American College of Radiology
ACR Appropriateness Criteria®

Chronic Back Pain: Suspected Sacroiliitis/Spondyloarthropathy

Variant 1: Inflammatory sacroiliac or back symptoms. Suspected axial spondyloarthropathy. Initial evaluation.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography spine Usually appropriate ☢☢☢ 1-10 mSv 9 n/a 0 0 0 0 0 0 0 0 0
Radiography sacroiliac joints Usually appropriate ☢☢ 0.1-1mSv 9 n/a 0 0 0 0 0 0 0 0 0
CT sacroiliac joints without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT sacroiliac joints without and with IV contrast Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT sacroiliac joints with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT spine without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT spine without and with IV contrast Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT spine with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MRI sacroiliac joints without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI sacroiliac joints without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI spine without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI spine without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan with SPECT spine Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US sacroiliac joints Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Inflammatory sacroiliac symptoms. Suspected axial spondyloarthropathy. Radiographs negative or equivocal.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI sacroiliac joints without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
MRI sacroiliac joints without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
CT sacroiliac joints without IV contrast Usually appropriate ☢☢☢ 1-10 mSv 7 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan with SPECT spine May be appropriate ☢☢☢ 1-10 mSv 4 n/a 0 0 0 0 0 0 0 0 0
CT sacroiliac joints without and with IV contrast Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT sacroiliac joints with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US sacroiliac joints Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Inflammatory back pain symptoms. Suspected axial spondyloarthropathy. Radiographs negative or equivocal.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI sacroiliac joints without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
MRI spine without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
MRI spine without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
CT spine without IV contrast Usually appropriate ☢☢☢ 1-10 mSv 7 n/a 0 0 0 0 0 0 0 0 0
MRI sacroiliac joints without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan with SPECT spine Usually not appropriate ☢☢☢ 1-10 mSv 3 n/a 0 0 0 0 0 0 0 0 0
US sacroiliac joints Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT spine without and with IV contrast Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT spine with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Inflammatory sacroiliac symptoms. Suspected axial spondyloarthropathy. Negative radiographs and MRI of the sacroiliac joints.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography spine Usually appropriate ☢☢☢ 1-10 mSv 9 n/a 0 0 0 0 0 0 0 0 0
MRI spine without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
CT spine without IV contrast Usually appropriate ☢☢☢ 1-10 mSv 7 n/a 0 0 0 0 0 0 0 0 0
MRI spine without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan with SPECT spine Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT spine without and with IV contrast Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT spine with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Spine ankylosis. Suspected fracture.
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 Varies Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
MRI spine area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
Radiography spine area of interest Usually appropriate Varies Varies Varies 8 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan with SPECT spine Usually not appropriate ☢☢☢ 1-10 mSv 2 n/a 0 0 0 0 0 0 0 0 0
CT spine area of interest without and with IV contrast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT spine area of interest with IV contrast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
MRI spine area of interest without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Known axial spondyloarthropathy. Follow-up for treatment response or disease progression.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography sacroiliac joints Usually appropriate ☢☢ 0.1-1mSv 9 n/a 0 0 0 0 0 0 0 0 0
Radiography spine area of interest Usually appropriate Varies Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
MRI sacroiliac joints and spine area of interest without IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
MRI sacroiliac joints and spine area of interest without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
CT sacroiliac joints and spine area of interest without IV contrast May be appropriate Varies Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan with SPECT spine Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT sacroiliac joints and spine area of interest without and with IV contrast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
CT sacroiliac joints and spine area of interest with IV contrast Usually not appropriate Varies Varies Varies 1 n/a 0 0 0 0 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.