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Variant: 1 Child. Back pain. No clinical red flags. Initial imaging.

Procedure	Appropriateness Category
Radiography complete spine	Usually Not Appropriate
US spine area of interest	Usually Not Appropriate
Radiography spine area of interest	Usually Not Appropriate
MRI complete spine with IV contrast	Usually Not Appropriate
MRI complete spine without and with IV contrast	Usually Not Appropriate
MRI complete spine without IV contrast	Usually Not Appropriate
MRI spine area of interest with IV contrast	Usually Not Appropriate
MRI spine area of interest without and with IV contrast	Usually Not Appropriate
MRI spine area of interest without IV contrast	Usually Not Appropriate
Bone scan whole body with SPECT or SPECT/CT area of interest	Usually Not Appropriate
Bone scan whole body with SPECT or SPECT/CT complete spine	Usually Not Appropriate
CT complete spine with IV contrast	Usually Not Appropriate
CT complete spine without and with IV contrast	Usually Not Appropriate
CT complete spine without IV contrast	Usually Not Appropriate
CT myelography complete spine	Usually Not Appropriate
CT myelography spine area of interest	Usually Not Appropriate
CT spine area of interest with IV contrast	Usually Not Appropriate
CT spine area of interest without and with IV contrast	Usually Not Appropriate
CT spine area of interest without IV contrast	Usually Not Appropriate

Variant: 2 Child. Back pain. With at least one clinical red flag. Initial imaging.

Procedure	Appropriateness Category
Radiography spine area of interest	Usually Appropriate
Radiography complete spine	May Be Appropriate
MRI complete spine without and with IV contrast	May Be Appropriate
MRI complete spine without IV contrast	May Be Appropriate (Disagreement)
MRI spine area of interest without and with IV contrast	May Be Appropriate (Disagreement)
MRI spine area of interest without IV contrast	May Be Appropriate (Disagreement)
CT spine area of interest with IV contrast	May Be Appropriate
CT spine area of interest without IV contrast	May Be Appropriate
US spine area of interest	Usually Not Appropriate
MRI complete spine with IV contrast	Usually Not Appropriate
MRI spine area of interest with IV contrast	Usually Not Appropriate
Bone scan whole body with SPECT or SPECT/CT area of interest	Usually Not Appropriate
Bone scan whole body with SPECT or SPECT/CT complete spine	Usually Not Appropriate
CT complete spine with IV contrast	Usually Not Appropriate
CT complete spine without and with IV contrast	Usually Not Appropriate
CT complete spine without IV contrast	Usually Not Appropriate
CT myelography complete spine	Usually Not Appropriate
CT myelography spine area of interest	Usually Not Appropriate
CT spine area of interest without and with IV contrast	Usually Not Appropriate

Variant: 3 Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.

Procedure	Appropriateness Category
MRI spine area of interest without and with IV contrast	Usually Appropriate
MRI spine area of interest without IV contrast	Usually Appropriate
MRI complete spine with IV contrast	May Be Appropriate (Disagreement)
MRI complete spine without and with IV contrast	May Be Appropriate (Disagreement)
MRI complete spine without IV contrast	May Be Appropriate (Disagreement)
MRI spine area of interest with IV contrast	May Be Appropriate (Disagreement)
CT complete spine with IV contrast	May Be Appropriate
CT complete spine without IV contrast	May Be Appropriate
CT spine area of interest with IV contrast	May Be Appropriate
CT spine area of interest without IV contrast	May Be Appropriate
US spine area of interest	Usually Not Appropriate
Bone scan whole body with SPECT or SPECT/CT area of interest	Usually Not Appropriate
Bone scan whole body with SPECT or SPECT/CT complete spine	Usually Not Appropriate
CT complete spine without and with IV contrast	Usually Not Appropriate
CT myelography complete spine	Usually Not Appropriate
CT myelography spine area of interest	Usually Not Appropriate
CT spine area of interest without and with IV contrast	Usually Not Appropriate

Variant: 4 Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.

Procedure	Appropriateness Category
MRI complete spine without and with IV contrast	Usually Appropriate
Radiography complete spine	May Be Appropriate (Disagreement)
Radiography spine area of interest	May Be Appropriate (Disagreement)
MRI complete spine with IV contrast	May Be Appropriate (Disagreement)
MRI complete spine without IV contrast	May Be Appropriate
CT complete spine with IV contrast	May Be Appropriate (Disagreement)
CT complete spine without and with IV contrast	May Be Appropriate (Disagreement)
CT complete spine without IV contrast	May Be Appropriate
CT spine area of interest with IV contrast	May Be Appropriate (Disagreement)
CT spine area of interest without and with IV contrast	May Be Appropriate (Disagreement)
CT spine area of interest without IV contrast	May Be Appropriate
US spine area of interest	Usually Not Appropriate
Bone scan whole body with SPECT or SPECT/CT area of interest	Usually Not Appropriate
Bone scan whole body with SPECT or SPECT/CT complete spine	Usually Not Appropriate
CT myelography complete spine	Usually Not Appropriate
CT myelography spine area of interest	Usually Not Appropriate

Variant: 5 Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.

Procedure	Appropriateness Category
MRI complete spine without and with IV contrast	Usually Appropriate
MRI spine area of interest without and with IV contrast	Usually Appropriate
MRI complete spine without IV contrast	May Be Appropriate (Disagreement)
MRI spine area of interest with IV contrast	May Be Appropriate (Disagreement)
MRI spine area of interest without IV contrast	May Be Appropriate (Disagreement)
Bone scan whole body with SPECT or SPECT/CT area of interest	May Be Appropriate
Bone scan whole body with SPECT or SPECT/CT complete spine	May Be Appropriate (Disagreement)
CT complete spine with IV contrast	May Be Appropriate (Disagreement)
CT complete spine without IV contrast	May Be Appropriate
FDG-PET/CT whole body	May Be Appropriate (Disagreement)
CT spine area of interest with IV contrast	May Be Appropriate
CT spine area of interest without IV contrast	May Be Appropriate
US spine area of interest	Usually Not Appropriate
MRI complete spine with IV contrast	Usually Not Appropriate
CT complete spine without and with IV contrast	Usually Not Appropriate
CT myelography complete spine	Usually Not Appropriate
CT myelography spine area of interest	Usually Not Appropriate
CT spine area of interest without and with IV contrast	Usually Not Appropriate

Variant: 6 Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.

Procedure	Appropriateness Category
Radiography spine area of interest	Usually Appropriate
Radiography complete spine	May Be Appropriate (Disagreement)
MRI spine area of interest without IV contrast	May Be Appropriate (Disagreement)
Bone scan whole body with SPECT or SPECT/CT area of interest	May Be Appropriate
CT spine area of interest without IV contrast	May Be Appropriate
US spine area of interest	Usually Not Appropriate
MRI complete spine with IV contrast	Usually Not Appropriate
MRI complete spine without and with IV contrast	Usually Not Appropriate
MRI complete spine without IV contrast	Usually Not Appropriate
MRI spine area of interest with IV contrast	Usually Not Appropriate
MRI spine area of interest without and with IV contrast	Usually Not Appropriate
Bone scan whole body with SPECT or SPECT/CT complete spine	Usually Not Appropriate
CT complete spine with IV contrast	Usually Not Appropriate
CT complete spine without and with IV contrast	Usually Not Appropriate
CT complete spine without IV contrast	Usually Not Appropriate
CT myelography complete spine	Usually Not Appropriate
CT myelography spine area of interest	Usually Not Appropriate
CT spine area of interest with IV contrast	Usually Not Appropriate
CT spine area of interest without and with IV contrast	Usually Not Appropriate

Variant: 7 Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.

Procedure	Appropriateness Category
US spine area of interest	Usually Appropriate
MRI spine area of interest without and with IV contrast	Usually Appropriate
MRI spine area of interest without IV contrast	Usually Appropriate
MRI complete spine without and with IV contrast	May Be Appropriate (Disagreement)
MRI complete spine without IV contrast	May Be Appropriate (Disagreement)
MRI spine area of interest with IV contrast	May Be Appropriate (Disagreement)
Radiography complete spine	Usually Not Appropriate
Radiography spine area of interest	Usually Not Appropriate
MRI complete spine with IV contrast	Usually Not Appropriate
Bone scan whole body with SPECT or SPECT/CT area of interest	Usually Not Appropriate
Bone scan whole body with SPECT or SPECT/CT complete spine	Usually Not Appropriate
CT complete spine with IV contrast	Usually Not Appropriate
CT complete spine without and with IV contrast	Usually Not Appropriate
CT complete spine without IV contrast	Usually Not Appropriate
CT myelography complete spine	Usually Not Appropriate
CT myelography spine area of interest	Usually Not Appropriate
CT spine area of interest with IV contrast	Usually Not Appropriate
CT spine area of interest without and with IV contrast	Usually Not Appropriate
CT spine area of interest without IV contrast	Usually Not Appropriate

Hisham Dahmoush, MBBCh^a; Durga Sivacharan Gaddam, MD^b; Mai-Lan Ho, MD^c; David F. Bauer, MD, MPH^d; Thangamadhan Bosemani, MD^e; Jeffrey Buchhalter, MD, PhD^f; Roshni A. Dasgupta, MD^g; Orit A. Glenn, MD^h; Carolina V. Guimaraes, MDⁱ; Helen R. Nadel, MD^j; Cory M. Pfeifer, MD, MS, MBA, MPH^k; Rupa Radhakrishnan, MBBS, MS^l; Charles Reitman, MD^m; Anna K. Thomas, MDⁿ; Unni K. Udayasankar, MD^o; Jessica J. Wall, MD, MSCE, MPH^p; Jason N. Wright, MD^q; Courtney J. Wusthoff, MD, MS^r; Sumit Pruthi, MD, MBBS^s.

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please visit https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

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 (RRL) 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, because of both 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 with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	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 “Varies.”

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The 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 examinations 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 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

Back Pain-Child