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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Murray CJ, Lopez AD. Measuring the global burden of disease. N Engl J Med. 2013;369(5):448-457. Review/Other-Dx N/A A review article on measuring the global burden of disease. No results stated. 4
2. Johnson SM, Shah LM. Imaging of Acute Low Back Pain. [Review]. Radiologic Clinics of North America. 57(2):397-413, 2019 Mar. Review/Other-Dx N/A To discuss the imaging of acute low back pain. No results stated in the abstract. 4
3. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491. Review/Other-Dx N/A Practice guideline by American College of Physicians and the American Pain Society on diagnosis and treatment of LBP. Recommendations are mentioned include: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific LBP (strong recommendation, moderate-quality evidence). Clinicians should perform diagnostic imaging and testing for patients with LBP when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). Clinicians should evaluate patients with persistent LBP and signs or symptoms of radiculopathy or spinal stenosis with MRI (preferred) or CT only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). 4
4. Chou R, Qaseem A, Owens DK, Shekelle P. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Annals of Internal Medicine. 154(3):181-9, 2011 Feb 01. Review/Other-Dx N/A A report based on a systematic review conducted for a 2007 low back pain guideline and a subsequent meta-analysis to help clinicians practice high-value health care by following a more rational and cost-conscious diagnostic approach. Good evidence indicates that routine back imaging is not associated with clinically meaningful benefits and exposes patients to unnecessary harms, but imaging remains overused. More evidence-based approach to imaging is needed. 4
5. Institute for Clinical Systems Improvement. Low Back Pain, Adult Acute and Subacute. Revision Date: March 2018/Sixteenth Edition.  Available at: https://www.icsi.org/guideline/low-back-pain/. Review/Other-Dx N/A To discuss:the percentage of adult patients with acute or subacute low back pain with or without radiculopathy who have imaging ordered for low back pain in the absence of red flags at the initial visit.Decrease the percentage of adult patients with acute or subacute low back pain with or without radiculopathy who are prescribed opioids. No results stated in the abstract. 4
6. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 289(21):2810-8, 2003 Jun 04. Experimental-Dx 380 total patients: 190 – radiograph, 190 – rapid MRI Randomized trial to determine the clinical and economic consequences of replacing spine radiographs with rapid MRI for primary care patients. Rapid MRIs and radiographs resulted in nearly identical outcomes for primary care patients with LBP. The rapid MRI strategy had a mean cost of $2,380 vs $2,059 dollars for the radiograph strategy. 1
7. Modic MT, Obuchowski NA, Ross JS, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology. 237(2):597-604, 2005 Nov. Experimental-Dx 246 total patients: 150 with LBP and 96 with radiculopathy Randomized prospective study of prognostic role of MRI findings and effect on outcome in patients with uncomplicated acute LBP or radiculopathy. MRI does not have measurable value in conservative management of patients with typical uncomplicated LBP or radiculopathy. 1
8. Bigos SJ, Bowyer OR, Braen GR, et al. Acute Low Back Problems in Adults.  Clinical Practice Guideline No. 14.  AHCPR Publication No. 95-0642.  Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.  December 1994.  Available at: http://d4c2.com/d4c2-000038.htm. Review/Other-Dx N/A Findings and recommendations on the assessment and treatment of adults with acute low back problems are presented in this practice guideline. n/a 4
9. Jarvik JG, Gold LS, Comstock BA, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 313(11):1143-53, 2015 Mar 17. Observational-Dx 5239 patients To compare function and pain at the 12-month follow-up visit among older adults who received early imaging with those who did not receive early imaging after a new primary care visit for back pain without radiculopathy. Among the 5239 patients, 1174 had early radiographs and 349 had early MRI/CT. At 12 months, neither the early radiograph group nor the early MRI/CT group differed significantly from controls on the disability questionnaire. The mean score for patients who underwent early radiography was 8.54 vs 8.74 among the control group (difference, -0.10 [95% CI, -0.71 to 0.50]; mixed model, P = .36). The mean score for the early MRI/CT group was 9.81 vs 10.50 for the control group (difference,-0.51 [-1.62 to 0.60]; mixed model, P = .18). 3
10. Looker AC, Borrud LG, Dawson-Hughes B, Shepherd JA, Wright NC. Osteoporosis or low bone mass at the femur neck or lumbar spine in older adults: United States, 2005-2008. NCHS Data Brief. (93)1-8, 2012 Apr. Review/Other-Dx N/A A review of older adults with osteoporosis or low bone mass at the femur neck or lumbar spine. No results stated in the abstract. 4
11. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990;72(3):403-408. Review/Other-Dx 67 patients, 3 reviewers To prospectively examine MRI results in patients with no history of LBP, sciatica or neurogenic claudication. Abnormalities on MRI must be strictly correlated with age and any clinical signs and symptoms before operative treatment is contemplated. 4
12. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. [Review]. AJNR Am J Neuroradiol. 36(4):811-6, 2015 Apr. Review/Other-Dx 33 articles To estimate the prevalence, by age, of common degenerative spine conditions by performing a systematic review studying the prevalence of spine degeneration on imaging in asymptomatic individuals. Thirty-three articles reporting imaging findings for 3110 asymptomatic individuals met the study inclusion criteria. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age. 4
13. Carragee E, Alamin T, Cheng I, Franklin T, van den Haak E, Hurwitz E. Are first-time episodes of serious LBP associated with new MRI findings? Spine J. 2006;6(6):624-635. Observational-Dx 200 total patients; 51 had 67 MR scans, 2 independent and blinded readers Prospective observational study to determine if new and serious episodes of LBP are associated with new and relevant findings on MRI. Findings on MRI within 12 weeks of serious LBP inception are highly unlikely to represent any new structural change. Most new changes (loss of disc signal, facet arthrosis, and end plate signal changes) represent progressive age changes not associated with acute events. Primary radicular syndromes may have new root compression findings associated with root irritation. 3
14. Bernard SA, Kransdorf MJ, Beaman FD, et al. ACR Appropriateness Criteria R Chronic Back Pain Suspected Sacroiliitis-Spondyloarthropathy. [Review]. Journal of the American College of Radiology. 14(5S):S62-S70, 2017 May. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for chronic back pain suspected sacroiliitis-spondyloarthropathy. No results stated in abstract. 4
15. Panagopoulos J, Magnussen JS, Hush J, et al. Prospective Comparison of Changes in Lumbar Spine MRI Findings over Time between Individuals with Acute Low Back Pain and Controls: An Exploratory Study. AJNR Am J Neuroradiol. 38(9):1826-1832, 2017 Sep. Observational-Dx 20 patients To determine the following:1.Whether lumbar spine MR imaging findings change more commonly during a 12-week period in individuals with acute nonspecific LBP compared with a pain-free control group.2.Which MR imaging findings change most commonly during the 12-week period in individuals with acute nonspecific LBP. In 85% of subjects, we identified a change in at least 1 MR imaging finding during the 12 weeks; however, the proportion was similar in the controls (80%). A change in disc herniation, annular fissure, and nerve root compromise was reported more than twice as commonly in the subjects as in controls (65% versus 30%, 25% versus 10%, and 15% versus 0%, respectively). Caution is required in interpreting these findings due to wide confidence intervals, including no statistical difference. For all other MR imaging findings, the proportions of subjects and controls in whom MR imaging findings were reported to change during 12 weeks were similar. 2
16. Autio RA, Karppinen J, Niinimaki J, et al. Determinants of spontaneous resorption of intervertebral disc herniations. Spine (Phila Pa 1976). 2006;31(11):1247-1252. Review/Other-Dx Patients rescanned at 2 months (n = 74) and after 12 months (n = 53) To assess the determinants of resorption of herniated nucleus pulposus. Significant resorption of herniated nucleus pulposus occurred from baseline to 2 months, although the resorption rate was more pronounced over the whole 1-year follow-up. Higher baseline scores of rim enhancement thickness, higher degree of herniated nucleus pulposus displacement in the Komori classification, and age category 41–50 years were associated with a higher resorption rate. Thickness of rim enhancement was a stronger determinant of spontaneous resorption than extent of rim enhancement. Clinical symptom alleviation occurs concordantly with a faster resorption rate. 4
17. Graves JM, Fulton-Kehoe D, Jarvik JG, Franklin GM. Health care utilization and costs associated with adherence to clinical practice guidelines for early magnetic resonance imaging among workers with acute occupational low back pain. Health Serv Res. 49(2):645-65, 2014 Apr. Observational-Dx 1770 patients To estimate health care utilization and costs associated with adherence to clinical practice guidelines for the use of early magnetic resonance imaging (MRI; within the first 6 weeks of injury) for acute occupational low back pain (LBP). Of 1,770 workers, 336 (19.0 percent) were classified as nonadherent to guidelines. Outpatient and physical/occupational therapy utilization was 52-54 percent higher for workers whose imaging was not adherent to guidelines compared to workers with guideline-adherent imaging; utilization of chiropractic care was significantly lower (18 percent). 2
18. Tan A, Zhou J, Kuo YF, Goodwin JS. Variation among Primary Care Physicians in the Use of Imaging for Older Patients with Acute Low Back Pain. Journal of General Internal Medicine. 31(2):156-163, 2016 Feb. Observational-Dx 145,320 patients To estimate the variation among primary care providers (PCPs) in the use of diagnostic imaging for older patients with non-specific acute low back pain. Among patients, 27.2 % received radiography and 11.1 % received CT or MRI within 4 weeks of the initial visit for low back pain. PCPs varied substantially in the use of imaging. The average rate of radiography within 4 weeks was 53.9 % for PCPs in the highest decile, compared to 6.1 % for PCPs in the lowest decile. The average rates of CT/MRI within 4 weeks were 18.5 % vs. 3.2 % for PCPs in the highest and lowest deciles, respectively. The specific physician seen by a patient accounted for 25 % of the variability in whether imaging was performed, while only 0.44 % of the variance was due to measured patient characteristics and 1.4 % to known physician characteristics. Use of imaging by individual physicians was stable over time. 2
19. Last AR, Hulbert K. Chronic low back pain: evaluation and management. American Family Physician. 79(12):1067-74, 2009 Jun 15. Review/Other-Dx N/A Article reviews the evaluation and management of chronic LBP. Most patients with chronic LBP will not benefit from surgery. A surgical evaluation may be considered for select patients with functional disabilities or refractory pain despite multiple nonsurgical treatments. 4
20. Brinjikji W, Diehn FE, Jarvik JG, et al. MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. [Review]. AJNR Am J Neuroradiol. 36(12):2394-9, 2015 Dec. Meta-analysis 280 studies. To compare the prevalence of MR imaging features of lumbar spine degeneration in adults 50 years of age and younger with and without self-reported low back pain. An initial search yielded 280 unique studies. Fourteen (5.0%) met the inclusion criteria (3097 individuals; 1193, 38.6%, asymptomatic; 1904, 61.4%, symptomatic). Imaging findings with a higher prevalence in symptomatic individuals 50 years of age or younger included disc bulge (OR, 7.54; 95% CI, 1.28-44.56; P = .03), spondylolysis (OR, 5.06; 95% CI, 1.65-15.53; P < .01), disc extrusion (OR, 4.38; 95% CI, 1.98-9.68; P < .01), Modic 1 changes (OR, 4.01; 95% CI, 1.10-14.55; P = .04), disc protrusion (OR, 2.65; 95% CI, 1.52-4.62; P < .01), and disc degeneration (OR, 2.24; 95% CI, 1.21-4.15, P = .01). Imaging findings not associated with low back pain included any Modic change (OR, 1.62; 95% CI, 0.48-5.41, P = .43), central canal stenosis (OR, 20.58; 95% CI, 0.05-798.77; P = .32), high-intensity zone (OR = 2.10; 95% CI, 0.73-6.02; P = .17), annular fissures (OR = 1.79; 95% CI, 0.97-3.31; P = .06), and spondylolisthesis (OR = 1.59; 95% CI, 0.78-3.24; P = .20). Good
21. Suri P, Boyko EJ, Goldberg J, Forsberg CW, Jarvik JG. Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK). BMC Musculoskelet Disord. 15:152, 2014 May 13. Review/Other-Dx 123 patients To examine the association of incident lumbar MRI findings with two specific spine-related symptom outcomes: 1) incident chronic bothersome LBP, and 2) incident radicular symptoms such as pain, weakness, or sensation alterations in the lower extremity. Three-year cumulative incidence of new MRI findings ranged between 2 and 8%, depending on the finding. Incident annular fissures were associated with incident chronic LBP, after adjustment for prior back pain and depression (adjusted odds ratio [OR] 6.6; 95% confidence interval [CI] 1.2-36.9). All participants with incident disc extrusions (OR 5.4) and nerve root impingement (OR 4.1) reported incident radicular symptoms, although associations were not statistically significant. No other incident MRI findings showed large magnitude associations with symptoms. 4
22. Bartynski WS, Lin L. Lumbar root compression in the lateral recess: MR imaging, conventional myelography, and CT myelography comparison with surgical confirmation. AJNR Am J Neuroradiol. 24(3):348-60, 2003 Mar. Observational-Dx 26 patients To assess the accuracy of MRI, conventional myelography, and postmyelography CT (CT myelography) of the lumbar level in identifying degenerative lateral recess root compression with surgical confirmation. MRI underestimated root compression in 28% to 29% of the cases in which root impingement was surgically confirmed. Conventional myelography underestimated root compression in only 5% to 7% of the cases and correctly predicted impingement in 93% to 95%. CT myelography underestimated root compression in 38% of the surgically confirmed cases. 3
23. Nazarian S, Beinart R, Halperin HR. Magnetic resonance imaging and implantable devices. Circ Arrhythm Electrophysiol 2013;6:419-28. Review/Other-Dx N/A To discuss the magnetic resonance imaging and implantable devices. No results stated in the abstract. 4
24. Tarpada SP, Cho W, Chen F, Amorosa LF. Utility of Supine Lateral Radiographs for Assessment of Lumbar Segmental Instability in Degenerative Lumbar Spondylolisthesis. Spine (Phila Pa 1976) 2018;43:1275-80. Review/Other-Dx 59 patients To determine whether supine lateral radiographs increase the amount of segmental instability visualized in single-level lumbar degenerative spondylolisthesis, when compared to traditional lateral flexion-extension radiographs. A total of 59 patients (51 women, 8 men), with a mean age of 63.0 years (±9.85 yr) were included. The mean mobility seen with flexion-extension was 5.53 ± 4.11. The mean mobility seen with flexion-supine was 7.83% ± 4.67%. This difference was significant in paired t test (P = 0.00133), and independent of age and body mass index. Maximal mobility was seen between flexion and supine radiographs in 37 patients, between neutral and supine radiographs in 11 cases, and between traditional flexion-extension studies in 11 cases. 4
25. Yao G, Cheung JPY, Shigematsu H, et al. Characterization and Predictive Value of Segmental Curve Flexibility in Adolescent Idiopathic Scoliosis Patients. Spine (Phila Pa 1976) 2017;42:1622-28. Observational-Dx 80 patients To characterize segmental curve flexibility and to determine its predictive value in curve correction in AIS patients. Eighty patients were included with mean age of 15 years. Preoperative mean segmental Cobb angles were 18, 31, and 17 degrees in the upper, mid, and lower segments, respectively. Segmental bending Cobb angles were 6, 13, and 4 degrees, respectively, corresponding to segmental flexibilities of 50%, 47%, and 83% in the upper, mid, and lower segments, respectively (P < 0.001). At 2-year follow up, the mean segmental FBCI were 155%, 131%, and 100% in the upper, mid, and lower segments, respectively (P < 0.001), which suggested that the lower segment of the curve was more flexible than the other segments and that higher correction was noted in the upper segments. A significant, positive correlation was noted between the segmental bending Cobb angle and the segmental FBCI (P < 0.05), whereby the strength of the correlation varied based on the curve segment. 2
26. Senoglu M, Karadag A, Kinali B, Bozkurt B, Middlebrooks EH, Grande AW. Cortical Bone Trajectory Screw for Lumbar Fixation: A Quantitative Anatomic and Morphometric Evaluation. World Neurosurg 2017;103:694-701. Observational-Dx 100 patients To evaluate variations in anatomy relevant to CBT screw placement and to determine optimal screw location, trajectory, and length using measures obtained from computed tomography (CT) scans. Across all lumbar levels, the mean right pedicle-pars interarticularis junction length ranged from 7.58 ± 1.18 mm to 8.37 ± 1.42 mm, and the mean left pedicle-pars interarticularis junction length ranged from 7.95 ± 1.42 mm to 8.6 ± 1.74 mm. The pedicle-pars interarticularis junction from L1 to L5 was deemed too small for a 5-mm-diameter CBT screw in 35%, 24%, 17%, 17%, and 19%, respectively, on the right, and in 30%, 17%, 17%, 17%, and 20%, respectively, on the left. The average length of a screw placed along the cranial cortical bone of the pedicle ranged from 27 ± 2.5 mm to 30.5 ± 3.4 mm, and the angle of the screw with respect to the vertebral body endplate ranged from 44 ± 4.1° to 48 ± 6.2°. 2
27. Peacock JG, Timpone VM. Doing More with Less: Diagnostic Accuracy of CT in Suspected Cauda Equina Syndrome. Ajnr: American Journal of Neuroradiology. 38(2):391-397, 2017 Feb. Observational-Dx 151 patients To evaluate discuss the diagnostic accuracy of CT in suspected cauda equina syndrome. Forty of 151 patients had a percentage thecal sac effacement of =50% on MR imaging. Nineteen of 40 had cauda equina impingement. Readers determined that there was a CT percentage thecal sac effacement of <50% in 97/151 cases, and CT percentage thecal sac effacement of =50% in 54/151 cases. Reader sensitivity for the detection of significant spinal stenosis (MR percentage thecal sac effacement of =50%) was 0.98; specificity, 0.86; positive predictive value, 0.72; and negative predictive value, 0.99. No cases read as CT percentage thecal sac effacement of <50% were found to have cauda equina impingement. 2
28. Jain A, Jain S, Agarwal A, Gambhir S, Shamshery C, Agarwal A, Evaluation of Efficacy of Bone Scan With SPECT/CT in the Management of Low Back Pain: A Study Supported by Differential Diagnostic Local Anesthetic Blocks. Clinical Journal of Pain. 31(12):1054-9, 2015 Dec. Experimental-Dx 80 patients To evaluate the role of bone scan with SPECT/CT in management of patients with low back pain (LBP). In both the groups, sacroilitis was the most common diagnosis followed by facet joint arthropathy. The number of patients obtaining pain relief of >50% was significantly higher in the bone scan-positive group as compared with the control group. Three new clinical conditions were identified in the bone scan group. These conditions were multiple myeloma, avascular necrosis of the femoral head, and ankylosing spondylitis. 2
29. Russo VM, Dhawan RT, Baudracco I, Dharmarajah N, Lazzarino AI, Casey AT. Hybrid Bone SPECT/CT Imaging in Evaluation of Chronic Low Back Pain: Correlation with Facet Joint Arthropathy. World Neurosurgery. 107:732-738, 2017 Nov. Observational-Dx 99 patients To compare the scintigraphic patterns on bone SPECT/CT with the degree of structural facet joint (FJ) degeneration on CT in patients with ow back pain (LBP). Ninety-nine patients were included (59 female, mean age 56.2 years). The mean ODI score was 38.5% (range, 8% to 72%). In all, 792 FJ (L2-3 to L5-S1) were examined. Of the FJs, 49.6% were Pathria grade 0-1 (normal to mild degeneration) on CT, 35% were grade 2 (moderate degeneration), and 16% were grade 3 (severe degeneration). Sixty-seven percent of the patients had scintigraphically active FJs on SPECT/CT. Sixty-nine percent of Pathria grade 3 FJs were scintigraphically active; 5.5% and 16.8% of Pathria grade 0-1 and Pathria grade 2, respectively, were active. Of the metabolically active FJs, 71.4% were at the L4-5/L5-S1 levels. 2
30. Russo VM, Dhawan RT, Dharmarajah N, Baudracco I, Lazzarino AI, Casey AT. Hybrid Bone Single Photon Emission Computed Tomography Imaging in Evaluation of Chronic Low Back Pain: Correlation with Modic Changes and Degenerative Disc Disease. World Neurosurg. 104:816-823, 2017 Aug. Observational-Dx 99 patients To assess the value of the hybrid bone SPECT/CT imaging in patients with chronic LBP. We evaluate the correlation of hybrid bone SPECT/CT imaging patterns with MCs and disc abnormalities on magnetic resonance imaging (MRI). A total of 99 patients were included in the study (58 women, 41 men; mean age, 56.2 years). Mean Oswestry disability index score was 38.5% (range, 8%-72%). The L2-3 through to L5-S1 levels were studied. MCs were found in 54% of patients. Of the 396 levels examined 85 were found to have MCs (21.5%). The most affected levels were L4-5 (31.3%) and L5-S1 (40.9%). Pfirrmann grade 5 disc space (72.9%) was associated with MC (Pp<0.001). MC (70.6%) and Pfirrmann grade 5 disc spaces (73%) resulted in scintigraphically active endplate/disc space on SPECT/CT (P< 0.001). Bone SPECT/CT showed high metabolic activity in 96.1% of endplates with MC type I, 56% with MC type II, and 77.8% with MC type III. 2
31. Matesan M, Behnia F, Bermo M, Vesselle H. SPECT/CT bone scintigraphy to evaluate low back pain in young athletes: common and uncommon etiologies. [Review]. Journal of Orthopaedic Surgery. 11(1):76, 2016 Jul 07. Review/Other-Dx N/A To discuss the utility of SPECT/CT bone scintigraphy for the evaluation of low back pain in young athletes. No results stated in the abstract. 4
32. Manchikanti L, Benyamin RM, Singh V, et al. An update of the systematic appraisal of the accuracy and utility of lumbar discography in chronic low back pain. Pain Physician. 2013;16(2 Suppl):SE55-95. Review/Other-Dx 160 studies To systematically assess and re-evaluate the diagnostic accuracy of lumbar discography. Over 160 studies were considered for inclusion. Of these, 33 studies compared discography with other diagnostic tests, 30 studies assessed the diagnostic accuracy of discography, 22 studies assessed surgical outcomes for discogenic pain, and 3 studies assessed the prevalence of lumbar discogenic pain. The quality of the overall evidence supporting provocation discography based on the above studies appears to be fair. The prevalence of internal disc disruption is estimated to be 39% to 42%, whereas the prevalence of discogenic pain without assessing internal disc disruption is 26%. 4
33. Colosimo C, Cianfoni A, Di Lella GM, Gaudino S. Contrast-enhanced MR imaging of the spine: when, why and how? How to optimize contrast protocols in MR imaging of the spine. Neuroradiology 2006;48 Suppl 1:18-33. Review/Other-Dx N/A To discuss the applications and clinical utility of post-contrast MR imaging with regard to different spinal diseases. No results stated in the abstract. 4
34. el Barzouhi A, Vleggeert-Lankamp CL, Lycklama a Nijeholt GJ, et al. Influence of low back pain and prognostic value of MRI in sciatica patients in relation to back pain. PLoS ONE. 9(3):e90800, 2014. Observational-Dx 379 patients To compare the efficacy of early surgery with prolonged conservative care for sciatica. Of 379 included sciatica patients, 158 (42%) had disabling back pain. Of the patients with both sciatica and disabling back pain 68% did reveal a herniated disc with nerve root compression on MRI, compared to 88% of patients with predominantly sciatica (P<0.001). The existence of disabling back pain in sciatica at baseline was negatively associated with perceived recovery at one year (Odds ratio [OR] 0.32, 95% Confidence Interval 0.18-0.56, P<0.001). Sciatica patients with disabling back pain in absence of nerve root compression on MRI at baseline reported less perceived recovery at one year compared to those with predominantly sciatica and nerve root compression on MRI (50% vs 91%, P<0.001). 1
35. Kobayashi A, Kobayashi T, Kato K, Higuchi H, Takagishi K. Diagnosis of radiographically occult lumbar spondylolysis in young athletes by magnetic resonance imaging. Am J Sports Med. 2013;41(1):169-176. Observational-Dx 200 consecutive young athletes To evaluate the usefulness of MRI in diagnosing active spondylolysis early and in determining the prevalence of active spondylolysis in cases where findings were not detected on plain radiography. In addition, specific clinical features to aid in the early detection of active spondylolysis were evaluated. Ninety-seven (48.5%) patients showed evidence of active spondylolysis on MRI, findings that had been missed by plain radiography. These pars defects were organized into the following categories based on CT findings: nonlysis stage, 52; very early stage, 37; late early stage, 22; progressive stage, 10; and terminal stage, 0. No significant physical examination factors were identified that could assist in the early detection of active spondylolysis. 3
36. Butt S, Saifuddin A. The imaging of lumbar spondylolisthesis. Clin Radiol 2005;60:533-46. Review/Other-Dx N/A To present a present a pictorial review of the imaging features of lumbar spondylolisthesis and explain the differentiating points between different groups of this disorder. No results stated in the abstract. 4
37. Cabraja M, Mohamed E, Koeppen D, Kroppenstedt S. The analysis of segmental mobility with different lumbar radiographs in symptomatic patients with a spondylolisthesis. Eur Spine J 2012;21:256-61. Observational-Dx 100 patients To test the hypothesis that imaging in standing and recumbent position (SRP) reveals a higher sagittal translation (ST) and sagittal rotation (SR) in symptomatic patients than with SFE. The measurement of ST revealed an absolute value of 2.3 ± 1.5 mm in SFE and 4.0 ± 2.0 mm in SRP and differed significantly (p = 0.001). The analysis of the relative value showed an ST of 5.9 ± 3.9% in SFE and 7.8 ± 5.4% in SRP (p = 0.008). The assessment of ST in flexion and in a recumbent position (FRP) revealed the highest ST (4.6 ± 2.5 mm or 9.2 ± 5.7%). Comparison of SR showed the highest rotation in SFE (6.1° ± 3.8°), however, compared to SRP (5.4° ± 3.3°), it missed the level of significance (p = 0.051). 2
38. Fraser S, Roberts L, Murphy E. Cauda equina syndrome: a literature review of its definition and clinical presentation. Arch Phys Med Rehabil. 2009;90(11):1964-1968. Review/Other-Dx 105 articles To review the current evidence for the signs and symptoms of cauda equina syndrome (CES). There are marked inconsistencies in the current evidence base surrounding the etiology and clinical presentation of CES, with 17 definitions identified. Subclassifications of the definition of CES are ambiguous and should be avoided. From reviewing 105 articles, a single definition of CES is proposed. For a diagnosis of CES, one or more of the following must be present: (1) bladder and/or bowel dysfunction, (2) reduced sensation in the saddle area, and (3) sexual dysfunction, with possible neurologic deficit in the lower limb (motor/sensory loss, reflex change). 4
39. Fairbank J, Hashimoto R, Dailey A, Patel AA, Dettori JR. Does patient history and physical examination predict MRI proven cauda equina syndrome? Evid Based Spine Care J. 2011;2(4):27-33. Review/Other-Dx 4 articles To determine if there are there elements from the history or physical examination that are associated with CES as established by MRI. The mean prevalence of CES as diagnosed by MRI ranged from 14%-48% of patients. No symptoms or signs reported by more than one study showed high sensitivity and specificity, and all likelihood ratios were low. Symptoms included back/low back pain, bilateral sciatica, bladder retention, bladder incontinence, frequent urination, decreased urinary sensation, and bowel incontinence; signs included saddle numbness and reduced anal tone.There is low evidence that individual symptoms or signs from the patient history or clinical examination, respectively, can be used to diagnose CES. 4
40. American College of Radiology. ACR Appropriateness Criteria®: Myelopathy. Available at: https://acsearch.acr.org/docs/69484/Narrative/. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. No abstract available. 4
41. Bell DA, Collie D, Statham PF. Cauda equina syndrome: what is the correlation between clinical assessment and MRI scanning? Br J Neurosurg. 2007;21(2):201-203. Observational-Dx 23 patients To assess the ability of neurosurgical residents to predict on clinical grounds in which patients with cauda equina syndrome (CES) this was due to prolapsed intervertebral disc thereby justifying a request for urgent MR imaging MRI was normal in 10 (43%) patients. A disc prolapse causing cauda equina distortion was present in 5 (22%) patients. The diagnostic accuracy of urinary retention, urinary frequency, urinary incontinence, altered urinary sensation and altered perineal sensation were 0.57, 0.65, 0.61 ,0.65 and 0.60 respectively. 3
42. Koontz NA, Wiggins RH 3rd, Mills MK, et al. Less Is More: Efficacy of Rapid 3D-T2 SPACE in ED Patients with Acute Atypical Low Back Pain. Academic Radiology. 24(8):988-994, 2017 08. Review/Other-Dx 206 patients To determine the efficacy of a rapid lumbar spine (LS) magnetic resonance imaging (MRI) screening protocol consisting of a single 3D-T2 SPACE FS (3D-T2 Sampling Perfection with Application optimized Contrasts using different flip angle Evolution fat saturated) sequence relative to conventional LS MRI to exclude emergently treatable pathologies in this complex patient population. Of the 206 ED patients who obtained MRI for acute atypical LBP, 118 (43.3?±?13.5 years of age; 61 female) were included. Specific pathologies detected on reference standard conventional MRI included disc herniation (n?=?30), acute fracture (n?=?3), synovial cyst (n?=?3), epidural hematoma (n?=?2), cerebrospinal fluid leak (n?=?1), and leptomeningeal metastases (n?=?1), and on multiple occasions these pathologies resulted in nerve root impingement (n?=?36), severe spinal canal stenosis (n?=?13), cord/conus compression (n?=?2), and cord signal abnormality (n?=?2). The 3D-T2 SPACE FS sequence was an effective screen for fracture (sensitivity [sens]?=?100%, specificity [spec]?=?100%), cord signal abnormality (sens?=?100%, spec?=?99%), and severe spinal canal stenosis (sens?=?100%, spec?=?96%), and identified cord compression not seen on reference standard. Motion artifact was not seen on the 3D-T2 SPACE FS but noted on 8.5% of conventional LS MRI. 4
43. Bundschuh CV, Modic MT, Ross JS, Masaryk TJ, Bohlman H. Epidural fibrosis and recurrent disk herniation in the lumbar spine: MR imaging assessment. AJR Am J Roentgenol 1988;150:923-32. Observational-Dx 20 patients To evaluate MR imaging in the differentiation of epidural scar and herniated disk material. No results stated in the abstract. 2
44. Hayashi D, Roemer FW, Mian A, Gharaibeh M, Muller B, Guermazi A. Imaging features of postoperative complications after spinal surgery and instrumentation. AJR Am J Roentgenol. 199(1):W123-9, 2012 Jul. Review/Other-Dx N/A To illustrate common postoperative complications and their imaging appearances after spinal surgery, including stabilization, fusion, and disk replacement with various techniques and devices. No results stated in the abstract. 4
45. Ko CC, Tsai HW, Huang WC, et al. Screw loosening in the Dynesys stabilization system: radiographic evidence and effect on outcomes. Neurosurgical Focus. 28(6):E10, 2010 Jun. Review/Other-Dx 71 patients To evaluate the incidence of screw loosening and its effect on clinical outcomes. The 71 patients in the study sample had a mean age of 59.2 +/- 11.65 years (range 23-80 years), with slight female predominance (39 women, 32 men). The mean follow-up duration was 16.6 months (range 8-29 months). There were loose screws in 14 of 71 patients (19.7%), for a rate of 4.6% per screw (17 of 368 screws). Most screw loosening occurred in patients >/= 55 years old (13 of 14 patients) although age and sex had no effect on screw loosening (p = 0.233 and 0.109, respectively). Both the loose screw and solid screw groups experienced significant improvement after the surgery in VAS and ODI scores. On the VAS, scores improved from 5.9 +/- 2.99 to 2.1 +/- 2.14 in the loose screw group (p = 0.003), and from 5.7 +/- 3.45 to 2.9 +/- 2.68 in the solid screw group (p < 0.001). For the ODI scale, scores improved from 43.5 +/- 16.78% to 28.0 +/- 18.18% (p = 0.006) in the loose screw group, and from 52.1 +/- 20.92% to 24.6 +/- 19.78% (p < 0.001) in the solid screw group. There were no significant differences between the 2 groups (p = 0.334 for VAS, p = 0.567 for ODI). 4
46. Wu JC, Huang WC, Tsai HW, et al. Pedicle screw loosening in dynamic stabilization: incidence, risk, and outcome in 126 patients. Neurosurgical Focus. 31(4):E9, 2011 Oct. Review/Other-Dx 126 patients To investigate the incidence, risk factors, and outcomes associated with screw loosening in a dynamic stabilization system. The authors analyzed 658 screws in 126 patients, including 54 women (42.9%) and 72 men (57.1%) (mean age 60.4 ± 11.8 years). During the mean clinical follow-up period of 37.0 ± 7.1 months, 31 screws (4.7%) in 25 patients (19.8%) were shown to have loosened. The mean age of patients with screw loosening was significantly higher than those without loosening (64.8 ± 8.8 vs 59.3 ± 12.2, respectively; p = 0.036). Patients with diabetes mellitus had a significantly higher rate of screw loosening compared with those without diabetes (36.0% vs 15.8%, respectively; p = 0.024). Diabetic patients with well-controlled serum glucose (HbA1c = 8.0%) had a significantly lower chance of screw loosening than those without well-controlled serum glucose (28.6% vs 71.4%, respectively; p = 0.021). Of the 25 patients with screw loosening, 22 cases (88%) were identified within 6.6 months of surgery; 18 patients (72%) had the loosened screws in the inferior portion of the spinal construct, whereas 7 (28%) had screw loosening in the superior portion of the construct. The overall clinical outcomes at 3, 12, and 24 months, measured by VAS for back pain, VAS for leg pain, and ODI scores, were significantly improved after surgery compared with before surgery (all p < 0.05). There were no significant differences between the patients with and without screw loosening at all evaluation time points (all p > 0.05). All 25 patients with screw loosening were asymptomatic, and in 6 (24%) osseous integration was demonstrated on later follow-up. Also, there were 3 broken screws (2.38% in 126 patients or 0.46% in 658 screws). To date, none of these loosened or broken screws have required revision surgery. 4
47. Darouiche RO. Spinal epidural abscess. N Engl J Med 2006;355:2012-20. Review/Other-Dx N/A To explain the diagnostic and therapeutic challenges and how to avoid spinal cord infarction. No results stated in the abstract. 4
48. Park CK, Lee HJ, Ryu KS. Comparison of Root Images between Post-Myelographic Computed Tomography and Magnetic Resonance Imaging in Patients with Lumbar Radiculopathy. J Korean Neurosurg Soc 2017;60:540-49. Observational-Dx 91 patients To evaluate the diagnostic value of computed tomography-myelography (CTM) compared to that of magnetic resonance imaging (MRI) in patients with lumbar radiculopathy. McNemar's test revealed that the two diagnostic modalities did not show diagnostic concurrence (p<0.0001). Electromyography results did not correlate with grades on either MRI or CTM. The visual analog pain scale score results were correlated better with changes of the grades on CTM than those on MRI (p=0.0007). 2
49. Splettstosser A, Khan MF, Zimmermann B, et al. Correlation of lumbar lateral recess stenosis in magnetic resonance imaging and clinical symptoms. World J Radiol 2017;9:223-29. Observational-Dx 927 Patients To assess the correlation of lateral recess stenosis (LRS) of lumbar segments L4/5 and L5/S1 and the Oswestry Disability Index (ODI) Approximately half of the LR revealed stenosis (grade 1-3; 52% at level L4/5 and 42% at level L5/S1) with 2.2% and 1.9% respectively reveal a nerve root compression. The ODI score ranged from 0%-91.11% with an arithmetic mean of 34.06% ± 16.89%. We observed a very weak statistically significant positive correlation between ODI and LRS at lumbar levels L4/5 and L5/S1, each bilaterally (L4/5 left: rho < 0.105, P < 0.01; L4/5 right: rho < 0.111, P < 0.01; L5/S1 left: rho 0.128, P < 0.01; L5/S1 right: rho < 0.157, P < 0.001). 2
50. Harada GK, Siyaji ZK, Younis S, Louie PK, Samartzis D, An HS. Imaging in Spine Surgery: Current Concepts and Future Directions. Spine Surg Relat Res 2020;4:99-110. Review/Other-Dx 97 articles To review and highlight the historical and recent advances of imaging in spine surgery and to discuss current applications and future directions. We reviewed 97 articles that discussed past, present, and future applications for imaging in spine surgery. Although most historical approaches relied heavily upon basic radiography, more recent advances have begun to expand upon advanced modalities, including the integration of more sophisticated equipment and artificial intelligence. 4
51. Damgaard M, Nimb L, Madsen JL. The role of bone SPECT/CT in the evaluation of lumbar spinal fusion with metallic fixation devices. Clin Nucl Med. 35(4):234-6, 2010 Apr. Observational-Dx 9 patients To discuss the role of bone SPECT/CT in the evaluation of lumbar spinal fusion with metallic fixation devices. In 6 of 9 patients, the SPECT/CT fully or partially detected the vertebral level of loose pedicle screws. Of 9 cases, 2 were considered inconclusive, whereas in 1 case loose pedicle screws were detected at a wrong vertebral level. 3
52. Peters MJM, Bastiaenen CHG, Brans BT, Weijers RE, Willems PC. The diagnostic accuracy of imaging modalities to detect pseudarthrosis after spinal fusion-a systematic review and meta-analysis of the literature. Skeletal Radiol. 48(10):1499-1510, 2019 Oct. Review/Other-Dx 15 studies To determine the diagnostic accuracy of imaging modalities to detect pseudarthrosis after thoracolumbar spinal fusion, with surgical exploration as reference standard. Fifteen studies were included. Risk of bias was classified as high/unclear in 58% of the studies. Concerns of applicability was classified as high/unclear in 40% of the studies. Four scintigraphy studies including 93 patients in total were pooled to OR?=?2.91 (95% confidence interval [CI]: 0.93-9.13). Five studies on plain radiography with 398 patients in total were pooled into OR?=?7.07 (95% CI: 2.97-16.86). Two studies evaluating flexion-extension radiography of 75 patients in total were pooled into OR?=?4.00 (95% CI: 0.15-105.96). Two studies of 68 patients in total were pooled for CT and yielded OR?=?17.02 (95% CI: 6.42-45.10). A single study reporting on polytomography, OR?=?10.15 (95% CI 5.49-18.78), was also considered to be an accurate study. 4
53. Rager O, Schaller K, Payer M, Tchernin D, Ratib O, Tessitore E. SPECT/CT in differentiation of pseudarthrosis from other causes of back pain in lumbar spinal fusion: report on 10 consecutive cases. Clinical Nuclear Medicine. 37(4):339-43, 2012 Apr. Review/Other-Dx 10 patients To compare the findings of SPECT fused with CT (SPECT/CT) with those of CT alone for the diagnosis of pseudarthrosis. All patients showing screw loosening on CT alone showed also an abnormal uptake on SPECT/CT. SPECT/CT did not show abnormal uptake in 3 of 5 patients who had nonunion through/around the cages on CT alone. SPECT/CT was able to show increased uptake in 6 cases in which CT alone did not show facet joint degeneration. 4
54. Sumer J, Schmidt D, Ritt P, et al. SPECT/CT in patients with lower back pain after lumbar fusion surgery. Nuclear Medicine Communications. 34(10):964-70, 2013 Oct. Review/Other-Dx 37 patients To investigate the incremental diagnostic value of skeletal hybrid imaging with single-photon emission computed tomography and X-ray computed tomography (SPECT/CT) over conventional nuclear medical imaging in patients with lower back pain after lumbar fusion surgery (LFS). In the case of eight patients no lesions were visible on their planar scintigraphy and SPECT (planar/SPECT) or SPECT/CT images. In the remaining 29 patients, planar/SPECT disclosed 62 pathological foci of uptake within the graft region and SPECT/CT revealed 55. The rate of reclassification by SPECT/CT compared with planar/SPECT was 5/12 for lesions categorized as metal loosening by planar/SPECT, 16/29 for foci with a planar/SPECT diagnosis of insufficient stabilizing function, 7/20 when the planar/SPECT diagnosis had been adjacent instability, and 1/1 for the lesions indeterminate on planar/SPECT. Two lesions had been detected on SPECT/CT only. The overall rate of reclassification was 45.2% (28/62) (95% confidence interval, 33.4-57.5%). 4
55. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137(7):586-597. Review/Other-Dx N/A Summary review (1966-2001) of articles relevant to accuracy of clinical and radiographic examination of LBP patients. Sensitivity for cancer was highest for MRI (0.83 to 0.93) and radionuclide scanning (0.74 to 0.98); specificity was highest for MRI (0.9 to 0.97) and radiography (0.95 to 0.99). MRI was the most sensitive (0.96) and specific (0.92) test for infection. The sensitivity and specificity of MRI for herniated discs were slightly higher than those for CT but very similar for the diagnosis of spinal stenosis. Support for 1994 Agency for Health Care Policy and Research guidelines: symptomatic therapy without imaging for adults <50years old without evidence of systemic disease; plain radiography and lab tests can reliably rule out systemic disease; and reserve advanced imaging for surgical candidates or strong suspicion of systemic disease. 4
56. Beckmann NM, West OC, Nunez D, Jr., et al. ACR Appropriateness Criteria® Suspected Spine Trauma. J Am Coll Radiol 2019;16:S264-S85. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for suspected spine trauma. No results stated in abstract. 4
57. Shah LM, Jennings JW, Kirsch CFE, et al. ACR Appropriateness Criteria R Management of Vertebral Compression Fractures. Journal of the American College of Radiology. 15(11S):S347-S364, 2018 Nov. Review/Other-Dx Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for management of vertebral compression fractures. No results stated in abstract. 4
58. Jung HS, Jee WH, McCauley TR, Ha KY, Choi KH. Discrimination of metastatic from acute osteoporotic compression spinal fractures with MR imaging. Radiographics. 2003; 23(1):179-187. Observational-Dx 27 patients with metastatic compression fractures and 55 patients with acute osteoporotic compression fractures To determine which MRI findings are useful in discrimination between metastatic compression fractures and acute osteoporotic compression fractures of the spine. MRI findings suggestive of metastatic compression fractures were as follows: a convex posterior border of the vertebral body, abnormal signal intensity of the pedicle or posterior element, an epidural mass, an encasing epidural mass, a focal paraspinal mass, and other spinal metastases. MRI findings suggestive of acute osteoporotic compression fractures were as follows: a low-signal-intensity band on T1- and T2-weighted images spared normal bone marrow signal intensity of the vertebral body, retropulsion of a posterior bone fragment, and multiple compression fractures. The signal intensity on fast spin-echo T2-weighted images obtained without fat suppression played little role in distinguishing between metastatic compression fractures and acute osteoporotic compression fractures. 2
59. Karam M, Lavelle WF, Cheney R. The role of bone scintigraphy in treatment planning, and predicting pain relief after kyphoplasty. Nuclear Medicine Communications. 29(3):247-53, 2008 Mar. Observational-Dx 60 patients To determine the accuracy of bone scanning in patient selection, planning treatment and predicting response to kyphoplasty. Sixty-six procedures on 60 patients fulfilled the selection criteria. Fifty-three patients were managed by X-ray and bone scanning (A) and seven were managed byX-ray only (B). There was a significant difference in the rates of sub-optimal results between (A) and (B) (11/53 vs. 7/7, P = 0.0001). There was also a significant difference in chronic fracture rates between patients with excellent outcome and those with sub-optimal results (3/42 vs. 7/11, P= 0.0002). A high rate of incorrect level selection (3/7) was found in (B). In 12 patients (20%) X-ray showed multiple fractures but the bone scanning demonstrated only one level of acute disease. 2
60. Cho WI, Chang UK. Comparison of MR imaging and FDG-PET/CT in the differential diagnosis of benign and malignant vertebral compression fractures. J Neurosurg Spine. 14(2):177-83, 2011 Feb. Observational-Dx 96 patients To investigate the findings of MR imaging and FDG-PET/CT for the differentiation of ertebral compression fractures (VCFs). Posterior cortical bulging was seen in 26 (74%) of 35 malignant lesions and 30 (45%) of 67 benign ones, epidural mass formation in 27 (77%) of the malignant lesions and 25% of the benign ones, and pedicle enhancement in 30 (91%) of the 33 malignant lesions and 18 (39%) of the 46 benign ones evaluated with Gd-enhanced MR imaging. These differences were statistically significant for each feature. Sensitivity and specificity for predicting malignancy were, respectively, 74% and 55% for posterior cortical bulging, 77% and 74% for epidural mass formation, and 90% and 61% for pedicle enhancement. Simultaneous occurrence of 3 significant features was found in 21 (64%) of the 33 malignant and 8 (17%) of the 46 benign lesions for which complete MR imaging data were available and showed sensitivity of 64% and specificity of 83%. The presence of radiotracer uptake on FDG-PET/CT was seen in all 20 (100%) of the 20 malignant lesions and 12 (71%) 17 of the benign lesions evaluated by FDG-PET/CT and showed a sensitivity of 100% and specificity of 29%. There was a significant difference in mean (± SD) SUV(max) for the malignant (6.29 ± 3.50) and benign (2.38 ± 1.90) lesions (p < 0.001). The most reliable threshold for SUV(max) was found to be 4.25, which yielded a sensitivity of 85% and a specificity of 71%. 2
61. Henschke N, Maher CG, Ostelo RW, de Vet HC, Macaskill P, Irwig L. Red flags to screen for malignancy in patients with low-back pain. Cochrane Database Syst Rev. 2013;2:CD008686. Review/Other-Dx 8 cohort studies To assess the diagnostic performance of clinical characteristics identified by taking a clinical history and conducting a physical examination ("red flags") to screen for spinal malignancy in patients presenting with LBP. The authors included eight cohort studies of which six were performed in primary care (total number of patients; n = 6622), one study was from an accident and emergency setting (n = 482), and one study was from a secondary care setting (n = 257). In the six primary care studies, the prevalence of spinal malignancy ranged from 0% to 0.66%. Overall, data from 20 index tests were extracted and presented, however only seven of these were evaluated by more than one study. Because of the limited number of studies and clinical heterogeneity, statistical pooling of diagnostic accuracy data was not performed.There was some evidence from individual studies that having a previous history of cancer meaningfully increases the probability of malignancy. Most "red flags" such as insidious onset, age > 50, and failure to improve after one month have high false positive rates.All of the tests were evaluated in isolation and no study presented data on a combination of positive tests to identify spinal malignancy. The authors conclude that for most "red flags," there is insufficient evidence to provide recommendations regarding their diagnostic accuracy or usefulness for detecting spinal malignancy. The available evidence indicates that in patients with LBP, an indication of spinal malignancy should not be based on the results of one single "red flag" question. 4
62. Shah LM, Salzman KL. Imaging of spinal metastatic disease. International Journal of Surgical Oncology Print. 2011:769753, 2011. Review/Other-Dx N/A To discuss the review of the imaging techniques and typical imaging appearances of spinal metastatic disease. Awareness of the different manifestations of spinal metastatic disease is essential as the spine is the most common site of osseous metastatic disease. Imaging modalities have complimentary roles in the evaluation of spinal metastatic disease. CT best delineates osseous integrity, while MRI is better at assessing soft tissue involvement. Physiologic properties, particularly in treated disease, can be evaluated with other imaging modalities such as FDG PET and advanced MRI sequences. Imaging plays a fundamental role in not only diagnosis but also treatment planning of spinal metastatic disease. 4
63. Algra PR, Bloem JL, Tissing H, Falke TH, Arndt JW, Verboom LJ. Detection of vertebral metastases: comparison between MR imaging and bone scintigraphy. Radiographics. 11(2):219-32, 1991 Mar. Observational-Dx 71 patients; 4 independent observers Prospective, double blinded study to compare the sensitivity of bone scintigraphy and MRI in detection of vertebral metastases. Bone scintigraphy permitted identification of 499 abnormal vertebrae and MRI, 818 abnormal vertebrae. MRI depicted additional abnormal vertebrae in 49 patients. MRI is more sensitive than bone scintigraphy, in detection of vertebral metastases. 1
64. Edelstyn GA, Gillespie PJ, Grebbell FS. The radiological demonstration of osseous metastases. Experimental observations. Clinical Radiology. 18(2):158-62, 1967 Apr. Review/Other-Dx N/A To examine the efficiency of conventional radiological methods in detecting osseous destruction. Using human lumbar vertebrae, detection of a defect on lateral x-ray was only possible when between 50 9/00 and 75 ~ of the cancellous bone thickness had been removed, whilst on A.P. view a greater deficit was necessary. 4
65. Bredella MA, Essary B, Torriani M, Ouellette HA, Palmer WE. Use of FDG-PET in differentiating benign from malignant compression fractures. Skeletal Radiology. 37(5):405-13, 2008 May. Observational-Dx 33 patients with 43 compression fractures To evaluate the use of FDG-PET in differentiating benign from malignant compression fractures. There were 14 malignant and 29 benign compression fractures, including 5 acute benign fractures. On FDG-PET, 5 benign fractures were falsely classified as malignant (false-positive). Three of these patients underwent prior treatment with bone marrow-stimulating agents. There were two false-negative results. Sensitivity, specificity, PPV, NPV, and accuracy of FDG-PET in differentiating benign from malignant compression fractures were 86%, 83%, 84%, 71%, and 92% respectively. The difference between SUV values of benign and malignant fractures was statistically significant (1.9 +/- 0.97 for benign and 3.9 +/- 1.52 for malignant fractures, P<0.001). SUV of benign acute and chronic fractures were not statistically significant. 3
66. He X, Zhao L, Guo X, et al. Differential diagnostic value of (18)F-FDG PET/CT for benign and malignant vertebral compression fractures: comparison with magnetic resonance imaging. Cancer Manag Res 2018;10:2105-15. Observational-Dx 87 patients To evaluate the differential diagnostic value of 2-[fluorine-18]-fluoro-2-deoxy-d-glucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT) for benign and malignant vertebral compression fractures (VCFs), where the diagnostic accuracy of 18F-FDG PET/CT was compared with magnetic resonance imaging (MRI). The results of our investigation showed that the sensitivity and specificity for predicting malignant VCFs were 75.6% and 77.3% for convex posterior cortex, 82.9% and 813% for epidural mass formation, and 85.7% and 70.8% for pedicle enhancement. 18F-FDG PET/CT demonstrated higher sensitivity (100%) but lower specificity (38.9%) as compared to MRI with regard to differentiation between benign and malignant VCFs. A significant difference in the SUVmax values was observed between the benign and malignant fractures (2.9 ± 1.0 vs 5.0 ± 1.8, P < 0.01). Besides the value of SUVmax, it has been noticed that the FDG uptake pattern differed in malignant and benign fractures. 2
67. Hong SH, Choi JY, Lee JW, Kim NR, Choi JA, Kang HS. MR imaging assessment of the spine: infection or an imitation?. [Review] [42 refs]. Radiographics. 29(2):599-612, 2009 Mar-Apr. Review/Other-Dx N/A To discuss the MR imaging assessment of the spine. No results stated in the abstract. 4
68. Jarvik JG. Imaging of adults with low back pain in the primary care setting. Neuroimaging Clin N Am. 2003;13(2):293-305. Review/Other-Dx N/A Review imaging modalities used in adults with LBP in the primary care setting. MRI is likely in most cases to offer the greatest sensitivity and specificity for systemic diseases, and its performance is superior to that of radiographs and comparable with CT and radionuclide bone scans for most conditions causing neurologic compromise. 4
69. Evans AJ, Robertson JF. Magnetic resonance imaging versus radionuclide scintigraphy for screening in bone metastases. Clin Radiol 2000;55:653; author reply 53-4. Review/Other-Dx N/A To discuss Magnetic resonance imaging versus radionuclide scintigraphy for screening in bone metastases No results stated in the abstract. 4
70. Schmidt GP, Schoenberg SO, Schmid R, et al. Screening for bone metastases: whole-body MRI using a 32-channel system versus dual-modality PET-CT. Eur Radiol. 17(4):939-49, 2007 Apr. Observational-Dx 30 patients Prospective, blinded study to evaluate the diagnostic accuracy of WB-MRI compared with combined FDG-PET/CT for screening for bone metastases. Sensitivity: WB-MRI 94%, PET/CT 78%. Specificity: WB-MRI 76%, PET/CT 80% Diagnostic accuracy: WB-MRI 91%, PET/CT 78%. WB-MRI revealed 10 additional bone metastases due to the larger field of view. 2
71. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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