ACR logo

Appropriateness Criteria

Variant 1: New symptomatic vertebral compression fracture (VCF) identified on radiographs. No known malignancy. 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 IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 9 10
References Study Quality
46 (23619191) 2
47 (18831901) 2
45 (19504131) 4
43 (19282740) 4
48 (21779855) 4
49 (21217433) 2
44 (21162942) 2
50 (25946722) 2
51 (16687528) 2
CT spine area of interest without IV contrast Usually appropriate Strong Varies Varies 8 8 0 0 0 1 1 1 3 7 7
References Study Quality
40 (28065376) 2
12 (14519867) 4
39 (22091375) 4
41 (26537691) 2
42 (26928067) 2
Bone scan whole body May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 2 6 8 3 0 0 0
References Study Quality
53 (20706042) 3
54 (18349795) 2
56 (21165311) 3
52 (22927151) 3
55 (26364958) 3
SPECT or SPECT/CT spine area of interest May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 3 16 2 0 0 0
References Study Quality
59 (22208854) 2
57 (23559712) 4
58 (24694774) 3
60 (29893749) 2
CT spine area of interest with IV contrast Usually not appropriate Strong Varies Varies 3 3 5 2 8 0 3 2 0 0 0
References Study Quality
40 (28065376) 2
12 (14519867) 4
39 (22091375) 4
41 (26537691) 2
42 (26928067) 2
CT spine area of interest without and with IV contrast Usually not appropriate Strong Varies Varies 3 3 6 3 4 1 4 1 1 0 0
References Study Quality
40 (28065376) 2
12 (14519867) 4
39 (22091375) 4
41 (26537691) 2
42 (26928067) 2
MRI spine area of interest with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 8 1 12 0 0 0 0 0 0
References Study Quality
46 (23619191) 2
47 (18831901) 2
45 (19504131) 4
43 (19282740) 4
48 (21779855) 4
49 (21217433) 2
44 (21162942) 2
50 (25946722) 2
51 (16687528) 2
MRI spine area of interest without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 5 1 5 6 4 0 0 0 0
References Study Quality
46 (23619191) 2
47 (18831901) 2
45 (19504131) 4
43 (19282740) 4
48 (21779855) 4
49 (21217433) 2
44 (21162942) 2
50 (25946722) 2
51 (16687528) 2
CT myelography spine area of interest Usually not appropriate Expert Consensus Varies Varies 2 2 8 3 3 4 2 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 5 3 3 3 0 0 0 0
References Study Quality
61 (12195540) 4
63 (12811277) 1
62 (11914890) 4
64 (3277565) 4
65 (29348133) 4
Variant 2: New symptomatic VCF identified on radiographs. History of malignancy. 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 Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 8 10
References Study Quality
46 (23619191) 2
47 (18831901) 2
66 (28670417) 3
70 (21857034) 3
69 (21214309) 2
65 (29348133) 4
71 (21555353) 2
68 (2740506) 4
CT spine area of interest without IV contrast Usually appropriate Strong Varies Varies 7 7 0 0 0 0 0 1 13 6 1
References Study Quality
40 (28065376) 2
12 (14519867) 4
39 (22091375) 4
66 (28670417) 3
67 (26376170) 4
41 (26537691) 2
42 (26928067) 2
MRI spine area of interest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 1 0 0 0 3 3 5 5 3
References Study Quality
46 (23619191) 2
47 (18831901) 2
66 (28670417) 3
70 (21857034) 3
69 (21214309) 2
65 (29348133) 4
71 (21555353) 2
68 (2740506) 4
FDG-PET/CT skull base to mid-thigh May be appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 1 0 1 6 4 4 4 0
References Study Quality
61 (12195540) 4
64 (3277565) 4
74 (27694173) 4
73 (32105873) Good
Bone scan whole body May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 2 9 5 3 0 0
References Study Quality
53 (20706042) 3
54 (18349795) 2
56 (21165311) 3
52 (22927151) 3
55 (26364958) 3
58 (24694774) 3
72 (22487972) 4
Image-guided biopsy spine area of interest May be appropriate Limited Varies Varies 5 5 0 0 0 1 10 9 1 0 0
References Study Quality
75 (19829253) 3
MRI spine area of interest with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 6 0 7 0 1 7 0 0 0
References Study Quality
46 (23619191) 2
47 (18831901) 2
66 (28670417) 3
70 (21857034) 3
69 (21214309) 2
65 (29348133) 4
71 (21555353) 2
68 (2740506) 4
SPECT or SPECT/CT spine area of interest May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 1 18 1 1 0 0
References Study Quality
59 (22208854) 2
57 (23559712) 4
58 (24694774) 3
CT myelography spine area of interest May be appropriate Expert Consensus Varies Varies 4 4 3 2 2 4 7 2 0 0 0
CT spine area of interest with IV contrast Usually not appropriate Strong Varies Varies 3 3 9 0 4 6 2 0 0 0 0
References Study Quality
40 (28065376) 2
12 (14519867) 4
39 (22091375) 4
66 (28670417) 3
67 (26376170) 4
41 (26537691) 2
42 (26928067) 2
CT spine area of interest without and with IV contrast Usually not appropriate Strong Varies Varies 3 3 9 0 5 1 6 0 0 0 0
References Study Quality
40 (28065376) 2
12 (14519867) 4
39 (22091375) 4
66 (28670417) 3
67 (26376170) 4
41 (26537691) 2
42 (26928067) 2
Variant 3: New back pain. Previously treated VCF or multiple VCFs. Initial Imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT spine area of interest without IV contrast Usually appropriate Strong Varies Varies 8 8 0 0 0 0 2 3 4 4 7
References Study Quality
12 (14519867) 4
39 (22091375) 4
78 (20528649) 2
76 (22637642) 2
77 (15690210) 4
MRI spine area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 1 2 7 9
References Study Quality
80 (17361377) 2
79 (24792612) 4
MRI spine area of interest without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 9 4 7 1 0
References Study Quality
80 (17361377) 2
79 (24792612) 4
Bone scan whole body May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 1 6 6 5 1 0 0
References Study Quality
53 (20706042) 3
54 (18349795) 2
56 (21165311) 3
52 (22927151) 3
55 (26364958) 3
FDG-PET/CT skull base to mid-thigh May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 3 2 4 1 8 1 0 1 0
References Study Quality
61 (12195540) 4
63 (12811277) 1
62 (11914890) 4
64 (3277565) 4
SPECT or SPECT/CT spine area of interest May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 2 17 1 0 1 0
References Study Quality
59 (22208854) 2
57 (23559712) 4
58 (24694774) 3
60 (29893749) 2
CT myelography spine area of interest Usually not appropriate Expert Consensus Varies Varies 3 3 7 2 4 5 2 0 0 0 0
CT spine area of interest with IV contrast Usually not appropriate Strong Varies Varies 3 3 9 1 10 1 0 0 0 0 0
References Study Quality
12 (14519867) 4
39 (22091375) 4
78 (20528649) 2
76 (22637642) 2
77 (15690210) 4
CT spine area of interest without and with IV contrast Usually not appropriate Strong Varies Varies 3 3 9 1 4 5 2 0 0 0 0
References Study Quality
12 (14519867) 4
39 (22091375) 4
78 (20528649) 2
76 (22637642) 2
77 (15690210) 4
MRI spine area of interest with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 7 1 6 0 7 0 0 0 0
References Study Quality
80 (17361377) 2
79 (24792612) 4
Variant 4: Asymptomatic VCF identified on radiographs. History of malignancy. 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 Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 0 3 6 10
References Study Quality
96 (23960179) 4
89 (22194515) 2
88 (24484060) 2
66 (28670417) 3
67 (26376170) 4
91 (20580503) 3
93 (19530588) 3
94 (26204297) 4
70 (21857034) 3
95 (27441748) 4
16 (20809724) 4
90 (8059251) 4
92 (-3194747) 4
CT spine area of interest without IV contrast Usually appropriate Strong Varies Varies 8 8 0 0 1 1 1 3 4 7 3
References Study Quality
40 (28065376) 2
12 (14519867) 4
39 (22091375) 4
66 (28670417) 3
41 (26537691) 2
42 (26928067) 2
MRI spine area of interest without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 1 0 0 0 3 1 7 8 0
References Study Quality
96 (23960179) 4
89 (22194515) 2
88 (24484060) 2
66 (28670417) 3
67 (26376170) 4
91 (20580503) 3
93 (19530588) 3
94 (26204297) 4
70 (21857034) 3
95 (27441748) 4
16 (20809724) 4
90 (8059251) 4
92 (-3194747) 4
Bone scan whole body May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 0 3 10 3 2 0 1
References Study Quality
98 (12369658) 2
97 (11110531) 4
FDG-PET/CT skull base to mid-thigh May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 0 17 2 1 0 0
References Study Quality
101 (23251117) 4
61 (12195540) 4
63 (12811277) 1
62 (11914890) 4
74 (27694173) 4
73 (32105873) Good
Image-guided biopsy spine area of interest May be appropriate Limited Varies Varies 5 5 0 0 0 2 15 3 1 0 0
References Study Quality
102 (30767427) 2
SPECT or SPECT/CT spine area of interest May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 4 16 0 1 0 0
References Study Quality
57 (23559712) 4
99 (8254410) 3
100 (18993040) 3
CT myelography spine area of interest Usually not appropriate Expert Consensus Varies Varies 3 3 6 2 4 3 4 1 0 0 0
CT spine area of interest with IV contrast Usually not appropriate Strong Varies Varies 3 3 9 1 10 1 0 0 0 0 0
References Study Quality
40 (28065376) 2
12 (14519867) 4
39 (22091375) 4
66 (28670417) 3
41 (26537691) 2
42 (26928067) 2
CT spine area of interest without and with IV contrast Usually not appropriate Strong Varies Varies 3 3 8 1 10 2 0 0 0 0 0
References Study Quality
40 (28065376) 2
12 (14519867) 4
39 (22091375) 4
66 (28670417) 3
41 (26537691) 2
42 (26928067) 2
MRI spine area of interest with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 8 0 5 0 7 1 0 0 0
References Study Quality
96 (23960179) 4
89 (22194515) 2
88 (24484060) 2
66 (28670417) 3
67 (26376170) 4
91 (20580503) 3
93 (19530588) 3
94 (26204297) 4
70 (21857034) 3
95 (27441748) 4
16 (20809724) 4
90 (8059251) 4
92 (-3194747) 4
Variant 5: Asymptomatic, osteoporotic VCF. Initial treatment.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Medical management only Usually appropriate Strong N/A N/A 9 9 0 0 0 0 0 0 1 4 15
References Study Quality
36 (24325929) 4
108 (19478654) 1
103 (1836154) 4
104 (1627411) 4
107 (24077202) 3
109 (28739478) 4
111 (12052450) 1
110 (12879220) 2
Percutaneous vertebral augmentation Usually not appropriate Expert Consensus N/A N/A 3 3 7 3 11 0 0 0 0 0 0
Surgical consultation Usually not appropriate Expert Consensus N/A N/A 3 3 7 2 4 4 2 0 1 0 0
Percutaneous ablation spine Usually not appropriate Limited N/A N/A 1 1 14 2 4 0 0 0 0 0 0
References Study Quality
112 (18566009) 4
Radiation oncology consultation Usually not appropriate Expert Consensus N/A N/A 1 1 14 2 4 0 0 0 0 0 0
Variant 6: Symptomatic osteoporotic VCF with bone marrow edema or intravertebral cleft. Initial treatment.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Medical management only Usually appropriate Strong N/A N/A 8 8 0 0 1 0 2 0 4 7 6
References Study Quality
101 (23251117) 4
108 (19478654) 1
113 (19657122) 1
103 (1836154) 4
104 (1627411) 4
107 (24077202) 3
Percutaneous vertebral augmentation Usually appropriate Strong N/A N/A 8 8 0 0 0 0 1 1 7 7 4
References Study Quality
125 (26630417) 1
120 (27400110) 2
22 (27544377) 1
118 (25787683) 2
122 (25404372) 2
21 (24315046) 1
121 (23391839) 3
33 (23021641) 1
23 (21375382) 1
129 (21076886) 3
124 (20625321) 2
128 (20372942) 3
20 (25822543) 1
34 (22116114) 2
36 (24325929) 4
108 (19478654) 1
116 (20190623) 1
113 (19657122) 1
117 (19246088) 1
115 (20701962) 1
114 (19657121) 1
89 (22194515) 2
119 (16429288) 4
123 (18989668) 2
127 (30552168) 4
126 (31325625) 1
Surgical consultation May be appropriate Limited N/A N/A 5 5 0 0 0 1 17 1 1 1 0
References Study Quality
130 (25808687) 4
Percutaneous ablation spine Usually not appropriate Limited N/A N/A 1 1 14 2 3 0 1 0 0 0 0
References Study Quality
112 (18566009) 4
Radiation oncology consultation Usually not appropriate Expert Consensus N/A N/A 1 1 15 2 3 0 0 0 0 0 0
Systemic radionuclide therapy Usually not appropriate Expert Consensus N/A N/A 1 1 17 1 2 0 0 0 0 0 0
Variant 7: New symptomatic VCF. History of prior vertebroplasty or surgery. Initial treatment.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Percutaneous vertebral augmentation Usually appropriate Strong N/A N/A 8 8 0 0 0 0 3 0 7 8 2
References Study Quality
136 (19581311) 2
135 (20672965) 2
133 (29743284) 2
134 (28072794) Good
Medical management only Usually appropriate Limited N/A N/A 7 7 0 0 2 0 3 1 5 6 3
References Study Quality
36 (24325929) 4
108 (19478654) 1
107 (24077202) 3
Surgical consultation May be appropriate Limited N/A N/A 5 5 0 0 0 1 12 7 1 0 0
References Study Quality
137 (21629164) 4
Percutaneous ablation spine Usually not appropriate Limited N/A N/A 1 1 11 3 4 0 2 0 0 0 0
References Study Quality
112 (18566009) 4
Radiation oncology consultation Usually not appropriate Expert Consensus N/A N/A 1 1 12 3 2 2 1 0 0 0 0
Systemic radionuclide therapy Usually not appropriate Expert Consensus N/A N/A 1 1 15 1 3 1 0 0 0 0 0
Variant 8: Benign VCF with worsening pain, deformity, or pulmonary dysfunction. Initial treatment.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Percutaneous vertebral augmentation Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 1 6 8 5
References Study Quality
27 (26109687) 2
30 (25844701) Good
22 (27544377) 1
29 (26071690) 1
28 (25884343) 2
26 (26280719) 2
25 (25300981) 2
24 (24901876) 1
21 (24315046) 1
17 (24253785) 1
141 (24077200) 2
33 (23021641) 1
32 (22628598) 3
23 (21375382) 1
124 (20625321) 2
34 (22116114) 2
36 (24325929) 4
89 (22194515) 2
1 (8324412) 4
107 (24077202) 3
123 (18989668) 2
31 (14736654) 2
138 (10892628) 4
139 (8324411) 4
Surgical consultation Usually appropriate Expert Consensus N/A N/A 7 7 0 0 1 0 1 2 9 6 2
Medical management only May be appropriate Limited N/A N/A 5 5 0 1 2 0 12 6 0 0 0
References Study Quality
36 (24325929) 4
108 (19478654) 1
103 (1836154) 4
104 (1627411) 4
107 (24077202) 3
Percutaneous ablation spine Usually not appropriate Limited N/A N/A 1 1 13 2 5 0 0 0 0 0 0
References Study Quality
112 (18566009) 4
Radiation oncology consultation Usually not appropriate Expert Consensus N/A N/A 1 1 16 1 3 0 0 0 0 0 0
Systemic radionuclide therapy Usually not appropriate Expert Consensus N/A N/A 1 1 16 1 3 0 0 0 0 0 0
Variant 9: Pathological VCF with ongoing or increasing mechanical pain. Initial treatment.
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 3 0 6 8 3
References Study Quality
96 (23960179) 4
157 (6178497) 1
159 (15450875) 4
158 (7607970) 2
156 (21277118) 4
95 (27441748) 4
165 (27479724) 4
15 (29048517) Good
163 (32540335) 2
161 (31119099) 4
Surgical consultation Usually appropriate Strong N/A N/A 8 8 0 0 0 0 2 1 3 9 5
References Study Quality
154 (16112300) 1
150 (20562730) 4
137 (21629164) 4
14 (21709187) 3
153 (15450879) 4
151 (-3121235) 4
152 (26337716) Good
155 (28937455) 4
Percutaneous ablation spine Usually appropriate Strong N/A N/A 7 7 0 0 1 1 4 2 9 2 1
References Study Quality
144 (24927327) 3
146 (26635286) 2
145 (33308579) 4
143 (29794238) 2
147 (31677728) 4
Percutaneous vertebral augmentation Usually appropriate Strong N/A N/A 7 7 0 0 0 0 2 1 10 4 3
References Study Quality
17 (24253785) 1
148 (21333599) 1
149 (8685351) 2
Medical management only May be appropriate Limited N/A N/A 5 5 0 1 0 1 16 2 0 1 0
References Study Quality
142 (15047923) 4
Systemic radionuclide therapy May be appropriate Limited N/A N/A 4 4 5 1 4 1 10 0 0 0 0
References Study Quality
166 (15653650) 4
167 (15925817) 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.