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Appropriateness Criteria

Variant 1: Acute low back pain with or without 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 lumbar spine Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 2 4 1 0 0 0 0 0
References Study Quality
4 (21282698) 4
6 (12783911) 1
7 (16244269) 1
9 (25781443) 3
17 (23910019) 2
MRI lumbar spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 2 0 0 0 1 0 0
MRI lumbar spine without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 14 2 2 0 0 0 2 0 0
References Study Quality
4 (21282698) 4
6 (12783911) 1
7 (16244269) 1
9 (25781443) 3
17 (23910019) 2
MRI lumbar spine without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 16 4 2 0 0 0 0 0 0
References Study Quality
4 (21282698) 4
6 (12783911) 1
7 (16244269) 1
9 (25781443) 3
17 (23910019) 2
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 18 1 1 0 0 0 0 0 0
CT lumbar spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 3 1 0 0 0 0 0
CT lumbar spine without IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 3 2 1 2 1 0 0 0
References Study Quality
4 (21282698) 4
6 (12783911) 1
7 (16244269) 1
9 (25781443) 3
17 (23910019) 2
Discography and post-discography CT lumbar spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 17 1 2 0 0 0 0 0 0
CT lumbar spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 3 1 0 0 0 0 0 0
CT myelography lumbar spine Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 16 1 1 0 2 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 1 1 0 0 0 0 0 0
Variant 2: Subacute or chronic low back pain with or without 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 lumbar spine Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 4 2 2 2 0 0 0 0
References Study Quality
4 (21282698) 4
6 (12783911) 1
7 (16244269) 1
9 (25781443) 3
17 (23910019) 2
MRI lumbar spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 3 0 0 1 0 0 0
MRI lumbar spine without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 13 3 2 0 0 1 0 1 0
References Study Quality
4 (21282698) 4
6 (12783911) 1
7 (16244269) 1
9 (25781443) 3
17 (23910019) 2
MRI lumbar spine without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 13 5 1 3 0 0 0 0 0
References Study Quality
4 (21282698) 4
6 (12783911) 1
7 (16244269) 1
9 (25781443) 3
17 (23910019) 2
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 4 1 0 0 0 0 0 0
CT lumbar spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 2 2 1 0 0 0 0 0
CT lumbar spine without IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 3 2 0 2 2 0 0 0
References Study Quality
4 (21282698) 4
6 (12783911) 1
7 (16244269) 1
9 (25781443) 3
17 (23910019) 2
Discography and post-discography CT lumbar spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 17 0 3 0 0 0 0 0 0
CT lumbar spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 1 1 1 0 0 0 0 0
CT myelography lumbar spine Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 15 1 1 0 3 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 1 1 0 0 0 0 0 0
Variant 3: Subacute or chronic low back pain with or without radiculopathy. Surgery or intervention candidate with persistent or progressive symptoms during or following 6 weeks of optimal medical management. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI lumbar spine without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 0 1 8 10
References Study Quality
7 (16244269) 1
13 (17088193) 3
35 (23136176) 3
34 (24637890) 1
Radiography lumbar spine May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 0 1 1 5 9 3 1 0 2
References Study Quality
27 (27789449) 2
25 (27997505) 2
36 (15851040) 4
24 (29432395) 4
MRI lumbar spine without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 1 1 0 3 15 2 0 0 0
Bone scan whole body with SPECT or SPECT/CT complete spine May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 6 1 3 5 5 0 0 0 0
References Study Quality
31 (27387155) 4
29 (28847557) 2
30 (28377243) 2
28 (26550787) 2
CT lumbar spine without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 1 17 3 0 0 0
References Study Quality
27 (27789449) 2
26 (28478246) 2
CT myelography lumbar spine May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 0 5 14 2 1 0 0
References Study Quality
22 (12637281) 3
23 (23592868) 4
MRI lumbar spine with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 6 3 5 2 3 0 0 1 0
References Study Quality
33 (16699849) 4
CT lumbar spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 2 5 0 1 1 0 0 0
Discography and post-discography CT lumbar spine Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 6 1 5 4 2 2 0 0 0
References Study Quality
32 (23615887) 4
CT lumbar spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 3 1 2 1 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 3 1 0 0 0 0 0 0
References Study Quality
29 (28847557) 2
30 (28377243) 2
28 (26550787) 2
Variant 4: Low back pain with suspected 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 lumbar spine without and with IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 1 0 1 0 2 1 12 4 1
MRI lumbar spine without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 1 0 4 14
References Study Quality
41 (17453789) 3
42 (28385420) 4
CT lumbar spine without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 2 0 0 3 7 6 1 0 1
References Study Quality
27 (27789449) 2
CT myelography lumbar spine May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 1 2 14 4 1 0 0
References Study Quality
22 (12637281) 3
Radiography lumbar spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 18 0 1 0 1 1 1 0 0
MRI lumbar spine with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 3 6 3 2 0 1 1 0
References Study Quality
33 (16699849) 4
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 16 2 2 0 0 0 0 0 0
CT lumbar spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 2 4 2 1 0 0 0 0
Discography and post-discography CT lumbar spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 3 1 0 0 0 0 0 0
CT lumbar spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 2 3 0 2 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 2 1 0 0 0 0 0 0
Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography lumbar spine Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢ 0.03-0.3 mSv [ped] 7 7 0 0 0 0 3 2 11 5 1
References Study Quality
50 (32405554) 4
MRI lumbar spine without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 2 5 13
References Study Quality
43 (3258108) 2
MRI lumbar spine without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 1 0 0 0 3 4 4 7 2
References Study Quality
43 (3258108) 2
CT lumbar spine without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 1 0 0 0 6 5 5 2 2
References Study Quality
44 (22733920) 4
27 (27789449) 2
CT myelography lumbar spine May be appropriate Strong ☢☢☢☢ 10-30 mSv 5 5 1 0 0 2 8 3 6 1 0
References Study Quality
22 (12637281) 3
49 (28634513) 2
48 (28881117) 2
23 (23592868) 4
MRI lumbar spine with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 9 3 4 1 2 0 2 0 0
References Study Quality
33 (16699849) 4
Bone scan whole body with SPECT or SPECT/CT complete spine Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 4 3 1 0 0 0 0
References Study Quality
51 (20305409) 3
52 (30796507) 4
53 (22391701) 4
54 (23820764) 4
CT lumbar spine with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 8 1 4 7 0 1 0 0 0
References Study Quality
45 (20568916) 4
46 (21961872) 4
47 (17093252) 4
Discography and post-discography CT lumbar spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 2 4 0 2 1 0 0 0
CT lumbar spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 0 1 6 1 1 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 2 1 0 0 0 0 0 0
Variant 6: Low back pain with or without 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 lumbar spine Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢ 0.03-0.3 mSv [ped] 8 8 0 0 1 0 0 2 5 6 6
References Study Quality
55 (12353946) 4
MRI lumbar spine without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 1 0 2 2 5 10
References Study Quality
58 (12533652) 2
CT lumbar spine without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 2 1 4 9 4
References Study Quality
27 (27789449) 2
MRI lumbar spine without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 0 5 3 12 2 0 0 0
CT myelography lumbar spine May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 1 4 15 1 1 0 0
References Study Quality
22 (12637281) 3
MRI lumbar spine with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 11 1 4 1 3 0 0 0 0
References Study Quality
33 (16699849) 4
Bone scan whole body with SPECT or SPECT/CT complete spine Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 8 1 5 1 3 1 1 0 0
References Study Quality
59 (18349795) 2
CT lumbar spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 3 3 2 0 0 0 0 0
Discography and post-discography CT lumbar spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 2 1 1 0 0 0 0 0
CT lumbar spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 2 1 1 1 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 3 2 1 1 0 1 0 0
References Study Quality
60 (21214309) 2
Variant 7: Low back pain with or without 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 lumbar spine without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 6 13
References Study Quality
65 (18278491) 3
62 (22312523) 4
67 (19325068) 4
MRI lumbar spine without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 2 7 5 4
References Study Quality
62 (22312523) 4
Radiography lumbar spine May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 6 7 4 1 1 1 1 0 1
References Study Quality
70 (16951929) 2
64 (6023348) 4
69 (10964746) 4
CT lumbar spine with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 2 1 16 2 0 0 0
References Study Quality
45 (20568916) 4
46 (21961872) 4
47 (17093252) 4
CT lumbar spine without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 3 12 5 1 0 0
References Study Quality
45 (20568916) 4
46 (21961872) 4
47 (17093252) 4
CT myelography lumbar spine May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 0 9 11 2 0 0 0
References Study Quality
22 (12637281) 3
MRI lumbar spine with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 10 5 6 1 0 0 0 0 0
References Study Quality
33 (16699849) 4
Bone scan whole body with SPECT or SPECT/CT complete spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 5 10 1 1 0 0 0 0
Discography and post-discography CT lumbar spine Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 3 2 0 0 0 0 0 0
CT lumbar spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 9 1 3 3 2 0 2 0 0
FDG-PET/CT whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 8 5 4 2 0 0 0 0
References Study Quality
65 (18278491) 3
66 (30050321) 2
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.