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Appropriateness Criteria

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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI spine area of interest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 1 2 17
References Study Quality
3 (22643395) 4
51 (21669158) 4
14 (25296275) 4
16 (26585257) 2
66 (24999081) 4
7 (31103765) 2
6 (27616314) 4
64 (27452260) 2
67 (24742801) 1
24 (22922857) 2
65 (29582111) 2
27 (17416823) 2
18 (21417700) 4
68 (25899662) 2
17 (28379730) 2
37 (30971277) 2
10 (31399800) 4
63 (32554421) 2
MRI spine area of interest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 0 20 1 0
References Study Quality
3 (22643395) 4
51 (21669158) 4
14 (25296275) 4
16 (26585257) 2
66 (24999081) 4
7 (31103765) 2
6 (27616314) 4
64 (27452260) 2
67 (24742801) 1
24 (22922857) 2
65 (29582111) 2
27 (17416823) 2
18 (21417700) 4
68 (25899662) 2
17 (28379730) 2
37 (30971277) 2
10 (31399800) 4
63 (32554421) 2
Radiography spine area of interest May be appropriate Limited Varies Varies 5 5 0 0 1 9 9 3 0 0 0
References Study Quality
3 (22643395) 4
8 (23756630) 4
31 (29452617) 4
10 (31399800) 4
3-phase bone scan complete spine May be appropriate Limited ☢☢☢ 1-10 mSv 4 4 2 3 5 5 4 1 0 0 1
References Study Quality
3 (22643395) 4
31 (29452617) 4
Gallium scan whole body May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 2 1 4 6 6 1 0 0 1
References Study Quality
3 (22643395) 4
36 (27523445) 2
31 (29452617) 4
CT spine area of interest with IV contrast May be appropriate Strong Varies Varies 6 6 1 1 0 2 3 11 2 0 1
References Study Quality
3 (22643395) 4
57 (30691569) 4
30 (20515351) 2
33 (28249310) 2
52 (29915936) 4
CT spine area of interest without IV contrast May be appropriate Strong Varies Varies 5 5 0 1 1 4 9 5 1 0 0
References Study Quality
3 (22643395) 4
57 (30691569) 4
30 (20515351) 2
33 (28249310) 2
52 (29915936) 4
MRI spine area of interest with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 12 3 7 0 0 0 0 0 0
References Study Quality
3 (22643395) 4
51 (21669158) 4
14 (25296275) 4
16 (26585257) 2
66 (24999081) 4
7 (31103765) 2
6 (27616314) 4
64 (27452260) 2
67 (24742801) 1
24 (22922857) 2
65 (29582111) 2
27 (17416823) 2
18 (21417700) 4
68 (25899662) 2
17 (28379730) 2
37 (30971277) 2
10 (31399800) 4
63 (32554421) 2
FDG-PET/CT whole body Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 6 8 2 2 1 0 0 0
References Study Quality
43 (29256136) 2
42 (27160950) 2
38 (28299432) 2
31 (29452617) 4
44 (31729539) Good
10 (31399800) 4
WBC scan and sulfur colloid scan complete spine Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 10 3 4 2 0 1 0 0 1
References Study Quality
31 (29452617) 4
CT spine area of interest without and with IV contrast Usually not appropriate Strong Varies Varies 2 2 9 2 1 4 3 1 1 0 0
References Study Quality
3 (22643395) 4
57 (30691569) 4
30 (20515351) 2
33 (28249310) 2
52 (29915936) 4
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI spine area of interest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 0 6 14
References Study Quality
3 (22643395) 4
51 (21669158) 4
14 (25296275) 4
16 (26585257) 2
66 (24999081) 4
7 (31103765) 2
6 (27616314) 4
64 (27452260) 2
28 (24792614) 4
24 (22922857) 2
65 (29582111) 2
18 (21417700) 4
29 (27755204) 4
17 (28379730) 2
37 (30971277) 2
69 (1509065) 2
10 (31399800) 4
70 (28437330) 2
63 (32554421) 2
MRI spine area of interest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 0 1 18 2 0
References Study Quality
3 (22643395) 4
51 (21669158) 4
14 (25296275) 4
16 (26585257) 2
66 (24999081) 4
7 (31103765) 2
6 (27616314) 4
64 (27452260) 2
28 (24792614) 4
24 (22922857) 2
65 (29582111) 2
18 (21417700) 4
29 (27755204) 4
17 (28379730) 2
37 (30971277) 2
69 (1509065) 2
10 (31399800) 4
70 (28437330) 2
63 (32554421) 2
Radiography spine area of interest May be appropriate Limited Varies Varies 5 5 0 0 0 8 8 6 0 0 0
References Study Quality
3 (22643395) 4
10 (31399800) 4
3-phase bone scan complete spine May be appropriate Limited ☢☢☢ 1-10 mSv 4 4 1 3 5 4 6 1 0 0 1
References Study Quality
31 (29452617) 4
Gallium scan whole body May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 1 4 4 10 1 0 0 1
References Study Quality
3 (22643395) 4
36 (27523445) 2
31 (29452617) 4
10 (31399800) 4
CT spine area of interest with IV contrast May be appropriate Strong Varies Varies 6 6 0 1 0 0 7 6 3 3 1
References Study Quality
3 (22643395) 4
8 (23756630) 4
30 (20515351) 2
33 (28249310) 2
CT spine area of interest without IV contrast May be appropriate Strong Varies Varies 5 5 0 0 2 3 8 5 2 1 0
References Study Quality
3 (22643395) 4
8 (23756630) 4
30 (20515351) 2
33 (28249310) 2
MRI spine area of interest with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 11 4 7 0 0 0 0 0 0
References Study Quality
3 (22643395) 4
51 (21669158) 4
14 (25296275) 4
16 (26585257) 2
66 (24999081) 4
7 (31103765) 2
6 (27616314) 4
64 (27452260) 2
28 (24792614) 4
24 (22922857) 2
65 (29582111) 2
18 (21417700) 4
29 (27755204) 4
17 (28379730) 2
37 (30971277) 2
69 (1509065) 2
10 (31399800) 4
70 (28437330) 2
63 (32554421) 2
FDG-PET/CT whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 5 8 2 2 2 0 0 0
References Study Quality
31 (29452617) 4
40 (30711697) 2
10 (31399800) 4
WBC scan and sulfur colloid scan complete spine Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 10 3 5 0 1 0 1 0 1
References Study Quality
31 (29452617) 4
CT spine area of interest without and with IV contrast Usually not appropriate Strong Varies Varies 2 2 11 5 5 0 1 0 0 0 0
References Study Quality
3 (22643395) 4
8 (23756630) 4
30 (20515351) 2
33 (28249310) 2
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI spine area of interest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 0 0 20
References Study Quality
3 (22643395) 4
51 (21669158) 4
14 (25296275) 4
16 (26585257) 2
66 (24999081) 4
7 (31103765) 2
6 (27616314) 4
64 (27452260) 2
24 (22922857) 2
65 (29582111) 2
18 (21417700) 4
17 (28379730) 2
37 (30971277) 2
10 (31399800) 4
63 (32554421) 2
MRI spine area of interest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 0 0 19 2 0
References Study Quality
3 (22643395) 4
51 (21669158) 4
14 (25296275) 4
16 (26585257) 2
66 (24999081) 4
7 (31103765) 2
6 (27616314) 4
64 (27452260) 2
24 (22922857) 2
65 (29582111) 2
18 (21417700) 4
17 (28379730) 2
37 (30971277) 2
10 (31399800) 4
63 (32554421) 2
CT spine area of interest with IV contrast May be appropriate Strong Varies Varies 5 5 0 0 2 2 9 5 2 0 1
References Study Quality
8 (23756630) 4
71 (27789449) 2
33 (28249310) 2
CT spine area of interest without IV contrast May be appropriate Strong Varies Varies 5 5 0 1 3 6 7 3 0 1 0
References Study Quality
8 (23756630) 4
71 (27789449) 2
33 (28249310) 2
Radiography spine area of interest Usually not appropriate Limited Varies Varies 3 3 3 3 11 1 2 2 0 0 0
References Study Quality
72 (25911501) 4
MRI spine area of interest with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 11 3 8 0 0 0 0 0 0
References Study Quality
3 (22643395) 4
51 (21669158) 4
14 (25296275) 4
16 (26585257) 2
66 (24999081) 4
7 (31103765) 2
6 (27616314) 4
64 (27452260) 2
24 (22922857) 2
65 (29582111) 2
18 (21417700) 4
17 (28379730) 2
37 (30971277) 2
10 (31399800) 4
63 (32554421) 2
3-phase bone scan complete spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 3 4 0 0 0 0 0 1
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 3 4 0 2 0 0 1 0
Gallium scan whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 12 3 3 2 0 0 0 0 1
WBC scan and sulfur colloid scan complete spine Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 15 3 2 0 0 0 0 0 1
CT spine area of interest without and with IV contrast Usually not appropriate Strong Varies Varies 3 3 9 1 3 4 2 1 1 0 0
References Study Quality
8 (23756630) 4
71 (27789449) 2
33 (28249310) 2
Variant 4: Suspected spine infection (such as epidural abscess or discitis osteomyelitis), with decubitus ulcer or wound overlying spine. Initial imaging.
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 and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 0 3 17
References Study Quality
3 (22643395) 4
51 (21669158) 4
14 (25296275) 4
16 (26585257) 2
66 (24999081) 4
7 (31103765) 2
64 (27452260) 2
28 (24792614) 4
24 (22922857) 2
65 (29582111) 2
29 (27755204) 4
37 (30971277) 2
69 (1509065) 2
10 (31399800) 4
70 (28437330) 2
63 (32554421) 2
MRI spine area of interest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 1 18 2 0
References Study Quality
3 (22643395) 4
51 (21669158) 4
14 (25296275) 4
16 (26585257) 2
66 (24999081) 4
7 (31103765) 2
64 (27452260) 2
28 (24792614) 4
24 (22922857) 2
65 (29582111) 2
29 (27755204) 4
37 (30971277) 2
69 (1509065) 2
10 (31399800) 4
70 (28437330) 2
63 (32554421) 2
Radiography spine area of interest May be appropriate Limited Varies Varies 5 5 0 0 2 6 10 4 0 0 0
References Study Quality
3 (22643395) 4
8 (23756630) 4
3-phase bone scan complete spine May be appropriate Limited ☢☢☢ 1-10 mSv 4 4 1 2 5 8 3 1 0 0 1
References Study Quality
31 (29452617) 4
Gallium scan whole body May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 1 2 2 7 7 1 0 0 1
References Study Quality
31 (29452617) 4
CT spine area of interest with IV contrast May be appropriate Strong Varies Varies 6 6 0 0 1 0 4 8 6 1 1
References Study Quality
3 (22643395) 4
30 (20515351) 2
33 (28249310) 2
CT spine area of interest without IV contrast May be appropriate Strong Varies Varies 5 5 1 1 0 3 7 6 3 0 0
References Study Quality
3 (22643395) 4
30 (20515351) 2
33 (28249310) 2
MRI spine area of interest with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 12 4 6 0 0 0 0 0 0
References Study Quality
3 (22643395) 4
51 (21669158) 4
14 (25296275) 4
16 (26585257) 2
66 (24999081) 4
7 (31103765) 2
64 (27452260) 2
28 (24792614) 4
24 (22922857) 2
65 (29582111) 2
29 (27755204) 4
37 (30971277) 2
69 (1509065) 2
10 (31399800) 4
70 (28437330) 2
63 (32554421) 2
FDG-PET/CT whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 5 5 2 4 1 0 0 0
References Study Quality
31 (29452617) 4
10 (31399800) 4
WBC scan and sulfur colloid scan complete spine Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 10 2 6 0 2 0 0 0 1
References Study Quality
31 (29452617) 4
CT spine area of interest without and with IV contrast Usually not appropriate Strong Varies Varies 2 2 9 6 7 0 0 0 0 0 0
References Study Quality
3 (22643395) 4
30 (20515351) 2
33 (28249310) 2
Variant 5: Suspected spine infection (such as epidural abscess or discitis osteomyelitis). Abnormal radiographs or CT findings. 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 and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 0 1 19
References Study Quality
3 (22643395) 4
51 (21669158) 4
14 (25296275) 4
16 (26585257) 2
66 (24999081) 4
7 (31103765) 2
6 (27616314) 4
64 (27452260) 2
24 (22922857) 2
65 (29582111) 2
18 (21417700) 4
17 (28379730) 2
37 (30971277) 2
10 (31399800) 4
63 (32554421) 2
MRI spine area of interest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 1 0 1 0 3 2 11 2 1
References Study Quality
3 (22643395) 4
51 (21669158) 4
14 (25296275) 4
16 (26585257) 2
66 (24999081) 4
7 (31103765) 2
6 (27616314) 4
64 (27452260) 2
24 (22922857) 2
65 (29582111) 2
18 (21417700) 4
17 (28379730) 2
37 (30971277) 2
10 (31399800) 4
63 (32554421) 2
3-phase bone scan complete spine May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 2 0 3 4 5 5 2 0 0
References Study Quality
31 (29452617) 4
FDG-PET/CT whole body May be appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 3 2 6 7 1 0 1
References Study Quality
31 (29452617) 4
44 (31729539) Good
10 (31399800) 4
Gallium scan whole body May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 1 0 1 4 9 4 2 0 0
References Study Quality
3 (22643395) 4
31 (29452617) 4
10 (31399800) 4
MRI spine area of interest with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 12 4 6 0 0 0 0 0 0
References Study Quality
3 (22643395) 4
51 (21669158) 4
14 (25296275) 4
16 (26585257) 2
66 (24999081) 4
7 (31103765) 2
6 (27616314) 4
64 (27452260) 2
24 (22922857) 2
65 (29582111) 2
18 (21417700) 4
17 (28379730) 2
37 (30971277) 2
10 (31399800) 4
63 (32554421) 2
WBC scan and sulfur colloid scan complete spine Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 1 1 11 2 4 2 1 1 0 0 0
References Study Quality
31 (29452617) 4
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.