• Evidence-based guidelines

• Assist referring physicians to make the most

appropriate imaging or treatment decisions for

specific clinical conditions

• Enhance quality of care and contribute to the most

efficacious use of radiology

• Developed by expert panels in diagnostic imaging,

interventional radiology, and radiation oncology

• Panels include leaders in radiology and other


• Low Back Pain




• Myelopathy




• Spine Trauma




• Acute LBP +/- radiculopathy is one of the most

common health problems in US

• High prevalence and high cost

– Leading cause of disability for persons < 45 yo

– Cost of evaluating and treating acute LBP runs into billions

of dollars annually, not including time lost from work

• Extensive government sponsored studies, now part

of the growing body of literature

• Clear that uncomplicated acute LBP and/or

radiculopathy is a benign, self-limited condition that

does not warrant any imaging studies [Chou et al. Ann

Intern Med 2011]

• Uncomplicated acute LBP and/or

radiculopathy. No red flags.

• History of cancer

• Focal neurologic deficit(s) with progressive

or disabling symptoms, cauda equina


• Unexplained fever, urinary or other infection

• Unexplained weight loss, insidious onset

• Immunosuppression, diabetes mellitus

• Significant or cumulative trauma

• Prior surgery

• Intravenous drug use

• Prolonged use of corticosteroids,


• Age > 50 years, especially women, and

males with osteoporosis or compression


• Age > 70 years

• Duration longer than 6 weeks

• May be sufficient for initial evaluation of:

– Recent significant trauma (at any age)

– Osteoporosis

– Age >70 years

• Further imaging indicated for treatment planning if

findings abnormal or inconclusive

• Requires further imaging if other red flags such as

suspicion of cancer or infection are present

• Radiographs have role in evaluation of alignment,

instability, and scoliosis, and in postoperative

evaluation of instrumentation and fusion

• Studies often inadequate

– 24% of x-table laterals fail to visualize C7-T1

– 10-20% of C spine fractures at this level

– 78% of examinations required repeat films

• Study insensitive

– False negative rate of 33-66%

– > 50% of missed fractures unstable

– Most misses at craniocervical and

cervicothoracic junctions

• Superior bone detail

• Not nearly as useful in depicting extradural softtissue

pathologies such as disc disease

(compared with MRI)

• Intradural and cord pathologies are very poorly


• Multiplanar reformations (MPR) are useful for

depicting osseous structural problems

– Spondylolysis, pseudoarthrosis, fracture, scoliosis,

and stenosis and for postsurgical evaluation of

bone graft integrity, surgical fusion, and


• Trauma

• Surgical hardware

– Location, alignment, osteolysis

• Spondylolysis

• MRI contraindicated

• Most common indications include

– LBP complicated by radiculopathy,


– Cauda equina syndrome

– Neurogenic claudication

– Spinal stenosis

• Initial imaging modality of choice in

complicated LBP, displacing

myelography and CT

• Multidisciplinary agreement on terminology

facilitates reporting

– Recommendations of the Combined Task Forces

of the North American Spine Society, American

Society of Spine Radiology, and American

Society of Neuroradiology [Fardon et al. Spine 2001]

• Inter-rater reliability of reporting using lumbar

disc terminology has achieved only modest

agreement [Arana et al. Radiology 2010]

• Disc extrusion

vs. protrusion

• Migrated vs.


• MRI disc abnormalities

very common in

asymptomatic persons

• Acute LBP with

radiculopathy suggests

presence of anatomic

nerve root compression

on MRI

• Type I Modic endplate

change (edema),

anterolisthesis, or disc

extrusion are more strongly

associated with LBP than

findings of disc

degeneration without

endplate change

• MRI is efficacious for

evaluating facet

arthropathy and edema

• MRI with contrast is primary modality

for suspected infection and neoplasia


Post GAD T1-WI

Fat saturated

Post GAD T1-WI

• Large expansile

destructive osseous


• Cord compression

and edema



• Enhanced MRI allows distinction

between disc and scar



• “Plain” myelography was mainstay of lumbar

herniated disc diagnosis for decades

• Now combined with post-myelography CT

– Complementary to plain CT or MRI

– Occasionally more accurate in diagnosing disc herniation

– May also be useful in surgical planning

• Requires lumbar puncture and intrathecal contrast


• Weight-bearing and flexion extension views are

possible on myelography

• Moderately sensitive for detecting the

presence of tumor, infection, or occult


• Not specific

• SPECT/CT offers matched anatomic


• Remains valuable when a survey of

the entire skeleton is indicated

(metastatic disease)

• For spondylolysis or stress fracture in athletes,

bone scan with SPECT, followed by limited

CT if positive, is more sensitive than MRI [Masci

et al. Br J Sports Med 2006]

• Bone scan with SPECT can be useful to

identify symptomatic facet disease in

patients treated with facet injection

[Pneumaticos et al. Radiology 2006]

• May be helpful in detecting and localizing

the site of painful pseudoarthrosis following

lumbar spinal fusion [Holder et al. J Nucl Med 1995]

• Localizing source of back pain that is indeterminate with

other less invasive studies

• Multifocal abnormalities on MRI

• Reproducing reported pain may have diagnostic value

• Limitations include necessity of disc space injections,

variability of patient response, and limited specificity

[Carragee et al. Spine 2006]

• Type 1 Modic changes on MRI have a high PPV in

identification of a pain generator at discography

[Thompson et al. Radiology 2009]

• Other studies have found a less consistent role for MRI in

prediction of discography findings

• Acute uncomplicated LBP without red flags is a

benign, self-limited condition

– Does not require imaging evaluation

• MR has displaced CT and myelography as the initial

imaging modality of choice

• 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


• 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 not considered routine clinical

practice at this time

• Low-velocity trauma, osteoporosis, focal

and/or progressive deficit, prolonged

symptoms, age > 70 years

• Suspicion of cancer, infection, and/or


• LBP and/or radiculopathy, surgery or

intervention candidate.

• Prior lumbar surgery

• Cauda equina syndrome, multifocal or

progressive deficits

• Chou et al. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health

Care From the American College of Physicians. Ann Intern Med 2011

• Arana et al. Lumbar spine: agreement in the interpretation of 1.5-T MR images by

using the Nordic Modic Consensus Group classification form. Radiology 2010

• Carragee et al. A gold standard evaluation of the "discogenic pain" diagnosis as

determined by provocative discography. Spine 2006

• Thompson et al. Modic changes on MR images as studied with provocative

diskography: clinical relevance - a retrospective study of 2457 disks. Radiology 2009

• Fardon DF, Milette PC. Nomenclature and classification of lumbar disc pathology.

Recommendations of the Combined task Forces of the North American Spine

Society, American Society of Spine Radiology, and American Society of

Neuroradiology. Spine 2001

• Masci L, Pike J, Malara F, Phillips B, Bennell K, Brukner P. Use of the one-legged

hyperextension test and magnetic resonance imaging in the diagnosis of active

spondylolysis. Br J Sports Med 2006

• Pneumaticos SG, Chatziioannou SN, Hipp JA, Moore WH, Esses SI. Low back pain:

prediction of short-term outcome of facet joint injection with bone scintigraphy.

Radiology 2006

• Even-Sapir E, Martin RH, Mitchell MJ, Iles SE, Barnes DC, Clark AJ. Assessment of

painful late effects of lumbar spinal fusion with SPECT. J Nucl Med 1994

• Holder LE, Machin JL, Asdourian PL, Links JM, Sexton CC. Planar and high-resolution

SPECT bone imaging in the diagnosis of facet syndrome. J Nucl Med 1995

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