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Appropriateness Criteria

Variant 1: Child, 3 to 16 years of age, acute cervical spine trauma, meets low risk criteria (based on PECARN or NEXUS). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US cervical spine Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 23 1 0 0 0 0 0 0 0
Radiography cervical spine Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 10 6 4 2 1 0 0 0 1
References Study Quality
4 (20433260) 4
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 24 0 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 2 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 2 0 2 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 2 1 1 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 19 0 2 1 0 2 0 0 0
CT cervical spine with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 22 2 0 0 0 0 0 0 0
References Study Quality
30 (15920400) M
19 (19741398) 4
32 (26514612) 3
31 (26744446) 3
CT cervical spine without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 20 4 0 0 0 0 0 0 0
References Study Quality
30 (15920400) M
19 (19741398) 4
32 (26514612) 3
31 (26744446) 3
CT cervical spine without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 5 2 1 0 2 0 0
References Study Quality
30 (15920400) M
19 (19741398) 4
32 (26514612) 3
31 (26744446) 3
CTA neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 21 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 23 1 0 0 0 0 0 0 0
Variant 2: Child, 3 to 16 years of age, acute cervical spine trauma, at least one risk factor with reliable clinical examination (based on PECARN or NEXUS). 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 appropriate Strong ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 9 9 0 1 0 0 1 1 3 5 13
References Study Quality
45 (23075855) 2
41 (23489979) 4
38 (22663912) 4
35 (22531194) 2
30 (15920400) M
39 (11423804) 4
9 (19002679) 4
42 (20192648) 4
33 (15609065) 3
43 (15920399) 3
34 (17493540) 4
36 (20093616) 2
37 (22595586) 2
40 (19159734) 3
44 (22290498) 3
MRI cervical spine without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 3 5 4 3 3 5 0 1 0
References Study Quality
45 (23075855) 2
74 (23856632) M
61 (26151511) 3
69 (24119886) 3
68 (23232377) 4
60 (22491556) 3
67 (27334017) 4
66 (23321374) M
73 (21619408) M
70 (18188119) M
51 (19396479) 3
58 (20493656) 4
7 (16494197) 3
62 (24157265) 3
63 (19095100) 3
64 (18469647) 3
75 (18665403) 3
65 (18404054) 4
57 (16297679) 4
48 (23584614) 3
56 (24091790) 3
59 (16122000) 3
77 (26512624) 2
72 (19820570) 4
76 (-3144420) 4
71 (12198456) 3
CT cervical spine without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 3 2 7 3 4 4 0 0 1
References Study Quality
50 (27043893) 2
47 (23114489) 4
52 (23511151) 3
35 (22531194) 2
25 (18073623) 4
30 (15920400) M
19 (19741398) 4
54 (20889081) 4
17 (18301348) 4
51 (19396479) 3
12 (24528980) 3
43 (15920399) 3
46 (15920398) 3
48 (23584614) 3
53 (25033993) 2
55 (23453711) 3
49 (16374279) 2
US cervical spine Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 23 1 0 0 0 0 0 0 0
References Study Quality
87 (26167212) 4
88 (23709440) 3
89 (19927090) 2
Arteriography cervicocerebral Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 20 1 1 0 2 0 0 0 0
References Study Quality
68 (23232377) 4
78 (16688051) 3
MRA neck without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 15 4 1 1 3 0 0 0 0
References Study Quality
80 (24355656) 3
68 (23232377) 4
86 (20154559) 4
MRA neck without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 2 1 2 6 0 0 0 0
References Study Quality
80 (24355656) 3
68 (23232377) 4
86 (20154559) 4
MRI cervical spine without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 17 4 1 1 1 0 0 0 0
References Study Quality
45 (23075855) 2
74 (23856632) M
61 (26151511) 3
69 (24119886) 3
68 (23232377) 4
60 (22491556) 3
67 (27334017) 4
66 (23321374) M
73 (21619408) M
70 (18188119) M
51 (19396479) 3
58 (20493656) 4
7 (16494197) 3
62 (24157265) 3
63 (19095100) 3
64 (18469647) 3
75 (18665403) 3
65 (18404054) 4
57 (16297679) 4
48 (23584614) 3
56 (24091790) 3
59 (16122000) 3
77 (26512624) 2
72 (19820570) 4
76 (-3144420) 4
71 (12198456) 3
CT cervical spine with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 6 1 0 0 0 0 0 0
References Study Quality
50 (27043893) 2
47 (23114489) 4
52 (23511151) 3
35 (22531194) 2
25 (18073623) 4
30 (15920400) M
19 (19741398) 4
54 (20889081) 4
17 (18301348) 4
51 (19396479) 3
12 (24528980) 3
43 (15920399) 3
46 (15920398) 3
48 (23584614) 3
53 (25033993) 2
55 (23453711) 3
49 (16374279) 2
CT cervical spine without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 4 1 0 0 0 0 0 0
References Study Quality
50 (27043893) 2
47 (23114489) 4
52 (23511151) 3
35 (22531194) 2
25 (18073623) 4
30 (15920400) M
19 (19741398) 4
54 (20889081) 4
17 (18301348) 4
51 (19396479) 3
12 (24528980) 3
43 (15920399) 3
46 (15920398) 3
48 (23584614) 3
53 (25033993) 2
55 (23453711) 3
49 (16374279) 2
CTA neck with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 11 2 2 3 6 0 0 0 0
References Study Quality
80 (24355656) 3
81 (22990630) 3
82 (22137135) 4
68 (23232377) 4
78 (16688051) 3
85 (20019135) 3
83 (25803220) 3
84 (24722311) 3
79 (20496085) 4
CT myelography cervical spine Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 20 2 2 0 0 0 0 0 0
References Study Quality
90 (16439090) 4
Variant 3: Child, younger than 3 years of age, acute cervical spine trauma, Pieretti-Vanmarcke weighted score greater than or equal to 2 to 8 points. 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 appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 9 9 1 0 0 1 2 1 3 3 12
References Study Quality
45 (23075855) 2
42 (20192648) 4
19 (19741398) 4
91 (21980025) 4
54 (20889081) 4
44 (22290498) 3
MRI cervical spine without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 5 2 5 4 3 4 0 1 0
References Study Quality
92 (16458247) 4
51 (19396479) 3
US cervical spine Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 20 2 1 0 0 0 0 0 0
Arteriography cervicocerebral Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 20 1 0 1 1 0 0 0 0
References Study Quality
68 (23232377) 4
78 (16688051) 3
MRA neck without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 17 1 2 1 2 0 0 0 0
References Study Quality
80 (24355656) 3
68 (23232377) 4
86 (20154559) 4
MRA neck without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 11 0 4 1 7 0 0 0 0
References Study Quality
80 (24355656) 3
68 (23232377) 4
86 (20154559) 4
MRI cervical spine without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 14 3 3 2 0 0 0 1 0
References Study Quality
92 (16458247) 4
51 (19396479) 3
CT cervical spine with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 3 1 0 1 0 0 0 0
References Study Quality
19 (19741398) 4
54 (20889081) 4
53 (25033993) 2
55 (23453711) 3
CT cervical spine without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 5 0 0 0 0 0 0 0
References Study Quality
19 (19741398) 4
54 (20889081) 4
53 (25033993) 2
55 (23453711) 3
CT cervical spine without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 3 7 2 7 2 0 0 0
References Study Quality
19 (19741398) 4
54 (20889081) 4
53 (25033993) 2
55 (23453711) 3
CTA neck with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 12 2 2 1 6 0 0 0 0
References Study Quality
80 (24355656) 3
81 (22990630) 3
82 (22137135) 4
68 (23232377) 4
78 (16688051) 3
85 (20019135) 3
83 (25803220) 3
84 (24722311) 3
79 (20496085) 4
CT myelography cervical spine Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 20 3 0 0 0 0 0 0 0
References Study Quality
90 (16439090) 4
Variant 4: Child, younger than 16 years of age, suspected thoracolumbar spine trauma. 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 and lumbar spine Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 8 8 0 0 0 0 0 0 9 7 8
References Study Quality
24 (23276683) 3
3 (17566397) 4
29 (14654023) 4
94 (20699755) 3
95 (16303994) 2
96 (15385287) 1
93 (27886872) 4
MRI thoracic and lumbar spine without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 4 3 6 2 4 5 0 0 0
References Study Quality
24 (23276683) 3
27 (17224805) 3
28 (23276357) 2
29 (14654023) 4
91 (21980025) 4
98 (23425746) 4
59 (16122000) 3
93 (27886872) 4
CT thoracic and lumbar spine without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 5 3 5 4 3 4 0 0 0
References Study Quality
97 (26810978) 2
29 (14654023) 4
94 (20699755) 3
95 (16303994) 2
96 (15385287) 1
Arteriography thoracic and lumbar spine Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 23 1 0 0 0 0 0 0 0
MRA thoracic and lumbar spine without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 4 3 0 0 0 0 0 0
MRA thoracic and lumbar spine without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 2 2 2 1 0 0 1
MRI thoracic and lumbar spine without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 17 1 3 1 0 1 1 0 0
References Study Quality
24 (23276683) 3
27 (17224805) 3
28 (23276357) 2
29 (14654023) 4
91 (21980025) 4
98 (23425746) 4
59 (16122000) 3
93 (27886872) 4
CT thoracic and lumbar spine with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 3 1 0 0 1 1 0 0
References Study Quality
97 (26810978) 2
29 (14654023) 4
94 (20699755) 3
95 (16303994) 2
96 (15385287) 1
CT myelography thoracic and lumbar spine Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 21 2 1 0 0 0 0 0 0
References Study Quality
90 (16439090) 4
CT thoracic and lumbar spine without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 20 3 0 0 0 0 1 0 0
References Study Quality
97 (26810978) 2
29 (14654023) 4
94 (20699755) 3
95 (16303994) 2
96 (15385287) 1
CTA thoracic and lumbar spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 19 1 3 1 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.