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1 Imaging Guidelines: Lumbar Spine MRI February 12 , 2010 Note: MRI is the preferred imaging modality for the following circumstances unless contraindicated or not tolerated by the patient (i.e., due to presence of ferrous metal in body, or severe anxiety) or unavailable. w back pain (onset within past 6 Acute lo I. weeks) : MRI without contrast unless specified otherwise weeks) low back pain with or without suspected radiculopathy (no *Not Appropriate: uncomplicated acute (< 6 , NUC Tc X - ray, CT, myelography or CT xylograph y not warrant the use of MRI, - 99m bone scan es red flags) do ecific lumbar disc abnormalities are commonly found in asymptomatic patients. (Chou, with SPECT. Nonsp (American College of Radiology 2008) Qaseem et al. 2007) Progressive (objective) neurological signs Progressive motor weakness present Suspect Cauda Equina syndrome (either of the following) rologic signs and symptoms Bilateral neu Acute bladder or bowel dysfunction *ACR appropriateness recommendation ranks MRI without contrast highest (rating = 9). MRI with and without contrast (rating = 8) depends on clinical circumstances. Other methods: Myelography an d - postmyelography CT (rating = 6), CT with and without contrast (rating = 5) may be indicated if MRI is confusing or contraindicated, x ray, NUC Tc - 99m bone scan with SPECT and x - ray myelography are - rated < 5. Infection (any of the following) : MRI with a nd without contrast Fever Suspicion of systemic or spinal infection Immunosuppression (e.g. chronic steroid use) , IV drug use n own bacteremia K Elevated sedimentation rate History or suspicion of cancer with new onset of LBP. Suspicion of cancer criterion can be met if any two of the following are present: U nexplained weight loss, F ailure to improve after one month, A ge over 50. *ACP recommends plain radiography for unexplained weight loss, MRI or plain radiography if multiple risk factors present. ACR Guidelines for suspicion of cancer, infection or immunosuppression rate MRI without and with contract highest (rating = 8). CT wi thout contrast (rating = 6) - useful if MRI is contraindicated or unavailable. Other imaging methods: use of x - ray, NUC Tc - 99m bone scan whole body with optional targeted SPECT, myelography and postmyelography CT (appropriateness rating < 6 for these). Low velocity trauma (e.g., fall from height or struck by object) OR osteoporosis, AND/OR age >70 years *ACP Guideline recommends: if vertebral compression fracture is suspected due to history of osteoporosis, use of steroids, or age ≥ 70 plain radiography shou ld be completed prior to MRI. Vertebral compression fracture present on plain radiography Other fractures *For low velocity trauma, ACR Guidelines do not support use of NUC Tc - 99 m bone scan with SPECT, MRI with and without contrast, myelography and postmye lography CT, or x - ray mye lography (appropriateness ratings < 5 for these) II. Subacute Low back pain >6 weeks : MRI without contrast

2 Imaging Guidelines: Lumbar Spine MRI , 2010 February 12 At least 6 and: weeks medical/conservative treatment Any of the criteria under acute low back pain met OR Suspected radiculopathy with (all 3 present) : Leg pain is > than back pain Pain present in nerve root distribution Positive straight leg raising test < 45º OR positive crossed straight leg raising test OR Motor weakness or sensory loss in a radicular distribution OR EMG/NCS c onsistent with radiculopathy *ACP recommendation: consider EMG/NCS testing if symptoms > 1 month. For suspected radiculopathy, ACR CT without contrast may be useful if MRI is not Guidelines rate MRI without contrast as most appropriate. available or contraindicated. MRI with and without contrast may be indicated if noncontrast MRI is nondiagnostic or indeterminate. MRI is preferred over m yelography and post myelography CT, but may be indicated if MRI is nondiagnostic. In so me circumstances (facet arthropathy, stress fracture and spondylolysis) NUC Tc - 99m bone scan with SPECT may be useful. Least appropriate x ray (appropriateness rating 2) . - III. A. Chronic low back pain (> 3 months) with no prior MRI of lumbar spine : MRI witho ut contrast Any of the criteria under subacute low back pain (II above) Suspicion of substantial spinal stenosis on another imaging procedure B. Chronic low back pain (> 3 months) with prior MRI of lumbar spine : MRI without contrast neurological status by physical exam OR electrodiagnostic testing Objective worsening of Patient is considered a candidate for spine surgery, (one of the following) Progressive changes in objective neurological findings At least 1 year since last lumbar MRI (without objective change in neurological signs) CT without contrast may be useful if MRI ACR Guidelines rate MRI without contrast as most appropriate. * is not available or contraindicated. MRI with and without contrast may be indicated if noncontrast MRI is yelography and post myelography CT, but may be nondiagnostic or indeterminate. MRI is preferred over m if MRI is nondiagnostic. In some circumstances (facet arthropathy, stress fracture and indicated - - 99m bone scan with SPECT may be useful. Least appropriate x spondylolysis) NUC Tc ray (appropriateness rating 2) . Prior lumbar surgery (one of the following) Objecti ve and/or new or worsening neurological signs Plain radiography OR clinical findings suggest new adverse effects of surgery *Looking for epidural scarring *ACR appropriateness rates MRI with and without contrast highest (rating =8), CT without contrast (ra ting=6) may be indicated in postfusion patients or when MRI is contraindicated or indeterminate. Other methods rated lower: MRI without contrast (rating=6) as contrast is often necessary, myelography and postmyelography CT (rating = 5, x - ray (rating = 5) - flex/extension may be useful, NUC Tc - 99m bone scan and localize with SPECT (rating=5) helps detect - pseudoarthrosis, x - ray myelography (rating = 2). IV. Indication not listed : provide clinical justification

3 Imaging Guidelines: Lumbar Spine MRI February 12 , 2010 example, while the vast majority of true radiculopathy cases Indications here should be well documented. For specific syndromes (lateral stenosis, L1 would meet the criteria, L3 syndromes) may only meet some of these - criteria. In these cases, clinical correlation should be clearly documented. ces: Referen American College of Radiology (2008). ACR appropriateness criteria: low back pain. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicIma ging/LowbackPainDoc7.aspx Chou, R., A. Qaseem, et al. (2007). "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 147(7): 478 - 91.

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