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Appropriateness Criteria

Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography complete spine Usually not appropriate Limited ☢☢☢ 0.3-3 mSv [ped] 2 2 7 6 3 0 0 0 1 0 0
References Study Quality
3 (19926701) 4
12 (32603067) 4
16 (28786774) 4
US spine area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 1 0 0 1 1 0 0
Radiography spine area of interest Usually not appropriate Limited Varies Varies 2 2 3 6 2 1 4 0 1 0 0
References Study Quality
3 (19926701) 4
12 (32603067) 4
16 (28786774) 4
MRI complete spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 2 0 0 0 0 0
MRI complete spine without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 2 0 0 0 0
MRI complete spine without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 0 1 1 2 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 13 2 0 0 1 1 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 12 3 0 0 1 1 0 0 0
MRI spine area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 3 1 0 0 0 1 0 0
Bone scan whole body with SPECT or SPECT/CT area of interest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 3 1 0 0 0 0 0 0
Bone scan whole body with SPECT or SPECT/CT complete spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 1 0 0 0 0 0 0
CT complete spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 2 0 0 0 0 0 0
CT complete spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 3 0 0 0 0 0 0 0
CT complete spine without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 2 2 0 0 0 0 0 0
CT myelography complete spine Usually not appropriate Expert Consensus ☢☢☢☢☢ 30-100 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 0 1 0 0 0 0 0 0
CT myelography spine area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 16 0 1 0 0 0 0 0 0
CT spine area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 12 3 1 0 0 1 0 0 0
CT spine area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 3 0 0 0 1 0 0 0
CT spine area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 10 2 1 2 0 1 1 0 0
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography spine area of interest Usually appropriate Limited Varies Varies 8 8 0 0 0 0 3 0 3 4 7
References Study Quality
17 (24686297) 3
16 (28786774) 4
12 (32603067) 4
9 (28135365) 4
2 (34995265) 3
1 (33781487) 4
Radiography complete spine May be appropriate Limited ☢☢☢ 0.3-3 mSv [ped] 5 5 0 1 1 0 7 3 4 1 0
References Study Quality
17 (24686297) 3
16 (28786774) 4
12 (32603067) 4
9 (28135365) 4
2 (34995265) 3
1 (33781487) 4
MRI complete spine without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 1 1 3 8 2 0 1 0
References Study Quality
2 (34995265) 3
22 (32530746) 4
21 (33220471) 4
20 (35136714) 4
17 (24686297) 3
16 (28786774) 4
13 (26275972) 4
MRI complete spine without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 1 0 4 7 2 1 0 1
References Study Quality
2 (34995265) 3
21 (33220471) 4
17 (24686297) 3
16 (28786774) 4
13 (26275972) 4
MRI spine area of interest without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 1 0 2 7 4 1 1 0
References Study Quality
2 (34995265) 3
22 (32530746) 4
21 (33220471) 4
20 (35136714) 4
17 (24686297) 3
16 (28786774) 4
13 (26275972) 4
MRI spine area of interest without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 1 0 2 5 6 2 0 0
References Study Quality
2 (34995265) 3
13 (26275972) 4
16 (28786774) 4
17 (24686297) 3
21 (33220471) 4
CT spine area of interest with IV contrast May be appropriate Limited Varies Varies 5 5 0 2 0 5 9 0 1 0 0
References Study Quality
20 (35136714) 4
19 (32364883) 4
18 (23255735) 4
12 (32603067) 4
CT spine area of interest without IV contrast May be appropriate Limited Varies Varies 5 5 1 0 3 1 6 5 1 0 0
References Study Quality
18 (23255735) 4
19 (32364883) 4
US spine area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 2 3 1 1 0 1 0 0
MRI complete spine with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 8 3 3 0 1 1 1 0 0
References Study Quality
2 (34995265) 3
21 (33220471) 4
17 (24686297) 3
13 (26275972) 4
MRI spine area of interest with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 8 3 3 0 2 0 0 1 0
References Study Quality
2 (34995265) 3
21 (33220471) 4
17 (24686297) 3
13 (26275972) 4
Bone scan whole body with SPECT or SPECT/CT area of interest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 2 0 1 0 0 0 0
Bone scan whole body with SPECT or SPECT/CT complete spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 3 2 0 0 0 0 0 0
CT complete spine with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 2 0 0 2 0 0 0 0
References Study Quality
20 (35136714) 4
19 (32364883) 4
18 (23255735) 4
12 (32603067) 4
CT complete spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 2 0 1 1 1 0 0 0
CT complete spine without IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 4 4 1 1 0 0 0 0
References Study Quality
18 (23255735) 4
19 (32364883) 4
12 (32603067) 4
CT myelography complete spine Usually not appropriate Expert Consensus ☢☢☢☢☢ 30-100 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 3 0 0 0 0 0 0
CT myelography spine area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 14 0 3 0 0 0 0 0 0
CT spine area of interest without and with IV contrast Usually not appropriate Limited Varies Varies 1 1 9 2 2 2 1 1 0 0 0
References Study Quality
20 (35136714) 4
19 (32364883) 4
18 (23255735) 4
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. 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 Limited O 0 mSv O 0 mSv [ped] 7 7 1 0 1 0 2 2 6 3 2
References Study Quality
26 (30302556) 2
25 (32058837) 4
24 (28514223) 4
19 (32364883) 4
17 (24686297) 3
16 (28786774) 4
12 (32603067) 4
2 (34995265) 3
MRI spine area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 0 1 6 8 1
References Study Quality
26 (30302556) 2
25 (32058837) 4
24 (28514223) 4
19 (32364883) 4
17 (24686297) 3
16 (28786774) 4
12 (32603067) 4
2 (34995265) 3
MRI complete spine with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 5 3 6 0 1 0 1 1 0
References Study Quality
24 (28514223) 4
19 (32364883) 4
17 (24686297) 3
2 (34995265) 3
MRI complete spine without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 1 1 2 4 2 4 3 0
References Study Quality
26 (30302556) 2
25 (32058837) 4
24 (28514223) 4
19 (32364883) 4
17 (24686297) 3
16 (28786774) 4
12 (32603067) 4
2 (34995265) 3
MRI complete spine without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 1 1 1 3 4 4 3 0
References Study Quality
2 (34995265) 3
26 (30302556) 2
25 (32058837) 4
24 (28514223) 4
19 (32364883) 4
17 (24686297) 3
16 (28786774) 4
12 (32603067) 4
MRI spine area of interest with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 4 4 5 0 2 0 1 0 1
References Study Quality
24 (28514223) 4
19 (32364883) 4
17 (24686297) 3
2 (34995265) 3
CT complete spine with IV contrast May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 1 4 1 3 6 2 0 0 0
References Study Quality
2 (34995265) 3
23 (25969937) 4
20 (35136714) 4
19 (32364883) 4
18 (23255735) 4
CT complete spine without IV contrast May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 2 1 5 8 1 0 0 0
References Study Quality
2 (34995265) 3
18 (23255735) 4
23 (25969937) 4
CT spine area of interest with IV contrast May be appropriate Limited Varies Varies 5 5 0 1 1 1 8 5 1 0 0
References Study Quality
2 (34995265) 3
23 (25969937) 4
20 (35136714) 4
19 (32364883) 4
18 (23255735) 4
CT spine area of interest without IV contrast May be appropriate Limited Varies Varies 5 5 0 1 0 2 7 6 1 0 0
References Study Quality
2 (34995265) 3
18 (23255735) 4
23 (25969937) 4
US spine area of interest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 8 3 4 0 0 2 0 0 0
References Study Quality
24 (28514223) 4
Bone scan whole body with SPECT or SPECT/CT area of interest Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 3 1 0 6 1 0 0 0
References Study Quality
23 (25969937) 4
18 (23255735) 4
15 (27387155) 4
Bone scan whole body with SPECT or SPECT/CT complete spine Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 3 5 1 2 0 0 0 0
References Study Quality
15 (27387155) 4
23 (25969937) 4
18 (23255735) 4
12 (32603067) 4
CT complete spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 3 1 2 2 0 0 0 0
CT myelography complete spine Usually not appropriate Expert Consensus ☢☢☢☢☢ 30-100 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 2 2 0 0 0 0 0 0
CT myelography spine area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 13 2 2 0 0 0 0 0 0
CT spine area of interest without and with IV contrast Usually not appropriate Limited Varies Varies 3 3 4 3 2 4 2 1 0 0 1
References Study Quality
2 (34995265) 3
23 (25969937) 4
20 (35136714) 4
18 (23255735) 4
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI complete spine without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 2 1 2 9 3
References Study Quality
22 (32530746) 4
20 (35136714) 4
16 (28786774) 4
12 (32603067) 4
25 (32058837) 4
Radiography complete spine May be appropriate (Disagreement) Expert Opinion ☢☢☢ 0.3-3 mSv [ped] 5 5 2 1 2 5 4 2 2 0 0
References Study Quality
18 (23255735) 4
13 (26275972) 4
12 (32603067) 4
9 (28135365) 4
25 (32058837) 4
Radiography spine area of interest May be appropriate (Disagreement) Expert Opinion Varies Varies 5 5 1 2 2 1 3 2 6 1 0
References Study Quality
18 (23255735) 4
13 (26275972) 4
12 (32603067) 4
9 (28135365) 4
25 (32058837) 4
MRI complete spine with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 2 7 2 4 0 1 2 0 0
References Study Quality
22 (32530746) 4
20 (35136714) 4
16 (28786774) 4
12 (32603067) 4
25 (32058837) 4
MRI complete spine without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 1 0 0 8 6 3 0 0
References Study Quality
22 (32530746) 4
20 (35136714) 4
16 (28786774) 4
12 (32603067) 4
25 (32058837) 4
CT complete spine with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 4 0 2 9 1 2 0 0
References Study Quality
3 (19926701) 4
19 (32364883) 4
20 (35136714) 4
CT complete spine without and with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 3 11 1 0 0 2 1 0 0
References Study Quality
20 (35136714) 4
CT complete spine without IV contrast May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 2 4 3 7 0 2 0 0
References Study Quality
3 (19926701) 4
CT spine area of interest with IV contrast May be appropriate (Disagreement) Expert Opinion Varies Varies 5 5 0 1 2 1 8 4 1 0 1
References Study Quality
3 (19926701) 4
19 (32364883) 4
20 (35136714) 4
CT spine area of interest without and with IV contrast May be appropriate (Disagreement) Expert Opinion Varies Varies 5 5 2 5 4 3 1 2 1 0 0
References Study Quality
3 (19926701) 4
CT spine area of interest without IV contrast May be appropriate Limited Varies Varies 5 5 0 1 0 5 7 4 1 0 0
References Study Quality
3 (19926701) 4
US spine area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 0 1 1 1 0 0 0
Bone scan whole body with SPECT or SPECT/CT area of interest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 3 2 1 2 0 0 0 0
Bone scan whole body with SPECT or SPECT/CT complete spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 9 3 5 1 0 0 0 0 0
CT myelography complete spine Usually not appropriate Expert Consensus ☢☢☢☢☢ 30-100 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 3 2 0 0 0 0 0 0
CT myelography spine area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 12 3 2 0 0 0 0 0 0
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. 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 complete spine without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 1 0 1 0 1 2 4 5 3
References Study Quality
22 (32530746) 4
20 (35136714) 4
16 (28786774) 4
12 (32603067) 4
25 (32058837) 4
MRI spine area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 1 0 1 0 0 2 3 5 5
References Study Quality
22 (32530746) 4
20 (35136714) 4
16 (28786774) 4
12 (32603067) 4
25 (32058837) 4
MRI complete spine without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 1 2 1 3 7 2 1 0
References Study Quality
22 (32530746) 4
20 (35136714) 4
16 (28786774) 4
12 (32603067) 4
25 (32058837) 4
MRI spine area of interest with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 3 6 1 3 1 1 0 2 0
References Study Quality
20 (35136714) 4
MRI spine area of interest without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 1 1 1 3 7 2 1 0
References Study Quality
22 (32530746) 4
20 (35136714) 4
16 (28786774) 4
12 (32603067) 4
25 (32058837) 4
Bone scan whole body with SPECT or SPECT/CT area of interest May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 2 1 2 1 9 1 1 0 0
References Study Quality
25 (32058837) 4
20 (35136714) 4
18 (23255735) 4
Bone scan whole body with SPECT or SPECT/CT complete spine May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 4 3 3 2 1 2 1 1 0
References Study Quality
18 (23255735) 4
20 (35136714) 4
24 (28514223) 4
CT complete spine with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 2 0 4 8 1 0 2 0
References Study Quality
3 (19926701) 4
20 (35136714) 4
19 (32364883) 4
18 (23255735) 4
CT complete spine without IV contrast May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 2 2 5 6 1 0 1 0
References Study Quality
3 (19926701) 4
18 (23255735) 4
FDG-PET/CT whole body May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 1 0 0 6 7 1 1 0
References Study Quality
29 (30420225) 4
CT spine area of interest with IV contrast May be appropriate Limited Varies Varies 5 5 0 1 1 1 10 3 1 0 0
References Study Quality
3 (19926701) 4
20 (35136714) 4
19 (32364883) 4
18 (23255735) 4
CT spine area of interest without IV contrast May be appropriate Limited Varies Varies 5 5 0 1 1 3 11 0 0 1 0
References Study Quality
3 (19926701) 4
18 (23255735) 4
US spine area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 4 1 0 0 1 0 0 0
MRI complete spine with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 3 6 2 3 1 1 1 0 0
References Study Quality
20 (35136714) 4
CT complete spine without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 2 9 4 0 1 0 0 0 1
References Study Quality
3 (19926701) 4
20 (35136714) 4
CT myelography complete spine Usually not appropriate Limited ☢☢☢☢☢ 30-100 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 5 3 1 0 0 0 0 0
References Study Quality
23 (25969937) 4
CT myelography spine area of interest Usually not appropriate Limited Varies Varies 1 1 9 5 2 1 0 0 0 0 0
References Study Quality
23 (25969937) 4
CT spine area of interest without and with IV contrast Usually not appropriate Limited Varies Varies 3 3 4 4 5 2 1 0 0 0 1
References Study Quality
3 (19926701) 4
18 (23255735) 4
20 (35136714) 4
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography spine area of interest Usually appropriate Limited Varies Varies 8 8 0 0 1 1 0 0 4 3 8
References Study Quality
35 (23334124) 3
32 (35767547) 3
17 (24686297) 3
16 (28786774) 4
12 (32603067) 4
9 (28135365) 4
2 (34995265) 3
1 (33781487) 4
Radiography complete spine May be appropriate (Disagreement) Expert Opinion ☢☢☢ 0.3-3 mSv [ped] 5 5 4 5 2 0 2 3 1 0 0
References Study Quality
35 (23334124) 3
32 (35767547) 3
17 (24686297) 3
16 (28786774) 4
12 (32603067) 4
9 (28135365) 4
2 (34995265) 3
1 (33781487) 4
MRI spine area of interest without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 1 1 2 3 7 1 1 1
References Study Quality
3 (19926701) 4
14 (20495823) 4
16 (28786774) 4
Bone scan whole body with SPECT or SPECT/CT area of interest May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 3 3 2 4 3 1 1 0 0
References Study Quality
34 (16557139) 3
33 (29989259) 4
30 (28349205) 4
14 (20495823) 4
3 (19926701) 4
CT spine area of interest without IV contrast May be appropriate Limited Varies Varies 4 4 0 1 0 8 5 2 0 1 0
References Study Quality
2 (34995265) 3
18 (23255735) 4
23 (25969937) 4
US spine area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 3 1 0 1 0 0 0 0
MRI complete spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 3 0 1 0 1 1 0 0
MRI complete spine without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 3 0 1 0 1 0 1 0
MRI complete spine without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 6 4 0 0 1 0 0 0
References Study Quality
3 (19926701) 4
14 (20495823) 4
16 (28786774) 4
MRI spine area of interest with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 1 0 1 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 13 2 1 0 1 0 0 0 0
Bone scan whole body with SPECT or SPECT/CT complete spine Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 7 2 0 1 0 0 0 0
References Study Quality
34 (16557139) 3
33 (29989259) 4
30 (28349205) 4
14 (20495823) 4
3 (19926701) 4
CT complete spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 4 1 0 1 0 0 0 0
CT complete spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 3 0 0 2 0 0 0 0
CT complete spine without IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 8 1 0 1 0 0 0 0
References Study Quality
2 (34995265) 3
18 (23255735) 4
23 (25969937) 4
CT myelography complete spine Usually not appropriate Expert Consensus ☢☢☢☢☢ 30-100 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 3 1 0 0 0 0 0 0
CT myelography spine area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 13 2 0 2 0 0 0 0 0
CT spine area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 11 2 0 2 2 0 0 0 0
CT spine area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 11 2 0 1 2 1 0 0 0
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US spine area of interest Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 2 4 2 1 6
References Study Quality
27 (16224110) 4
36 (23601014) 4
MRI spine area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 3 1 5 3 3
References Study Quality
12 (32603067) 4
16 (28786774) 4
27 (16224110) 4
MRI spine area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 4 1 6 4 1
References Study Quality
12 (32603067) 4
16 (28786774) 4
27 (16224110) 4
MRI complete spine without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 1 1 3 6 1 1 2 1
References Study Quality
12 (32603067) 4
16 (28786774) 4
27 (16224110) 4
MRI complete spine without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 1 1 1 3 8 1 1 1
References Study Quality
12 (32603067) 4
16 (28786774) 4
27 (16224110) 4
MRI spine area of interest with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 7 4 3 0 1 0 1 1 0
References Study Quality
12 (32603067) 4
16 (28786774) 4
27 (16224110) 4
Radiography complete spine Usually not appropriate Expert Consensus ☢☢☢ 0.3-3 mSv [ped] 1 1 9 7 0 1 0 0 0 0 0
Radiography spine area of interest Usually not appropriate Expert Consensus Varies Varies 2 2 7 8 1 0 0 1 0 0 0
MRI complete spine with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 7 0 0 1 1 0 1 0
References Study Quality
27 (16224110) 4
16 (28786774) 4
12 (32603067) 4
Bone scan whole body with SPECT or SPECT/CT area of interest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 2 0 0 0 0 0 0 0
Bone scan whole body with SPECT or SPECT/CT complete spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 2 0 0 0 0 0 0 0
CT complete spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 2 1 1 0 1 0 0 0
CT complete spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 3 1 0 1 0 0 0
CT complete spine without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 1 2 1 1 0 0 0
CT myelography complete spine Usually not appropriate Expert Consensus ☢☢☢☢☢ 30-100 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 3 1 0 0 0 0 0 0
CT myelography spine area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 12 2 2 1 0 0 0 0 0
CT spine area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 10 3 2 0 0 2 0 0 0
CT spine area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 9 2 3 0 1 2 0 0 0
CT spine area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 9 2 2 2 1 1 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.