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Appropriateness Criteria

Variant 1: Adult. Acute thoracic back pain without myelopathy or radiculopathy. No red flags. No prior management. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography thoracic spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 2 1 0 0 0 1 0
MRI thoracic spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 1 1 1 0 0 0 0
MRI thoracic spine without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 0 1 1 0 0 0 0
MRI thoracic spine without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 1 1 2 1 0 0 0
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
Bone scan with SPECT or SPECT/CT thoracic spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 1 0 0 0 0 0 0 0
CT thoracic spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 0 0 1 1 0 1 0 0
CT thoracic spine without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 0 1 0 0 0 0 0 0
CT myelography thoracic spine Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 17 0 0 2 0 0 0 0 0
CT thoracic spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 0 1 1 0 1 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 1 0 0 0 0 0 0 0
Variant 2: Adult. Subacute or chronic thoracic back pain without myelopathy or radiculopathy. No red flags. Failed conservative management. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography thoracic spine May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 5 11 4 1 0 0 1 2 0 0
MRI thoracic spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 1 0 2 0 1 0 0
MRI thoracic spine without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 0 2 2 0 1 1 0
MRI thoracic spine without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 3 1 0 0 1 1 0 0
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 1 0 0 0 0 0 0 0
Bone scan with SPECT or SPECT/CT thoracic spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 2 0 0 0 0 0 0 0
CT thoracic spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 1 1 2 0 0 0 0
CT thoracic spine without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 1 1 0 1 0 0 0 0
CT myelography thoracic spine Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 16 0 1 1 0 0 1 0 0
CT thoracic spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 0 1 2 1 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 2 0 0 0 0 0 0
Variant 3: Adult. Thoracic back pain with myelopathy or radiculopathy. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI thoracic spine without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 3 3 4 8
References Study Quality
20 (22048067) 4
33 (31304197) 4
Radiography thoracic spine May be appropriate Limited ☢☢☢ 1-10 mSv 4 4 2 1 1 6 7 2 0 0 0
References Study Quality
11 (19412022) 1
MRI thoracic spine without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 2 0 1 0 1 0 8 4 3
CT thoracic spine without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 3 0 0 5 8 3 0 0 0
CT myelography thoracic spine May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 1 1 14 3 0 0 0
References Study Quality
32 (28338452) 4
MRI thoracic spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 3 0 0 0 0 0 0
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 2 0 0 0 0 0 0 0
Bone scan with SPECT or SPECT/CT thoracic spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 2 0 0 0 0 0 0
CT thoracic spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 2 0 2 0 0 0 0
CT thoracic spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 1 1 0 1 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 1 4 0 0 0 0 0
Variant 4: Adult. Thoracic back pain without or with myelopathy or radiculopathy. One or more of the following: low-velocity trauma, osteoporosis, elderly individual, or chronic steroid use. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography thoracic spine Usually appropriate Limited ☢☢☢ 1-10 mSv 7 7 0 0 1 0 1 0 13 2 2
References Study Quality
36 (15875926) 2
MRI thoracic spine without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 2 3 4 2 7
References Study Quality
36 (15875926) 2
CT thoracic spine without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 1 4 3 5 2 4
References Study Quality
36 (15875926) 2
MRI thoracic spine without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 2 0 1 3 11 2 0 0 0
Bone scan whole body May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 7 1 0 4 7 0 0 0 0
References Study Quality
36 (15875926) 2
Bone scan with SPECT or SPECT/CT thoracic spine May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 8 0 0 3 6 2 0 0 0
References Study Quality
36 (15875926) 2
MRI thoracic spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 4 2 0 2 0 0 0
CT thoracic spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 0 3 2 0 1 1 0 0
CT myelography thoracic spine Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 11 2 2 2 1 0 1 0 0
CT thoracic spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 0 1 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 1 1 1 0 0 0 0 0
Variant 5: Adult. Thoracic back pain without or with myelopathy or radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI thoracic spine without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 0 0 2 3 13
References Study Quality
42 (28677897) 4
41 (22312523) 4
40 (19325068) 4
39 (18278491) 3
38 (2028061) 1
36 (15875926) 2
MRI thoracic spine without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 2 3 8 2 3
References Study Quality
44 (32904056) 1
43 (29431498) 4
42 (28677897) 4
41 (22312523) 4
40 (19325068) 4
39 (18278491) 3
Radiography thoracic spine May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 1 0 0 2 12 4 0 0 0
References Study Quality
45 (31100530) 4
CT thoracic spine without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 1 12 5 0 0 0
References Study Quality
37 (35189892) 2
CT myelography thoracic spine May be appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 5 5 1 0 1 3 12 2 0 0 0
MRI thoracic spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 2 0 0 0 0 0 0
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 2 0 3 2 0 0 0
Bone scan with SPECT or SPECT/CT thoracic spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 1 1 3 1 1 0 0
CT thoracic spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 1 2 0 0 0 0 0 0
CT thoracic spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 3 0 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 1 0 1 0 0 0 0
Variant 6: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Radiograph shows bone destruction or fracture or spinal deformity. 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 thoracic spine without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 1 0 1 1 3 3 10
References Study Quality
44 (32904056) 1
MRI thoracic spine without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 3 2 5 4 4
References Study Quality
27 (33934648) 2
CT thoracic spine without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 3 2 7 5 2
References Study Quality
11 (19412022) 1
46 (33302988) 4
CT myelography thoracic spine May be appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 5 5 0 0 0 1 12 5 1 0 0
MRI thoracic spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 2 1 0 0 0 0 0 0
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 2 0 2 1 1 0 0 0
Bone scan with SPECT or SPECT/CT thoracic spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 0 0 4 0 0 0 0
CT thoracic spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 2 0 1 0 0 0 0
CT thoracic spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 0 2 3 2 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 2 0 0 0 0 0 0
Variant 7: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Post thoracic spine surgery. Follow-up imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography thoracic spine Usually appropriate Expert Consensus ☢☢☢ 1-10 mSv 7 7 0 0 0 0 1 0 13 3 2
MRI thoracic spine without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 1 4 4 3 6
References Study Quality
47 (33222899) 4
46 (33302988) 4
MRI thoracic spine without IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 3 6 5 3
CT thoracic spine without IV contrast Usually appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 4 5 2 6 2
CT myelography thoracic spine May be appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 6 6 0 1 1 0 5 6 4 2 0
MRI thoracic spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 2 0 0 0 0 0 0
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 1 0 0 1 0 0 0 0
Bone scan with SPECT or SPECT/CT thoracic spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 1 3 2 1 0 0 0 0
CT thoracic spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 1 2 0 0 0 0 0 0
CT thoracic spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 1 1 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 1 1 0 1 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.