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Guideline Summary
Guideline Title
ACR Appropriateness Criteria® low back pain.
Bibliographic Source(s)
Davis PC, Wippold FJ II, Cornelius RS, Angtuaco EJ, Broderick DF, Brown DC, Garvin CF, Hartl R, Holly L, McConnell CT Jr, Mechtler LL, Rosenow JM, Seidenwurm DJ, Smirniotopoulos JG, Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® low back pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2011. 8 p. [48 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Davis PC, Wippold FJ II, Brunberg JA, Cornelius RS, De La Paz RL, Dormont D, Gray L, Jordan JE, Mukherji SK, Seidenwurm DJ, Turski PA, Zimmerman RD, Sloan MA, Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® low back pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 7 p.

The appropriateness criteria are reviewed biennially and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

Scope

Disease/Condition(s)

Low back pain with or without radiculopathy

Guideline Category
Diagnosis
Evaluation
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Neurology
Nuclear Medicine
Oncology
Radiology
Intended Users
Health Plans
Hospitals
Managed Care Organizations
Physicians
Utilization Management
Guideline Objective(s)

To evaluate the appropriateness of initial radiologic examinations for patients with low back pain with or without radiculopathy

Target Population

Patients with low back pain with or without radiculopathy

Interventions and Practices Considered
  1. Magnetic resonance imaging (MRI) lumbar spine
    • Without contrast
    • Without and with contrast
  2. Computed tomography (CT) lumbar spine
    • With contrast
    • Without contrast
    • Without and with contrast
  3. X-ray
    • Lumbar spine
    • Myelography lumbar spine
    • Discography lumbar spine
    • X-ray discography and post-discography CT lumbar spine
  4. Myelography and postmyelography CT lumbar spine
  5. Tc-99m bone scan
    • With single photon emission computed tomography (SPECT) spine
    • Whole body with SPECT spine
Major Outcomes Considered

Utility of radiologic examinations in differential diagnosis

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Literature Search Procedure

The Medline literature search is based on keywords provided by the topic author. The two general classes of keywords are those related to the condition (e.g., ankle pain, fever) and those that describe the diagnostic or therapeutic intervention of interest (e.g., mammography, MRI).

The search terms and parameters are manipulated to produce the most relevant, current evidence to address the American College of Radiology Appropriateness Criteria (ACR AC) topic being reviewed or developed. Combining the clinical conditions and diagnostic modalities or therapeutic procedures narrows the search to be relevant to the topic. Exploding the term "diagnostic imaging" captures relevant results for diagnostic topics.

The following criteria/limits are used in the searches.

  1. Articles that have abstracts available and are concerned with humans.
  2. Restrict the search to the year prior to the last topic update or in some cases the author of the topic may specify which year range to use in the search. For new topics, the year range is restricted to the last 5 years unless the topic author provides other instructions.
  3. May restrict the search to Adults only or Pediatrics only.
  4. Articles consisting of only summaries or case reports are often excluded from final results.

The search strategy may be revised to improve the output as needed.

Number of Source Documents

The total number of source documents identified as the result of the literature search is not known.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Strength of Evidence Key

Category 1 - The conclusions of the study are valid and strongly supported by study design, analysis and results.

Category 2 - The conclusions of the study are likely valid, but study design does not permit certainty.

Category 3 - The conclusions of the study may be valid but the evidence supporting the conclusions is inconclusive or equivocal.

Category 4 - The conclusions of the study may not be valid because the evidence may not be reliable given the study design or analysis.

Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

The topic author drafts or revises the narrative text summarizing the evidence found in the literature. American College of Radiology (ACR) staff draft an evidence table based on the analysis of the selected literature. These tables rate the strength of the evidence for all articles included in the narrative text.

The expert panel reviews the narrative text, evidence table, and the supporting literature for each of the topic-variant combinations and assigns an appropriateness rating for each procedure listed in the table. Each individual panel member forms his/her own opinion based on his/her interpretation of the available evidence.

More information about the evidence table development process can be found in the ACR Appropriateness Criteria® Evidence Table Development document (see the "Availability of Companion Documents" field).

Methods Used to Formulate the Recommendations
Expert Consensus (Delphi)
Description of Methods Used to Formulate the Recommendations

Modified Delphi Technique

The appropriateness ratings for each of the procedures included in the Appropriateness Criteria topics are determined using a modified Delphi methodology. A series of surveys are conducted to elicit each panelist's expert interpretation of the evidence, based on the available data, regarding the appropriateness of an imaging or therapeutic procedure for a specific clinical scenario. American College of Radiology (ACR) staff distributes surveys to the panelists along with the evidence table and narrative. Each panelist interprets the available evidence and rates each procedure. The surveys are completed by panelists without consulting other panelists. The ratings are a scale between 1 and 9, which is further divided into three categories: 1, 2, or 3 is defined as "usually not appropriate"; 4, 5, or 6 is defined as "may be appropriate"; and 7, 8, or 9 is defined as "usually appropriate." Each panel member assigns one rating for each procedure per survey round. The surveys are collected and the results are tabulated, de-identified and redistributed after each round. A maximum of three rounds are conducted. The modified Delphi technique enables each panelist to express individual interpretations of the evidence and his or her expert opinion without excessive bias from fellow panelists in a simple, standardized and economical process.

Consensus among the panel members must be achieved to determine the final rating for each procedure. Consensus is defined as eighty percent (80%) agreement within a rating category. The final rating is determined by the median of all the ratings once consensus has been reached. Up to three rating rounds are conducted to achieve consensus.

If consensus is not reached, the panel is convened by conference call. The strengths and weaknesses of each imaging procedure that has not reached consensus are discussed and a final rating is proposed. If the panelists on the call agree, the rating is accepted as the panel's consensus. The document is circulated to all the panelists to make the final determination. If consensus cannot be reached on the call or when the document is circulated, "No consensus" appears in the rating column and the reasons for this decision are added to the comment sections.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

Criteria developed by the Expert Panels are reviewed by the American College of Radiology (ACR) Committee on Appropriateness Criteria.

Recommendations

Major Recommendations

ACR Appropriateness Criteria®

Clinical Condition: Low Back Pain

Variant 1: Uncomplicated acute low back pain and/or radiculopathy, nonsurgical presentation. No red flags. (Red flags defined in the text below.)

Radiologic Procedure Rating Comments RRL*
MRI lumbar spine without contrast 2   O
X-ray lumbar spine 2   radioactive radioactive radioactive
Myelography and postmyelography CT lumbar spine 2 In some cases postinjection CT imaging may be done without plain-film myelography. radioactive radioactive radioactive radioactive
X-ray myelography lumbar spine 2   radioactive radioactive radioactive
Tc-99m bone scan with SPECT spine 2   radioactive radioactive radioactive
CT lumbar spine without contrast 2   radioactive radioactive radioactive
CT lumbar spine with contrast 2   radioactive radioactive radioactive
MRI lumbar spine without and with contrast 2   O
CT lumbar spine without and with contrast 1   radioactive radioactive radioactive radioactive
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 2: Patient with one or more of the following: low velocity trauma, osteoporosis, focal and/or progressive deficit, prolonged symptom duration, age >70 years.

Radiologic Procedure Rating Comments RRL*
MRI lumbar spine without contrast 8   O
CT lumbar spine without contrast 6 MRI preferred. CT useful if MRI is contraindicated or unavailable, and/or for problem solving. radioactive radioactive radioactive
X-ray lumbar spine 6   radioactive radioactive radioactive
Tc-99m bone scan with SPECT spine 4 SPECT/CT may be useful for anatomic localization and problem solving. radioactive radioactive radioactive
MRI lumbar spine without and with contrast 3   O
CT lumbar spine with contrast 3   radioactive radioactive radioactive
CT lumbar spine without and with contrast 1   radioactive radioactive radioactive radioactive
Myelography and postmyelography CT lumbar spine 1 In some cases postinjection CT imaging may be done without plain-film myelography. radioactive radioactive radioactive radioactive
X-ray myelography lumbar spine 1   radioactive radioactive radioactive
X-ray discography lumbar spine 1   radioactive radioactive
X-ray discography and post-discography CT lumbar spine 1   radioactive radioactive radioactive
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 3: Patient with one or more of the following: suspicion of cancer, infection, and/or immunosuppression.

Radiologic Procedure Rating Comments RRL*
MRI lumbar spine without and with contrast 8 Contrast useful for neoplasia subjects suspected of epidural or intraspinal disease. See statement regarding contrast in text under "Anticipated Exceptions." O
MRI lumbar spine without contrast 7 Noncontrast MRI may be sufficient if there is low risk of epidural and/or intraspinal disease. O
CT lumbar spine with contrast 6 MRI preferred. CT useful if MRI is contraindicated or unavailable, and/or for problem solving. radioactive radioactive radioactive
CT lumbar spine without contrast 6 MRI preferred. CT useful if MRI is contraindicated or unavailable, and/or for problem solving. radioactive radioactive radioactive
X-ray lumbar spine 5   radioactive radioactive radioactive
Tc-99m bone scan whole body with SPECT spine 5 SPECT/CT may be useful for anatomic localization and problem solving. radioactive radioactive radioactive
CT lumbar spine without and with contrast 3   radioactive radioactive radioactive radioactive
X-ray myelography lumbar spine 2   radioactive radioactive radioactive
Myelography and postmyelography CT lumbar spine 2 In some cases postinjection CT imaging may be done without plain-film myelography. radioactive radioactive radioactive radioactive
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 4: Low back pain and/or radiculopathy. Surgery or intervention candidate.

Radiologic Procedure Rating Comments RRL*
MRI lumbar spine without contrast 8   O
CT lumbar spine with contrast 5 MRI preferred. CT useful if MRI is contraindicated or unavailable, and/or for problem solving. radioactive radioactive radioactive
CT lumbar spine without contrast 5 MRI preferred. CT useful if MRI contraindicated or unavailable, and/or for problem solving. radioactive radioactive radioactive
MRI lumbar spine without and with contrast 5 Indicated if noncontrast MRI is nondiagnostic or indeterminate. See statement regarding contrast in text under "Anticipated Exceptions." O
Myelography and postmyelography CT lumbar spine 5 MRI preferred. May be indicated if MRI is contraindicated or nondiagnostic. In some cases postinjection CT imaging may be done without plain-film myelography. radioactive radioactive radioactive radioactive
X-ray discography and post-discography CT lumbar spine 5   radioactive radioactive radioactive
X-ray lumbar spine 4 Usually not sufficient for decision making without MR and/or CT imaging. radioactive radioactive radioactive
Tc-99m bone scan with SPECT spine 4 May be particularly useful for facet arthropathy, stress fracture, and spondylolysis. SPECT/CT may be useful for anatomic localization and problem solving. radioactive radioactive radioactive
X-ray discography lumbar spine 4   radioactive radioactive
CT lumbar spine without and with contrast 3   radioactive radioactive radioactive radioactive
X-ray myelography lumbar spine 2   radioactive radioactive radioactive
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 5: Prior lumbar surgery.

Radiologic Procedure Rating Comments RRL*
MRI lumbar spine without and with contrast 8 Can differentiate disc from scar. See statement regarding contrast in text under "Anticipated Exceptions." O
CT lumbar spine with contrast 6 Most useful in postfusion patients or when MRI is contraindicated or indeterminate. radioactive radioactive radioactive
CT lumbar spine without contrast 6 Most useful in postfusion patients or when MRI is contraindicated or indeterminate. radioactive radioactive radioactive
MRI lumbar spine without contrast 6 Contrast often necessary. O
Myelography and postmyelography CT lumbar spine 5 In some cases postinjection CT imaging may be done without plain-film myelography. radioactive radioactive radioactive radioactive
X-ray lumbar spine 5 Flex/extension may be useful. radioactive radioactive radioactive
Tc-99m bone scan with SPECT spine 5 Helps detect and localize painful pseudoarthrosis. SPECT/CT may be useful for anatomic localization and problem solving. radioactive radioactive radioactive
X-ray discography and post-discography CT lumbar spine 5   radioactive radioactive radioactive
X-ray discography lumbar spine 4   radioactive radioactive
CT lumbar spine without and with contrast 3   radioactive radioactive radioactive radioactive
X-ray myelography lumbar spine 2   radioactive radioactive radioactive
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Variant 6: Cauda equina syndrome, multifocal deficits or progressive deficit.

Radiologic Procedure Rating Comments RRL*
MRI lumbar spine without contrast 9 Use of contrast depends on clinical circumstances. O
MRI lumbar spine without and with contrast 8 Use of contrast depends on clinical circumstances. See statement regarding contrast in text under "Anticipated Exceptions." O
Myelography and postmyelography CT lumbar spine 6 Useful if MRI is nondiagnostic or contraindicated. In some cases postinjection CT imaging may be done without plain-film myelography. radioactive radioactive radioactive radioactive
CT lumbar spine with contrast 5   radioactive radioactive radioactive
CT lumbar spine without contrast 5   radioactive radioactive radioactive
X-ray lumbar spine 4   radioactive radioactive radioactive
CT lumbar spine without and with contrast 3   radioactive radioactive radioactive radioactive
Tc-99m bone scan with SPECT spine 2   radioactive radioactive radioactive
X-ray myelography lumbar spine 2   radioactive radioactive radioactive
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.

Summary of Literature Review

Acute low back pain (LBP) with or without radiculopathy is one of the most common health problems in the United States and is the leading cause of disability for persons younger than age 45. The cost of evaluating and treating acute LBP runs into billions of dollars annually, not including time lost from work.

Because of the high prevalence and high cost of dealing with this problem, government agencies and other groups have sponsored extensive studies that are now part of the growing body of literature on this subject. It is now clear that uncomplicated acute LBP or radiculopathy is a benign, self-limited condition that does not warrant any imaging studies. Guidelines from the American College of Physicians (ACP) and the American Pain Society (APS) emphasize a focused history and physical examination, reassurance, initial pain management medications if necessary (acetaminophen or nonsteroidal anti-inflammatory drugs), and consideration of physical therapies without routine imaging in patients with nonspecific LBP. Imaging is considered for those without improvement after 6 weeks and for those with red flags as listed below, generally in categories of cauda equina syndrome, cancer, fracture, progressive or severe neurologic deficit(s), ankylosing spondylitis, symptomatic spinal stenosis, and/or infection. Adding to this controversy is the fact that nonspecific lumbar disc abnormalities are common in asymptomatic patients and can be demonstrated readily on myelography, computed tomography (CT), and magnetic resonance imaging (MRI).

The challenge for the clinician, therefore, is to distinguish that small segment within this large patient population that should be evaluated further because of suspicion of a more serious problem.

Indications of a more complicated status include back pain/radiculopathy in the following settings:

  1. Trauma, cumulative trauma
  2. Unexplained weight loss, insidious onset
  3. Age >50 years, especially women, and males with osteoporosis or compression fracture
  4. Unexplained fever, history of urinary or other infection
  5. Immunosuppression, diabetes mellitus
  6. History of cancer
  7. Intravenous (IV) drug use
  8. Prolonged use of corticosteroids, osteoporosis
  9. Age >70
  10. Focal neurologic deficit(s) with progressive or disabling symptoms, cauda equina syndrome
  11. Duration longer than 6 weeks
  12. Prior surgery

Radiographs

Radiographs may be useful in any of the categories above. Lumbar radiographs may be sufficient for the initial evaluation of the following red flags, with further imaging indicated for treatment planning if findings are abnormal or inconclusive:

  • Recent significant trauma (at any age)
  • Osteoporosis
  • Age >70 years

The initial evaluation of the LBP patient may also require further imaging if other red flags such as suspicion of cancer or infection are present. Radiographs have a role in evaluation of alignment, instability, and scoliosis, and in postoperative evaluation of instrumentation and fusion.

Magnetic Resonance Imaging

LBP complicated by the red flags listed above may justify early use of CT or MRI even if radiographs are negative. The most common indication for the use of these imaging procedures, however, is the clinical setting of LBP complicated by radiating pain (radiculopathy, sciatica), as well as in cauda equina syndrome (bilateral leg weakness, urinary retention, saddle anesthesia), neurogenic claudication, spinal stenosis, and/or risk factors as above. MRI of the lumbar spine has become the initial imaging modality of choice in complicated LBP, displacing myelography and CT in recent years. Multidisciplinary agreement on terminology facilitates reporting of MRI findings, although interrater reliability of reporting using lumbar disc terminology has achieved only modest agreement.

Although disc abnormalities are common on MRI in asymptomatic persons, acute back pain with radiculopathy suggests the presence of demonstrable nerve root compression on MRI. MRI findings of Modic endplate change, especially type 1, anterolisthesis, or disc extrusion are more strongly associated with LBP than disc degeneration without endplate change. MRI is efficacious for detecting red flag diagnoses, particularly using the short-tau inversion recovery (STIR) and fat-saturated T2 fast-spin-echo sequences as well as for evaluating facet arthropathy and edema. MRI with contrast is useful for suspected infection and neoplasia. In postoperative patients, enhanced MRI allows distinction between disc and scar when tissue extends beyond the interspace.

Computed Tomography

CT scans provide superior bone detail but are not as useful in depicting extradural soft-tissue pathologies such as disc disease when compared with multiplanar MRI. Intradural and cord pathologies are poorly depicted on CT. CT with multiplanar reformatted sagittal and coronal planes is useful for depicting bone structural problems such as spondylolysis, pseudoarthrosis, fracture, scoliosis, and stenosis and for postsurgical evaluation of bone graft integrity, surgical fusion, and instrumentation.

Myelography, Myelography/CT

"Plain" myelography was the mainstay of lumbar herniated disc diagnosis for decades. It is now usually combined with postmyelography CT. The combined study is complementary to plain CT or MRI and occasionally more accurate in diagnosing disc herniation, but it suffers the disadvantage of requiring lumbar puncture and contrast injection. It may also be useful in surgical planning. Weight-bearing and flexion extension views are also possible on myelography.

Discography, CT Discography

Discography may have a role in localizing the source of back pain that is indeterminate with other less invasive studies as well as in patients with multifocal abnormalities on MRI. Although radiographs, MRI, and postinjection CT images may depict nonspecific aging or degenerative changes, the injection itself may reproduce or provoke the patient's pain, which may have diagnostic value. Limitations include the necessity of disc space injections, variability of patient response, and limited specificity. A recent correlative MRI and discography study found type 1 Modic signal intensity changes on MRI to have a high positive predictive value in identification of a pain generator at discography, while other studies have found a less consistent role for MRI in prediction of discography findings.

Isotope Bone Scan

The role of the isotope bone scan in patients with acute LBP has changed in recent years with the wide availability of MRI and especially contrast-enhanced MRI. The bone scan is a moderately sensitive test for detecting the presence of tumor, infection, or occult fractures of the vertebrae but not for specifying the diagnosis. For spondylolysis or stress fracture in athletes, bone scintigraphy with single photon emission computed tomography (SPECT), followed by limited CT if scintigraphy is positive, is more sensitive than MRI. Bone scintigraphy with SPECT can be useful to identify symptomatic facet disease in patients treated with facet injection.

High-resolution isotope imaging, including SPECT, may localize the source of pain in patients with articular facet osteoarthritis prior to therapeutic facet injection. Similar scans may be helpful in detecting and localizing the site of painful pseudoarthrosis in patients following lumbar spinal fusion. SPECT/CT offers matched anatomic localization for SPECT abnormalities. Fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography/computed tomography (PET/CT) may prove useful for detecting lesions that appear photopenic with SPECT.

Plain and contrast-enhanced MRI has the ability to demonstrate inflammatory, neoplastic, and most traumatic lesions as well as show anatomic detail not available on isotope studies. Gadolinium-enhanced MRI reliably shows the presence and extent of spinal infection, and is useful in assessing therapy. MRI has therefore taken over the role of the isotope scan in many cases where the location of the lesion is known. The isotope scan remains invaluable when a survey of the entire skeleton is indicated (e.g., for metastatic disease).

Summary

  • Acute uncomplicated LBP without red flags is a benign, self-limited condition that does not require imaging evaluation.
  • MR has displaced CT and myelography as the initial imaging modality of choice in complicated LBP, with contrast useful for neoplasia, infection, and postoperative evaluation.
  • CT is useful in patients with surgical fusion/instrumentation or bone structural abnormalities, and in patients with MRI contraindications.
  • Myelography/CT, discography/CT, and radioisotope bone scans are useful in selected patients for problem solving.
  • Advanced imaging techniques such as SPECT/CT and PET/CT have value in selected patients but are not considered routine clinical practice at this time.
  • Also see the National Guideline Clearinghouse (NGC) summaries of the ACR Appropriateness Criteria® Myelopathy and ACR Appropriateness Criteria® Suspected Spine Trauma.

Anticipated Exceptions

Nephrogenic systemic fibrosis (NSF) is a disorder with a scleroderma-like presentation and a spectrum of manifestations that can range from limited clinical sequelae to fatality. It appears to be related to both underlying severe renal dysfunction and the administration of gadolinium-based contrast agents. It has occurred primarily in patients on dialysis, rarely in patients with very limited glomerular filtration rate (GFR) (i.e., <30 mL/min/1.73 m2), and almost never in other patients. There is growing literature regarding NSF. Although some controversy and lack of clarity remain, there is a consensus that it is advisable to avoid all gadolinium-based contrast agents in dialysis-dependent patients unless the possible benefits clearly outweigh the risk, and to limit the type and amount in patients with estimated GFR rates <30 mL/min/1.73 m2. For more information, please see the American College of Radiology (ACR) Manual on Contrast Media (see the "Availability of Companion Documents" field).

Abbreviations

  • CT, computed tomography
  • MRI, magnetic resonance imaging
  • SPECT, single photon emission computed tomography
  • Tc, technetium

Relative Radiation Level Designations

Relative Radiation Level* Adult Effective Dose Estimate Range Pediatric Effective Dose Estimate Range
O 0 mSv 0 mSv
radioactive <0.1 mSv <0.03 mSv
radioactive radioactive 0.1-1 mSv 0.03-0.3 mSv
radioactive radioactive radioactive 1-10 mSv 0.3-3 mSv
radioactive radioactive radioactive radioactive 10-30 mSv 3-10 mSv
radioactive radioactive radioactive radioactive radioactive 30-100 mSv 10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as NS (not specified).
Clinical Algorithm(s)

Algorithms were not developed from criteria guidelines.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The recommendations are based on analysis of the current literature and expert panel consensus.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Selection of appropriate radiologic imaging procedures for evaluation of patients with low back pain with or without radiculopathy

Potential Harms

Gadolinium-based Contrast Agents

Nephrogenic systemic fibrosis (NSF) is a disorder with a scleroderma-like presentation and a spectrum of manifestations that can range from limited clinical sequelae to fatality. It appears to be related to both underlying severe renal dysfunction and the administration of gadolinium-based contrast agents. It has occurred primarily in patients on dialysis, rarely in patients with very limited glomerular filtration rate (GFR) (i.e., <30 mL/min/1.73 m2), and almost never in other patients. Although some controversy and lack of clarity remain, there is a consensus that it is advisable to avoid all gadolinium-based contrast agents in dialysis-dependent patients unless the possible benefits clearly outweigh the risk, and to limit the type and amount in patients with estimated GFR rates <30 mL/min/1.73 m2. For more information, please see the American College of Radiology (ACR) Manual on Contrast Media (see the "Availability of Companion Documents" field).

Relative Radiation Level (RRL)

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, both because of organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared to those specified for adults. Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document (see the "Availability of Companion Documents" field).

Qualifying Statements

Qualifying Statements

An American College of Radiology (ACR) Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient's clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those exams generally used for evaluation of the patient's condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the U.S. Food and Drug Administration (FDA) have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Davis PC, Wippold FJ II, Cornelius RS, Angtuaco EJ, Broderick DF, Brown DC, Garvin CF, Hartl R, Holly L, McConnell CT Jr, Mechtler LL, Rosenow JM, Seidenwurm DJ, Smirniotopoulos JG, Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® low back pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2011. 8 p. [48 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
1996 (revised 2011)
Guideline Developer(s)
American College of Radiology - Medical Specialty Society
Source(s) of Funding

The American College of Radiology (ACR) provided the funding and the resources for these ACR Appropriateness Criteria®.

Guideline Committee

Committee on Appropriateness Criteria, Expert Panel on Neurologic Imaging

Composition of Group That Authored the Guideline

Panel Members: Patricia C. Davis, MD (Principal Author); Franz J. Wippold II, MD (Panel Chair); Rebecca S. Cornelius, MD (Panel Vice-chair); Edgardo J. Angtuaco, MD; Daniel F. Broderick, MD; Douglas C. Brown, MD; Charles F. Garvin, MD; Roger Hartl, MD; Langston Holly, MD; Charles T. McConnell Jr, MD; Laszlo L. Mechtler, MD; Joshua M. Rosenow, MD; David J. Seidenwurm, MD; James G. Smirniotopoulos, MD

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Davis PC, Wippold FJ II, Brunberg JA, Cornelius RS, De La Paz RL, Dormont D, Gray L, Jordan JE, Mukherji SK, Seidenwurm DJ, Turski PA, Zimmerman RD, Sloan MA, Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® low back pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 7 p.

The appropriateness criteria are reviewed biennially and updated by the panels as needed, depending on introduction of new and highly significant scientific evidence.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web site External Web Site Policy.

Print copies: Available from the American College of Radiology, 1891 Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

Availability of Companion Documents

The following are available:

  • ACR Appropriateness Criteria®. Overview. Reston (VA): American College of Radiology; 2 p. Electronic copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web site External Web Site Policy.
  • ACR Appropriateness Criteria®. Literature search process. Reston (VA): American College of Radiology; 1 p. Electronic copies: Available in Portable Document Format (PDF) from the ACR Web site External Web Site Policy.
  • ACR Appropriateness Criteria®. Evidence table development – diagnostic studies. Reston (VA): American College of Radiology; 2013 Nov. 3 p. Electronic copies: Available in PDF from the ACR Web site External Web Site Policy.
  • ACR Appropriateness Criteria®. Radiation dose assessment introduction. Reston (VA): American College of Radiology; 2 p. Electronic copies: Available in Portable Document Format (PDF) from the ACR Web site External Web Site Policy.
  • ACR Appropriateness Criteria® Manual on contrast media. Reston (VA): American College of Radiology; 90 p. Electronic copies: Available in PDF from the ACR Web site External Web Site Policy.
Patient Resources

None available

NGC Status

This summary was completed by ECRI on July 31, 2001. The information was verified by the guideline developer as of August 24, 2001. This summary was updated by ECRI on March 28, 2006. This summary was updated by ECRI Institute on May 17, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Gadolinium-based contrast agents. This summary was updated by ECRI Institute on June 20, 2007 following the U.S. Food and Drug Administration (FDA) advisory on gadolinium-based contrast agents. This summary was updated by ECRI Institute on July 1, 2009. This summary was updated by ECRI Institute on January 13, 2011 following the U.S. Food and Drug Administration (FDA) advisory on gadolinium-based contrast agents. This NGC summary was updated by ECRI Institute on February 28, 2012.

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