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Variant 1: New symptomatic compression fracture identified on radiographs or CT. No known malignancy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Medical management Usually appropriate Strong N/A N/A 8 8 0 0 0 1 0 0 3 4 6
References Study Quality
19 (27544377) 1
62 (19478654) 1
63 (19657122) 1
64 (1836154) 4
65 (1627411) 4
61 (24077202) 3
MRI spine area of interest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 1 0 2 4 6
References Study Quality
43 (23619191) 2
44 (18831901) 2
42 (19504131) 4
40 (19282740) 4
45 (21779855) 4
46 (21217433) 2
41 (21162942) 2
47 (25946722) 2
48 (16687528) 2
CT spine area of interest without IV contrast Usually appropriate Strong Varies Varies 7 7 0 0 0 1 5 0 3 3 2
References Study Quality
37 (28065376) 2
9 (14519867) 4
36 (22091375) 4
38 (26537691) 2
39 (26928067) 2
Percutaneous vertebral augmentation May be appropriate Strong N/A N/A 6 6 0 0 0 0 4 5 1 4 0
References Study Quality
82 (26630417) 1
76 (27400110) 2
19 (27544377) 1
74 (25787683) 2
78 (25404372) 2
77 (23391839) 3
30 (23021641) 1
20 (21375382) 1
84 (21076886) 3
80 (20625321) 2
83 (20372942) 3
85 (19829253) 3
31 (22116114) 2
33 (24325929) 4
69 (9403451) 4
62 (19478654) 1
72 (20190623) 1
67 (9536480) 4
63 (19657122) 1
66 (10529144) 2
73 (19246088) 1
71 (20701962) 1
70 (19657121) 1
81 (22194515) 2
75 (16429288) 4
79 (18989668) 2
Bone scan whole body May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 1 12 1 1 0 0
References Study Quality
50 (20706042) 3
51 (18349795) 2
53 (21165311) 3
49 (22927151) 3
52 (26364958) 3
SPECT or SPECT/CT spine area of interest May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 1 0 13 1 0 1 0
References Study Quality
56 (22208854) 2
54 (23559712) 4
55 (24694774) 3
Surgical consultation May be appropriate Expert Consensus N/A N/A 5 5 0 0 0 4 5 2 2 0 1
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 7 0 0 2 4 0 0 1 0
References Study Quality
57 (12195540) 4
59 (12811277) 1
58 (11914890) 4
60 (3277565) 4
MRI spine area of interest with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 7 2 3 0 1 0 1 0 0
References Study Quality
43 (23619191) 2
44 (18831901) 2
42 (19504131) 4
40 (19282740) 4
45 (21779855) 4
46 (21217433) 2
41 (21162942) 2
47 (25946722) 2
48 (16687528) 2
MRI spine area of interest without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 6 2 4 0 1 0 0 0 1
References Study Quality
43 (23619191) 2
44 (18831901) 2
42 (19504131) 4
40 (19282740) 4
45 (21779855) 4
46 (21217433) 2
41 (21162942) 2
47 (25946722) 2
48 (16687528) 2
CT spine area of interest with IV contrast Usually not appropriate Strong Varies Varies 1 1 8 2 3 0 1 0 0 0 0
References Study Quality
37 (28065376) 2
9 (14519867) 4
36 (22091375) 4
38 (26537691) 2
39 (26928067) 2
CT spine area of interest without and with IV contrast Usually not appropriate Strong Varies Varies 1 1 8 3 2 0 1 0 0 0 0
References Study Quality
37 (28065376) 2
9 (14519867) 4
36 (22091375) 4
38 (26537691) 2
39 (26928067) 2
Percutaneous thermal ablation Usually not appropriate Limited N/A N/A 1 1 12 0 2 0 0 0 0 0 0
References Study Quality
86 (18566009) 4
Radiation oncology consultation Usually not appropriate Expert Consensus N/A N/A 1 1 10 1 1 1 1 0 0 0 0
Variant 2: Osteoporotic compression fracture, with or without edema on MRI and no “red flags”. With or without spinal deformity, worsening symptoms, or pulmonary dysfunction.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Medical management Usually appropriate Limited N/A N/A 8 8 1 0 0 0 2 0 2 3 6
References Study Quality
69 (9403451) 4
67 (9536480) 4
64 (1836154) 4
65 (1627411) 4
66 (10529144) 2
68 (13677812) 4
Percutaneous vertebral augmentation Usually appropriate Strong N/A N/A 7 7 0 1 0 0 4 2 3 3 1
References Study Quality
91 (24744201) 3
18 (24315046) 1
14 (24253785) 1
92 (24077200) 2
29 (22628598) 3
20 (21375382) 1
80 (20625321) 2
31 (22116114) 2
33 (24325929) 4
81 (22194515) 2
1 (8324412) 4
61 (24077202) 3
79 (18989668) 2
89 (10892628) 4
90 (8324411) 4
Surgical consultation Usually not appropriate Expert Consensus N/A N/A 3 3 3 2 3 2 2 1 0 1 0
Percutaneous thermal ablation Usually not appropriate Limited N/A N/A 1 1 12 1 0 0 1 0 0 0 0
References Study Quality
86 (18566009) 4
Radiation oncology consultation Usually not appropriate Expert Consensus N/A N/A 1 1 9 2 2 0 1 0 0 0 0
Variant 3: Painful osteoporotic compression fracture with edema on MRI. Contraindication to vertebral augmentation or surgery (eg, fitness, pregnancy, infection, coagulation disorder, etc.).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Medical management Usually appropriate Expert Consensus N/A N/A 9 9 0 0 0 0 0 0 1 2 11
Surgical consultation May be appropriate Expert Consensus N/A N/A 5 5 0 0 0 2 7 2 2 0 1
Radiation oncology consultation Usually not appropriate Expert Consensus N/A N/A 1 1 11 1 2 0 0 0 0 0 0
Variant 4: Known malignancy and new back pain. Compression fracture identified on radiographs or CT.
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 0 0 0 0 0 0 2 4 8
References Study Quality
110 (23960179) 4
81 (22194515) 2
102 (24484060) 2
103 (28670417) 3
104 (26376170) 4
106 (20580503) 3
107 (19530588) 3
108 (26204297) 4
101 (21857034) 3
109 (27441748) 4
13 (20809724) 4
Image-guided biopsy spine area of interest Usually appropriate Expert Consensus Varies Varies 7 7 0 0 0 1 5 1 2 4 1
FDG-PET/CT skull base to mid-thigh May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 6 6 0 0 0 0 6 4 2 1 1
References Study Quality
113 (23251117) 4
57 (12195540) 4
59 (12811277) 1
58 (11914890) 4
114 (27694173) 4
Bone scan whole body May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 1 0 1 8 3 0 2 0
MRI spine area of interest without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 0 2 1 4 2 4 1 1
References Study Quality
110 (23960179) 4
81 (22194515) 2
102 (24484060) 2
103 (28670417) 3
104 (26376170) 4
106 (20580503) 3
107 (19530588) 3
108 (26204297) 4
101 (21857034) 3
109 (27441748) 4
13 (20809724) 4
SPECT or SPECT/CT spine area of interest May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 1 0 0 3 8 2 0 1 0
References Study Quality
111 (8254410) 3
112 (18993040) 3
MRI spine area of interest with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 3 0 4 1 6 0 1 0 0
References Study Quality
110 (23960179) 4
81 (22194515) 2
102 (24484060) 2
103 (28670417) 3
104 (26376170) 4
106 (20580503) 3
107 (19530588) 3
108 (26204297) 4
101 (21857034) 3
109 (27441748) 4
13 (20809724) 4
Variant 5: Asymptomatic pathologic spinal fracture with or without edema on MRI.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiation oncology consultation Usually appropriate Strong N/A N/A 9 9 0 0 0 0 2 0 4 0 8
References Study Quality
93 (21629164) 4
135 (17224814) 2
133 (17688054) 2
134 (25032525) 4
131 (21277118) 4
132 (28507888) Inadequate
Medical management Usually appropriate Expert Consensus N/A N/A 8 8 1 0 0 1 1 1 2 4 4
Percutaneous vertebral augmentation May be appropriate Strong N/A N/A 6 6 0 0 0 1 4 9 0 0 0
References Study Quality
116 (21333599) 1
117 (8685351) 2
118 (22130630) M
119 (23816297) 4
120 (24905395) 4
Percutaneous thermal ablation May be appropriate Strong N/A N/A 5 5 0 1 0 0 8 5 0 0 0
References Study Quality
121 (25054391) 3
122 (26427837) 2
130 (26022981) 2
127 (20041484) 2
128 (14722039) 2
129 (24927327) 3
123 (23065947) 2
124 (24238380) 4
125 (23265724) 2
126 (26635286) 2
Surgical consultation May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 0 0 2 1 5 4 2 0 0
Variant 6: Pathologic spinal fracture with severe and worsening pain.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiation oncology consultation Usually appropriate Strong N/A N/A 9 9 0 0 0 0 1 2 0 4 7
References Study Quality
143 (6178497) 1
135 (17224814) 2
131 (21277118) 4
Percutaneous thermal ablation Usually appropriate Strong N/A N/A 7 7 0 0 1 1 3 2 6 1 0
References Study Quality
121 (25054391) 3
86 (18566009) 4
140 (26606009) 2
122 (26427837) 2
130 (26022981) 2
127 (20041484) 2
128 (14722039) 2
129 (24927327) 3
123 (23065947) 2
126 (26635286) 2
138 (21170528) 4
139 (22840806) 3
Percutaneous vertebral augmentation Usually appropriate Strong N/A N/A 7 7 0 0 0 0 4 1 4 4 1
References Study Quality
14 (24253785) 1
110 (23960179) 4
116 (21333599) 1
137 (28041324) 2
117 (8685351) 2
Surgical consultation Usually appropriate Moderate N/A N/A 7 7 0 0 0 0 3 4 3 0 4
References Study Quality
142 (16112300) 1
93 (21629164) 4
141 (15450879) 4
Medical management May be appropriate Moderate N/A N/A 6 6 0 0 0 1 6 2 2 3 0
References Study Quality
95 (22956190) Not Assessed
97 (17054286) Not Assessed
136 (12954579) 1
Systemic radionuclide therapy May be appropriate Limited N/A N/A 5 5 1 0 1 1 7 3 1 0 0
References Study Quality
144 (15653650) 4
145 (15925817) 4
Variant 7: Pathologic spinal fracture with spinal deformity or pulmonary dysfunction.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiation oncology consultation Usually appropriate Strong N/A N/A 8 8 0 0 0 0 4 0 3 4 3
References Study Quality
110 (23960179) 4
93 (21629164) 4
143 (6178497) 1
140 (26606009) 2
150 (15450875) 4
119 (23816297) 4
149 (21533865) 2
Surgical consultation Usually appropriate Moderate N/A N/A 8 8 0 0 0 1 1 1 3 3 5
References Study Quality
142 (16112300) 1
148 (20562730) 4
93 (21629164) 4
11 (21709187) 3
141 (15450879) 4
Percutaneous vertebral augmentation Usually appropriate Strong N/A N/A 7 7 0 0 0 0 4 0 6 2 2
References Study Quality
24 (26109687) 2
146 (24935074) 4
91 (24744201) 3
14 (24253785) 1
110 (23960179) 4
80 (20625321) 2
81 (22194515) 2
116 (21333599) 1
137 (28041324) 2
79 (18989668) 2
117 (8685351) 2
Medical management May be appropriate Expert Consensus N/A N/A 5 5 0 1 0 0 7 4 0 2 0
Percutaneous thermal ablation May be appropriate Strong N/A N/A 5 5 0 0 0 1 7 6 0 0 0
References Study Quality
147 (23412159) 2
86 (18566009) 4
140 (26606009) 2
130 (26022981) 2
108 (26204297) 4
126 (26635286) 2
120 (24905395) 4
Variant 8: Pathologic spinal fracture with neurologic deficits.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical consultation Usually appropriate Moderate N/A N/A 9 9 0 0 0 0 0 0 1 1 12
References Study Quality
148 (20562730) 4
93 (21629164) 4
11 (21709187) 3
141 (15450879) 4
152 (-3121235) 4
153 (26337716) Good
Radiation oncology consultation Usually appropriate Strong N/A N/A 8 8 0 0 0 0 3 3 0 2 6
References Study Quality
143 (6178497) 1
150 (15450875) 4
154 (7607970) 2
131 (21277118) 4
155 (27479724) 4
Medical management May be appropriate Limited N/A N/A 5 5 0 0 0 1 8 1 1 1 2
References Study Quality
151 (15047923) 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.