American College of Radiology
ACR Appropriateness Criteria®

Osteoporosis and Bone Mineral Density

Variant 1: Asymptomatic BMD screening or individuals with established or clinically suspected low BMD.
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 ☢ <0.1 mSv 9 n/a 0 0 0 0 0 0 0 0 0
QCT lumbar spine and hip May be appropriate ☢☢☢ 1-10 mSv 6 n/a 0 0 0 0 0 0 0 0 0
DXA distal forearm May be appropriate ☢ <0.1 mSv 5 n/a 0 0 0 0 0 0 0 0 0
TBS lumbar spine May be appropriate ☢ <0.1 mSv 4 n/a 0 0 0 0 0 0 0 0 0
pQCT distal forearm Usually not appropriate ☢ <0.1 mSv 2 n/a 0 0 0 0 0 0 0 0 0
SXA distal forearm Usually not appropriate ☢ <0.1 mSv 2 n/a 0 0 0 0 0 0 0 0 0
QUS calcaneus Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
Radiography axial skeleton Usually not appropriate Varies Varies 1 n/a 0 0 0 0 0 0 0 0 0
Radiography appendicular skeleton Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: In patients with T-scores less than −1.0 and one or more of the following: a. Women age ≥70 years or men age ≥80 years b. Historical height loss >4 cm (>1.5 inches) c. Self-reported but undocumented prior vertebral fracture d. Glucocorticoid therapy equivalent to ≥5 mg of prednisone or equivalent per day for ≥3 months
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
DXA VFA Usually appropriate ☢ <0.1 mSv 9 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Follow-up. Patients demonstrated to have risk for fracture or low 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 ☢ <0.1 mSv 9 n/a 0 0 0 0 0 0 0 0 0
QCT lumbar spine and hip Usually appropriate ☢☢☢ 1-10 mSv 7 n/a 0 0 0 0 0 0 0 0 0
DXA VFA May be appropriate ☢ <0.1 mSv 5 n/a 0 0 0 0 0 0 0 0 0
pQCT distal forearm Usually not appropriate ☢ <0.1 mSv 3 n/a 0 0 0 0 0 0 0 0 0
TBS lumbar spine Usually not appropriate ☢ <0.1 mSv 2 n/a 0 0 0 0 0 0 0 0 0
SXA distal forearm Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
QUS calcaneus Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Identify low BMD. Premenopausal females with risk factors. Males 20-50 years old with risk factors.
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 ☢ <0.1 mSv 9 n/a 0 0 0 0 0 0 0 0 0
DXA distal forearm Usually appropriate ☢ <0.1 mSv 8 n/a 0 0 0 0 0 0 0 0 0
QCT lumbar spine and hip Usually not appropriate ☢☢☢ 1-10 mSv 3 n/a 0 0 0 0 0 0 0 0 0
pQCT distal forearm Usually not appropriate ☢ <0.1 mSv 3 n/a 0 0 0 0 0 0 0 0 0
QUS calcaneus Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
SXA distal forearm Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Follow-up to low BMD. Premenopausal females with risk factors. Males 20–50 years of age with risk factors.
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 ☢ <0.1 mSv 9 n/a 0 0 0 0 0 0 0 0 0
DXA distal forearm Usually appropriate ☢ <0.1 mSv 8 n/a 0 0 0 0 0 0 0 0 0
QCT lumbar spine and hip Usually not appropriate ☢☢☢ 1-10 mSv 3 n/a 0 0 0 0 0 0 0 0 0
pQCT distal forearm Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
QUS calcaneus Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
SXA distal forearm Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Diagnosis. Males and females >50 years of age with advanced degenerative changes of the spine with or without scoliosis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
QCT lumbar spine and hip(s) Usually appropriate ☢☢☢ 1-10 mSv 8 n/a 0 0 0 0 0 0 0 0 0
DXA lumbar spine and hip(s) Usually appropriate ☢ <0.1 mSv 7 n/a 0 0 0 0 0 0 0 0 0
DXA distal forearm Usually appropriate ☢ <0.1 mSv 7 n/a 0 0 0 0 0 0 0 0 0
Variant 7: Suspected fracture (nonscreening) of a vertebral body based on acute or subacute symptomatology in a patient with suspected osteoporosis or a patient treated with corticosteroids (>3 months). First examination.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography spine area of interest Usually appropriate Varies Varies Varies Varies 9 n/a 0 0 0 0 0 0 0 0 0
CT spine area of interest without IV contrast May be appropriate Varies Varies Varies Varies 5 n/a 0 0 0 0 0 0 0 0 0
MRI spine area of interest without IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 2 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
CT spine area of interest without and with IV contrast Usually not appropriate Varies 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 Varies 1 n/a 0 0 0 0 0 0 0 0 0
DXA VFA Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 8: Suspected fracture (nonscreening) of a vertebral body based on acute or subacute symptomatology in a patient with suspected osteoporosis or a patient treated with corticosteroids (>3 months). Initial radiograph is negative.
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 O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
CT lumbar spine without IV contrast Usually appropriate ☢☢☢ 1-10 mSv 7 n/a 0 0 0 0 0 0 0 0 0
MRI lumbar 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
CT lumbar 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 lumbar spine with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
DXA VFA Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 9: Patients on long-term treatment (3–5 years) of bisphosphonates with thigh or groin pain. First examination.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography femur Usually appropriate ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
DXA extended femur scan Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT thigh without and with IV contrast bilateral Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT thigh without IV contrast bilateral Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT thigh with IV contrast bilateral Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US thigh bilateral Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI thigh without IV contrast bilateral Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI thigh without and with IV contrast bilateral Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 10: Patients on long-term treatment (3–5 years) of bisphosphonates with thigh or groin pain and negative radiographs.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI thigh without IV contrast bilateral Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
CT thigh without IV contrast bilateral Usually appropriate ☢☢ 0.1-1mSv 8 n/a 0 0 0 0 0 0 0 0 0
Tc-99m bone scan whole body Usually appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
US thigh bilateral Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI thigh without and with IV contrast bilateral Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
DXA extended femur scan Usually not appropriate ☢ <0.1 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT thigh without and with IV contrast bilateral Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT thigh with IV contrast bilateral Usually not appropriate ☢☢ 0.1-1mSv 1 n/a 0 0 0 0 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.