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Appropriateness Criteria

Variant 1: Osteoporosis screening or initial imaging of clinically suspected low bone mineral density.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
DXA lumbar spine and hip(s) Usually appropriate Limited ☢ <0.1 mSv 9 9 0 0 0 0 0 0 0 0 13
References Study Quality
20 (15616758) 4
21 (15268886) M
28 (20464374) 4
29 (21779818) 4
25 (25182228) 4
22 (11846333) 4
23 (26277847) 4
30 (30142455) 4
7 (30456571) 4
18 (31400968) 4
19 (29946735) 4
24 (32427525) 4
26 (-3194793) 4
27 (30575489) 1
31 (27486526) 4
DXA distal forearm May be appropriate Limited ☢ <0.1 mSv 6 6 0 0 0 0 6 4 2 1 0
References Study Quality
20 (15616758) 4
21 (15268886) M
28 (20464374) 4
29 (21779818) 4
25 (25182228) 4
22 (11846333) 4
23 (26277847) 4
30 (30142455) 4
7 (30456571) 4
18 (31400968) 4
19 (29946735) 4
24 (32427525) 4
26 (-3194793) 4
27 (30575489) 1
31 (27486526) 4
QCT lumbar spine and hip May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 2 0 1 1 9 2 0 0 0
References Study Quality
33 (24880494) 4
36 (30790025) 3
12 (-3194791) 4
26 (-3194793) 4
32 (26277851) 4
34 (24637515) 3
35 (-3194795) 4
QUS calcaneus Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 1 0 1 0 0 1 0 0
References Study Quality
38 (18442758) 4
37 (11256897) 3
39 (29541626) 4
SXA distal forearm Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 11 1 0 0 0 0 0 0 1
TBS lumbar spine Usually not appropriate Strong ☢ <0.1 mSv 3 3 2 0 7 2 3 0 0 0 0
References Study Quality
45 (24443324) 4
52 (23341489) 4
48 (28988401) 4
46 (27900426) 4
54 (30093271) 3
47 (31628810) 3
53 (31525243) 3
51 (29416218) 3
18 (31400968) 4
43 (28276598) 4
44 (22749406) 3
49 (-3194796) 3
50 (26498132) Good
Radiography appendicular skeleton Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 12 1 0 0 0 0 0 0 0
References Study Quality
40 (1627412) 3
Radiography axial skeleton Usually not appropriate Limited Varies Varies 1 1 11 2 0 0 0 0 0 0 0
References Study Quality
41 (16534696) 3
42 (31959378) 3
Variant 2: Follow-up imaging of patients demonstrated to have risk for fracture or surveillance of established low bone mineral density.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
DXA lumbar spine and hip(s) Usually appropriate Limited ☢ <0.1 mSv 9 9 0 0 0 0 0 0 0 1 12
References Study Quality
13 (20559834) 4
60 (19193908) 4
25 (25182228) 4
57 (15292281) 4
59 (30693381) 4
24 (32427525) 4
55 (28554549) 4
56 (22256806) 4
58 (31378452) 4
DXA distal forearm May be appropriate Limited ☢ <0.1 mSv 6 6 0 0 0 0 3 4 3 2 1
References Study Quality
13 (20559834) 4
60 (19193908) 4
25 (25182228) 4
57 (15292281) 4
59 (30693381) 4
24 (32427525) 4
55 (28554549) 4
56 (22256806) 4
58 (31378452) 4
TBS lumbar spine May be appropriate Strong ☢ <0.1 mSv 4 4 0 0 1 8 4 1 0 0 0
References Study Quality
66 (23769698) 3
65 (27554425) 4
64 (21887701) 2
67 (26092650) 3
68 (26378772) 4
69 (29167971) 1
70 (32258965) 2
71 (27111239) 2
72 (28624340) 1
73 (28734710) 4
QCT lumbar spine and hip May be appropriate Strong ☢☢☢ 1-10 mSv 5 5 0 1 1 1 9 2 0 0 0
References Study Quality
23 (26277847) 4
61 (24898537) 2
62 (24038152) 1
63 (23871852) 1
QUS calcaneus Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 0 1 0 0 0 1 0
DXA VFA Usually not appropriate Limited ☢ <0.1 mSv 3 3 4 3 1 4 2 0 0 0 0
References Study Quality
18 (31400968) 4
SXA distal forearm Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 12 0 0 0 0 0 0 0 1
Variant 3: Follow-up imaging. Patients with T-scores less than −1.0 (by DXA) and one or more of the following: 1) Females equal to or greater than 70 years of age or males equal to or greater than 80 years of age; 2) Historical height loss greater than 4 cm (greater than 1.5 inches); 3) Self-reported but undocumented prior vertebral fracture; 4) Glucocorticoid therapy equivalent to equal to or greater than 5 mg of prednisone or equivalent per day for equal to or greater than 3 months.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
DXA lumbar spine and hip(s) Usually appropriate Limited ☢ <0.1 mSv 9 9 0 0 0 0 0 0 0 0 13
References Study Quality
56 (22256806) 4
DXA VFA Usually appropriate Strong ☢ <0.1 mSv 9 9 0 0 0 0 0 3 2 0 8
References Study Quality
78 (8237484) 4
92 (20571773) 4
93 (24599272) 4
94 (23769657) 4
79 (17245546) 4
95 (32095943) 3
96 (31352490) 3
18 (31400968) 4
76 (32268210) Good
77 (12054160) 4
80 (17563237) 4
82 (15940375) 3
81 (14555255) 3
83 (18584111) 4
84 (21732219) 4
85 (24582085) 4
86 (23959594) 4
87 (23097259) 4
88 (23818208) 4
89 (16574519) 4
90 (12377802) 4
91 (12181624) 3
97 (31375350) 4
DXA distal forearm May be appropriate Limited ☢ <0.1 mSv 6 6 1 0 0 0 4 3 2 2 1
References Study Quality
56 (22256806) 4
Radiography axial skeleton May be appropriate Limited Varies Varies 4 4 2 1 0 6 3 2 0 0 0
References Study Quality
78 (8237484) 4
18 (31400968) 4
98 (33145043) 3
QCT lumbar spine and hip May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 6 6 0 0 0 2 5 7 0 0 0
QUS calcaneus Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 1 0 0 0 1 0 0
SXA distal forearm Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 11 1 0 0 0 0 0 0 1
TBS lumbar spine Usually not appropriate Limited ☢ <0.1 mSv 3 3 2 2 6 3 1 0 0 0 0
References Study Quality
48 (28988401) 4
Radiography appendicular skeleton Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 10 3 0 0 0 0 0 0 0
Variant 4: Initial imaging for premenopausal females or males less than 50 years of age. Individual with risk factors that could alter bone mineral density.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
DXA lumbar spine and hip(s) Usually appropriate Limited ☢ <0.1 mSv 9 9 0 0 0 0 0 0 1 0 12
References Study Quality
57 (15292281) 4
18 (31400968) 4
99 (24091896) 4
100 (28131128) 4
101 (32453819) 4
102 (29657446) 4
103 (28585410) 4
104 (31318068) 4
105 (16189261) 1
106 (16731428) 4
DXA distal forearm May be appropriate Limited ☢ <0.1 mSv 5 5 0 0 0 0 7 2 1 1 2
References Study Quality
57 (15292281) 4
18 (31400968) 4
99 (24091896) 4
100 (28131128) 4
101 (32453819) 4
102 (29657446) 4
103 (28585410) 4
104 (31318068) 4
105 (16189261) 1
106 (16731428) 4
QUS calcaneus Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 11 0 0 1 1 0 0 0 0
References Study Quality
109 (18645695) 3
SXA distal forearm Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 12 0 0 0 0 0 0 0 1
TBS lumbar spine Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 11 0 0 0 1 0 0 0 1
Radiography appendicular skeleton Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 1 0 0 0 0 0 0 0
Radiography axial skeleton Usually not appropriate Expert Consensus Varies Varies 1 1 12 0 0 1 0 0 0 0 0
QCT lumbar spine and hip Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 5 0 7 1 0 0 0 0 0
References Study Quality
107 (22962425) 3
108 (19455271) 3
Variant 5: Premenopausal females with risk factors. Males less than 50 years of age with risk factors. Follow-up to low bone mineral density.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
DXA lumbar spine and hip(s) Usually appropriate Limited ☢ <0.1 mSv 9 9 0 0 0 0 1 0 0 0 12
References Study Quality
25 (25182228) 4
DXA distal forearm May be appropriate Limited ☢ <0.1 mSv 6 6 0 0 0 0 4 3 2 3 1
References Study Quality
25 (25182228) 4
QCT lumbar spine and hip May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 5 5 1 0 1 5 7 1 0 0 0
QUS calcaneus Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 0 1 1 0 0 0 0
SXA distal forearm Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 12 0 0 0 0 0 1 0 0
TBS lumbar spine Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 11 0 0 1 0 0 0 0 1
Variant 6: Males and females greater than or equal to 50 years of age. Suspected osteoporosis. Advanced degenerative changes of the spine with or without scoliosis, or other conditions that may spuriously elevate BMD. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
DXA distal forearm Usually appropriate Limited ☢ <0.1 mSv 7 7 0 0 0 0 4 1 6 1 2
References Study Quality
13 (20559834) 4
111 (27162010) 2
12 (-3194791) 4
110 (33655400) 4
DXA lumbar spine and hip(s) Usually appropriate Limited ☢ <0.1 mSv 8 8 0 0 0 0 1 0 2 6 5
References Study Quality
111 (27162010) 2
112 (30122533) 3
110 (33655400) 4
113 (30766896) 4
QCT lumbar spine and hip(s) Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 0 1 0 0 3 5 5
References Study Quality
33 (24880494) 4
115 (27327251) 3
114 (15981723) 2
QUS calcaneus Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 1 0 0 0 0 0 0
SXA distal forearm Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 13 0 0 1 0 0 0 0 0
Radiography appendicular skeleton Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 12 2 0 0 0 0 0 0 0
Radiography axial skeleton Usually not appropriate Expert Consensus Varies Varies 1 1 12 2 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.