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Appropriateness Criteria

Variant 1: Adult. Asymptomatic shoulder prosthesis. Routine surveillance.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography shoulder Usually appropriate Limited ☢ <0.1 mSv 9 9 0 0 0 0 0 0 0 1 9
References Study Quality
7 (39933540) 4
4 (39055392) 4
11 (24618199) 4
12 (22309766) 4
2 (31321452) 4
51 (34020004) 0
13 (22930212) 3
17 (23473606) 2
15 (30473242) 4
US shoulder Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 6 1 2 1 0 0 0 0 0
References Study Quality
7 (39933540) 4
Image-guided aspiration shoulder Usually not appropriate Expert Consensus Varies Varies 1 1 8 2 0 0 0 0 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 2 0 0 0 0 0 0 0
References Study Quality
7 (39933540) 4
MRI shoulder without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 3 0 0 0 0 0 0 0
References Study Quality
7 (39933540) 4
3-phase bone scan with SPECT or SPECT/CT shoulder Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 2 0 0 0 0 0 0 0
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 8 2 0 0 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 8 2 0 0 0 0 0 0 0
References Study Quality
7 (39933540) 4
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 8 2 0 0 0 0 0 0 0
CT shoulder without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 7 3 0 0 0 0 0 0 0
3-phase bone scan and WBC scan and sulfur colloid scan shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 9 1 0 0 0 0 0 0 0
References Study Quality
18 (26652693) 4
3-phase bone scan and WBC scan and sulfur colloid scan with SPECT or SPECT/CT shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 9 1 0 0 0 0 0 0 0
CT arthrography shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 7 2 1 0 0 0 0 0 0
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 9 1 0 0 0 0 0 0 0
WBC scan and sulfur colloid scan shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 9 1 0 0 0 0 0 0 0
Variant 2: Adult. Symptomatic shoulder prosthesis. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography shoulder Usually appropriate Limited ☢ <0.1 mSv 9 9 0 0 0 0 0 0 0 0 10
References Study Quality
7 (39933540) 4
28 (39618534) 3
11 (24618199) 4
2 (31321452) 4
4 (39055392) 4
51 (34020004) 0
12 (22309766) 4
21 (30241984) 4
14 (28131693) 4
16 (28111179) 3
US shoulder Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 2 5 3 0 0 0 0 0 0
References Study Quality
7 (39933540) 4
4 (39055392) 4
Image-guided aspiration shoulder Usually not appropriate Limited Varies Varies 2 2 5 3 1 0 0 1 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 1 1 1 0 0 0 0 0
References Study Quality
7 (39933540) 4
MRI shoulder without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 3 1 0 0 1 0 0 0
References Study Quality
7 (39933540) 4
4 (39055392) 4
2 (31321452) 4
3-phase bone scan with SPECT or SPECT/CT shoulder Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 6 3 0 1 0 0 0 0 0
References Study Quality
24 (-3194396) 3
Bone scan shoulder Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 6 3 0 0 0 1 0 0 0
References Study Quality
25 (19038601) 4
CT shoulder with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 8 1 0 1 0 0 0 0 0
References Study Quality
27 (20036583) 4
CT shoulder without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 7 2 0 1 0 0 0 0 0
References Study Quality
27 (20036583) 4
CT shoulder without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 3 5 0 1 0 1 0 0 0
References Study Quality
7 (39933540) 4
28 (39618534) 3
2 (31321452) 4
30 (39889755) 4
29 (38857595) 4
4 (39055392) 4
27 (20036583) 4
3-phase bone scan and WBC scan and sulfur colloid scan shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 7 2 0 1 0 0 0 0 0
3-phase bone scan and WBC scan and sulfur colloid scan with SPECT or SPECT/CT shoulder Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 1 1 7 2 0 1 0 0 0 0 0
CT arthrography shoulder Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 1 1 7 2 0 0 0 1 0 0 0
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 8 2 0 0 0 0 0 0 0
WBC scan and sulfur colloid scan shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 7 2 0 1 0 0 0 0 0
Variant 3: Adult. Symptomatic shoulder prosthesis. Infection not excluded. Radiography performed. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US shoulder Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 2 2 2 2 1
References Study Quality
7 (39933540) 4
23 (34536025) 4
35 (12720010) 4
37 (23971477) 4
2 (31321452) 4
4 (39055392) 4
22 (1515896) 4
Image-guided aspiration shoulder Usually appropriate Moderate Varies Varies 8 8 0 0 1 0 1 0 0 4 4
References Study Quality
38 (19605662) 4
MRI shoulder without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 1 0 1 4 1 1 2
References Study Quality
42 (25264437) 4
MRI shoulder without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 4 4 2 0 0 0
References Study Quality
40 (35730745) 3
2 (31321452) 4
42 (25264437) 4
3-phase bone scan with SPECT or SPECT/CT shoulder May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 1 3 3 3 0 0 0 0
References Study Quality
4 (39055392) 4
24 (-3194396) 3
44 (30193652) 4
47 (32657859) 4
CT shoulder with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 0 1 1 6 2 0 0 0
CT shoulder without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 0 1 4 4 0 0 1 0
References Study Quality
7 (39933540) 4
2 (31321452) 4
3-phase bone scan and WBC scan and sulfur colloid scan shoulder May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 0 2 4 0 3 1 0
References Study Quality
25 (19038601) 4
10 (16702459) 4
44 (30193652) 4
47 (32657859) 4
3-phase bone scan and WBC scan and sulfur colloid scan with SPECT or SPECT/CT shoulder May be appropriate Limited ☢☢☢☢ 10-30 mSv 6 6 0 0 0 0 4 3 2 1 0
References Study Quality
25 (19038601) 4
10 (16702459) 4
44 (30193652) 4
47 (32657859) 4
45 (33289359) 2
46 (33361187) 3
WBC scan and sulfur colloid scan shoulder May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 0 3 3 0 3 1 0
Bone scan shoulder Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 2 2 3 1 1 0 1 0 0
References Study Quality
44 (30193652) 4
CT shoulder without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 4 1 0 1 3 1 0 0 0
CT arthrography shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 7 0 2 0 0 1 0 0 0
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 1 1 8 1 0 0 0 0 1 0 0
References Study Quality
48 (31292698) 2
Variant 4: Adult. Symptomatic shoulder prosthesis. Infection excluded or considered unlikely. Suspected loosening. Radiography performed. 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 shoulder without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 2 2 1 3 2
References Study Quality
7 (39933540) 4
4 (39055392) 4
2 (31321452) 4
CT shoulder without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv 9 9 0 0 0 0 0 2 0 2 6
References Study Quality
7 (39933540) 4
4 (39055392) 4
54 (16829248) 4
62 (23412251) 4
2 (31321452) 4
30 (39889755) 4
60 (20551186) 1
63 (26234665) 3
61 (28561262) 4
56 (29426742) 4
59 (28796543) 2
58 (27186794) 2
3-phase bone scan with SPECT or SPECT/CT shoulder May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 0 2 3 2 1 0 0 0
References Study Quality
4 (39055392) 4
24 (-3194396) 3
44 (30193652) 4
CT arthrography shoulder May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 1 0 0 4 3 1 1 0 0
US shoulder Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 6 3 1 0 0 0 0 0 0
References Study Quality
7 (39933540) 4
Image-guided aspiration shoulder Usually not appropriate Expert Consensus Varies Varies 1 1 8 0 0 1 1 0 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 2 3 0 0 0 0 0 0
Bone scan shoulder Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 2 1 3 1 2 0 1 0 0
References Study Quality
44 (30193652) 4
CT shoulder with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv 2 2 5 0 2 2 1 0 0 0 0
References Study Quality
57 (23479714) 4
55 (24286563) 3
54 (16829248) 4
62 (23412251) 4
60 (20551186) 1
63 (26234665) 3
61 (28561262) 4
56 (29426742) 4
59 (28796543) 2
58 (27186794) 2
CT shoulder without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv 1 1 7 2 1 0 0 0 0 0 0
References Study Quality
54 (16829248) 4
62 (23412251) 4
60 (20551186) 1
63 (26234665) 3
61 (28561262) 4
56 (29426742) 4
59 (28796543) 2
58 (27186794) 2
3-phase bone scan and WBC scan and sulfur colloid scan shoulder Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 5 1 3 1 0 0 0 0 0
References Study Quality
44 (30193652) 4
3-phase bone scan and WBC scan and sulfur colloid scan with SPECT or SPECT/CT shoulder Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 3 3 4 1 2 2 1 0 0 0 0
References Study Quality
44 (30193652) 4
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 9 0 1 0 0 0 0 0 0
WBC scan and sulfur colloid scan shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 7 2 1 0 0 0 0 0 0
Variant 5: Adult. Symptomatic shoulder prosthesis. Infection excluded or considered unlikely. Suspected rotator cuff tear or other soft tissue abnormality. Radiography performed. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US shoulder Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 1 3 5
References Study Quality
7 (39933540) 4
23 (34536025) 4
36 (12646465) 4
64 (16979047) 3
2 (31321452) 4
4 (39055392) 4
65 (29396098) 4
MRI shoulder without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 4 3 3
References Study Quality
7 (39933540) 4
4 (39055392) 4
64 (16979047) 3
2 (31321452) 4
CT arthrography shoulder Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 0 0 0 1 3 0 4 2 0
References Study Quality
66 (3715028) 4
68 (15829828) 3
67 (8020238) 4
Image-guided aspiration shoulder Usually not appropriate Expert Consensus Varies Varies 1 1 8 1 1 0 0 0 0 0 0
MRI shoulder without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 2 2 1 0 0 0 0 0
3-phase bone scan with SPECT or SPECT/CT shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 2 0 0 0 0 0 0 0
References Study Quality
24 (-3194396) 3
Bone scan shoulder Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 8 1 0 1 0 0 0 0 0
CT shoulder with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 5 0 4 0 0 0 1 0 0
References Study Quality
7 (39933540) 4
54 (16829248) 4
69 (30268356) 3
CT shoulder without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 7 0 1 1 0 0 1 0 0
References Study Quality
54 (16829248) 4
69 (30268356) 3
CT shoulder without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 1 2 4 2 1 0 0 0 0
References Study Quality
54 (16829248) 4
69 (30268356) 3
3-phase bone scan and WBC scan and sulfur colloid scan shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 8 2 0 0 0 0 0 0 0
3-phase bone scan and WBC scan and sulfur colloid scan with SPECT or SPECT/CT shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 8 2 0 0 0 0 0 0 0
Fluoride PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 9 1 0 0 0 0 0 0 0
WBC scan and sulfur colloid scan shoulder Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 8 1 1 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.