Variant 1: Child. Back pain with none of the following clinical red flags: constant pain, night pain, radicular pain, pain lasting >4 weeks, abnormal neurologic examination. Initial imaging evaluation.
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 not appropriate | Varies | Varies | 2 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
MRI complete spine 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 complete 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 | |
MRI complete 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 | |
Bone scan whole body with SPECT or SPECT/CT complete spine | Usually not appropriate | ☢☢☢ 1-10 mSv | ☢☢☢☢ 3-10 mSv [ped] | 1 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
CT myelography complete spine | Usually not appropriate | ☢☢☢☢☢ 30-100 mSv | ☢☢☢☢ 3-10 mSv [ped] | 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 | 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 | 1 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
CT spine area of interest without IV contrast | Usually not appropriate | Varies | Varies | 1 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Variant 2: Child. Back pain with 1 or more of the following clinical red flags: constant pain, night pain, radicular pain, pain lasting >4 weeks, abnormal neurologic examination. Initial imaging evaluation.
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 | 8 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
MRI complete spine without and with IV contrast | May be appropriate | O 0 mSv | O 0 mSv [ped] | 4 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
MRI complete spine without IV contrast | May be appropriate | O 0 mSv | O 0 mSv [ped] | 5 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
MRI complete spine 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 | |
Bone scan whole body with SPECT or SPECT/CT complete spine | Usually not appropriate | ☢☢☢ 1-10 mSv | ☢☢☢☢ 3-10 mSv [ped] | 2 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
CT myelography complete spine | Usually not appropriate | ☢☢☢☢☢ 30-100 mSv | ☢☢☢☢ 3-10 mSv [ped] | 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 | 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 | 1 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
CT spine area of interest without IV contrast | Usually not appropriate | Varies | Varies | 3 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Variant 3: Child. Back pain with 1 or more of the following clinical red flags: constant pain, night pain, radicular pain, pain lasting >4 weeks, abnormal neurologic examination. Negative radiographs.
Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
MRI complete 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 | |
MRI complete spine 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 | |
Bone scan whole body with SPECT or SPECT/CT complete spine | May be appropriate | ☢☢☢ 1-10 mSv | ☢☢☢☢ 3-10 mSv [ped] | 5 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
CT spine area of interest without IV contrast | May be appropriate | Varies | Varies | 5 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
MRI complete spine 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 myelography complete spine | Usually not appropriate | ☢☢☢☢☢ 30-100 mSv | ☢☢☢☢ 3-10 mSv [ped] | 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 | 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 | 1 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Variant 4: Child. Back pain with 1 or more of the following clinical red flags: constant pain, night pain, radicular pain, pain lasting >4 weeks, abnormal neurologic examination. Positive radiographs.
Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
MRI complete spine 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 | |
MRI complete 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 | |
Bone scan whole body with SPECT or SPECT/CT complete spine | May be appropriate | ☢☢☢ 1-10 mSv | ☢☢☢☢ 3-10 mSv [ped] | 4 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
CT spine area of interest without IV contrast | May be appropriate | Varies | Varies | 5 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
MRI complete spine 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 myelography complete spine | Usually not appropriate | ☢☢☢☢☢ 30-100 mSv | ☢☢☢☢ 3-10 mSv [ped] | 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 | 3 | 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 | 1 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Variant 5: Child. Chronic back pain associated with overuse. Mechanical back pain.
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 | 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] | 7 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
Bone scan whole body with SPECT or SPECT/CT complete spine | May be appropriate | ☢☢☢ 1-10 mSv | ☢☢☢☢ 3-10 mSv [ped] | 6 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
CT spine area of interest without IV contrast | May be appropriate | Varies | Varies | 6 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
MRI spine area of interest 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 area of interest without and with IV contrast | Usually not appropriate | O 0 mSv | O 0 mSv [ped] | 3 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
CT myelography complete spine | Usually not appropriate | ☢☢☢☢☢ 30-100 mSv | ☢☢☢☢ 3-10 mSv [ped] | 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 | 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 | 1 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Variant 6: Child. Back pain associated with suspected inflammation, infection, or malignancy.
Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Radiography complete spine | Usually appropriate | ☢☢☢ 0.3-3 mSv [ped] | 8 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
MRI complete spine without and with IV contrast | Usually appropriate | O 0 mSv | O 0 mSv [ped] | 9 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
MRI complete spine without IV contrast | May be appropriate | O 0 mSv | O 0 mSv [ped] | 5 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
Bone scan whole body with SPECT or SPECT/CT complete spine | May be appropriate | ☢☢☢ 1-10 mSv | ☢☢☢☢ 3-10 mSv [ped] | 4 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
CT spine area of interest without IV contrast | May be appropriate | Varies | Varies | 5 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
MRI complete spine with IV contrast | Usually not appropriate | O 0 mSv | O 0 mSv [ped] | 3 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
CT myelography complete spine | Usually not appropriate | ☢☢☢☢☢ 30-100 mSv | ☢☢☢☢ 3-10 mSv [ped] | 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 | 3 | 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 | 2 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
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.