American College of Radiology
ACR Appropriateness Criteria®

Back Pain — Child

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
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
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 with IV contrast Usually not appropriate Varies Varies 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
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 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
Tc-99m bone scan whole body with SPECT complete spine Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 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 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 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
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
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
Tc-99m bone scan whole body with SPECT 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 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
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
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
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
Tc-99m bone scan whole body with SPECT 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 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
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
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 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 Usually appropriate O 0 mSv O 0 mSv [ped] 8 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
Tc-99m bone scan whole body with SPECT 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 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
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
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
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
Tc-99m bone scan whole body with SPECT complete spine May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 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 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 with IV contrast Usually not appropriate Varies Varies 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
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
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
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
Radiography complete spine Usually appropriate ☢☢☢ 0.3-3 mSv [ped] 8 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 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
Tc-99m bone scan whole body with SPECT 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 with IV contrast Usually not appropriate Varies Varies 3 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 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
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
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.