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 1 1 1 1 0 0 0 0
MRI spine area of interest with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 1 0 0 0 1 1 0 0
MRI spine area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 2 0 1 1 1 0 0
CT myelography spine area of interest Usually not appropriate Limited Varies Varies 3 3 10 0 4 3 4 1 0 0 0
References Study Quality
104 (15734929) 4
61 (24033302) 3
52 (16374279) 2
CTA spine area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 18 2 2 0 0 0 0 0 0
Variant 6: Age 16 years or older. Acute thoracic or lumbar spine blunt trauma in a high-risk or unexaminable patient. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT spine area of interest without IV contrast Usually appropriate Strong Varies Varies 9 9 0 0 0 0 0 0 3 6 13
References Study Quality
21 (31440893) 4
135 (14566120) 2
134 (27663571) 2
133 (23422283) 2
132 (20699755) 3
Radiography spine area of interest Usually not appropriate Strong Varies Varies 1 1 17 2 2 0 1 0 0 0 0
References Study Quality
133 (23422283) 2
135 (14566120) 2
136 (-3131250) 3
MRI spine area of interest with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 1 0 0 2 0 0 0 0
MRI spine area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 1 0 1 1 0 0 0 0
MRI spine area of interest without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 14 3 4 0 0 1 0 0 0
References Study Quality
18 (12554032) 3
56 (25997715) 4
108 (22407141) 4
CT myelography spine area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 19 2 1 0 0 0 0 0 0
CT spine area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 19 1 0 0 2 0 0 0 0
CT spine area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 18 1 1 1 1 0 0 0 0
Variant 7: Age 16 years or older. Acute cervical spine blunt trauma. Obtunded. No trauma identified on cervical spine CT without IV contrast. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI cervical spine without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 2 1 0 1 12 4 2 0 0
References Study Quality
140 (25076462) 3
111 (24731570) 3
138 (22491556) 3
55 (20336892) 4
144 (18073612) 2
51 (18073599) 4
139 (28993912) 4
143 (23856632) M
142 (27305663) 2
141 (25775316) 4
123 (25769487) 3
113 (29450715) 4
108 (22407141) 4
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 3 0 0 0 1 0 0 0
MRA neck with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 1 0 2 0 0 0 0 0
MRA neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 1 1 1 1 1 0 0 0
MRA neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 1 0 1 0 2 0 0 0
MRI cervical spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 1 0 0 2 0 0 0 0
MRI cervical spine without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 1 0 0 3 0 0 0 0
CTA head and neck with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 11 1 0 3 5 1 1 0 0
References Study Quality
73 (22327974) 3
CT myelography cervical spine Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 19 3 0 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.