Low Back Pain

Variant: 1 Acute low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography lumbar spine	Usually Not Appropriate	☢☢☢
MRI lumbar spine with IV contrast	Usually Not Appropriate	O
MRI lumbar spine without and with IV contrast	Usually Not Appropriate	O
MRI lumbar spine without IV contrast	Usually Not Appropriate	O
Bone scan whole body with SPECT or SPECT/CT complete spine	Usually Not Appropriate	☢☢☢
CT lumbar spine with IV contrast	Usually Not Appropriate	☢☢☢
CT lumbar spine without IV contrast	Usually Not Appropriate	☢☢☢
Discography and post-discography CT lumbar spine	Usually Not Appropriate	☢☢☢
CT lumbar spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT myelography lumbar spine	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢

Variant: 2 Subacute or chronic low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography lumbar spine	Usually Not Appropriate	☢☢☢
MRI lumbar spine with IV contrast	Usually Not Appropriate	O
MRI lumbar spine without and with IV contrast	Usually Not Appropriate	O
MRI lumbar spine without IV contrast	Usually Not Appropriate	O
Bone scan whole body with SPECT or SPECT/CT complete spine	Usually Not Appropriate	☢☢☢
CT lumbar spine with IV contrast	Usually Not Appropriate	☢☢☢
CT lumbar spine without IV contrast	Usually Not Appropriate	☢☢☢
Discography and post-discography CT lumbar spine	Usually Not Appropriate	☢☢☢
CT lumbar spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT myelography lumbar spine	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢

Variant: 3 Subacute or chronic low back pain with or without radiculopathy. Surgery or intervention candidate with persistent or progressive symptoms during or following 6 weeks of optimal medical management. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI lumbar spine without IV contrast	Usually Appropriate	O
Radiography lumbar spine	May Be Appropriate	☢☢☢
MRI lumbar spine without and with IV contrast	May Be Appropriate	O
Bone scan whole body with SPECT or SPECT/CT complete spine	May Be Appropriate	☢☢☢
CT lumbar spine without IV contrast	May Be Appropriate	☢☢☢
CT myelography lumbar spine	May Be Appropriate	☢☢☢☢
MRI lumbar spine with IV contrast	Usually Not Appropriate	O
CT lumbar spine with IV contrast	Usually Not Appropriate	☢☢☢
Discography and post-discography CT lumbar spine	Usually Not Appropriate	☢☢☢
CT lumbar spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢

Variant: 4 Low back pain with suspected cauda equina syndrome. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI lumbar spine without and with IV contrast	Usually Appropriate	O
MRI lumbar spine without IV contrast	Usually Appropriate	O
CT lumbar spine without IV contrast	May Be Appropriate	☢☢☢
CT myelography lumbar spine	May Be Appropriate	☢☢☢☢
Radiography lumbar spine	Usually Not Appropriate	☢☢☢
MRI lumbar spine with IV contrast	Usually Not Appropriate	O
Bone scan whole body with SPECT or SPECT/CT complete spine	Usually Not Appropriate	☢☢☢
CT lumbar spine with IV contrast	Usually Not Appropriate	☢☢☢
Discography and post-discography CT lumbar spine	Usually Not Appropriate	☢☢☢
CT lumbar spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢

Variant: 5 Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography lumbar spine	Usually Appropriate	☢☢☢
MRI lumbar spine without and with IV contrast	Usually Appropriate	O
MRI lumbar spine without IV contrast	Usually Appropriate	O
CT lumbar spine without IV contrast	May Be Appropriate	☢☢☢
CT myelography lumbar spine	May Be Appropriate	☢☢☢☢
MRI lumbar spine with IV contrast	Usually Not Appropriate	O
Bone scan whole body with SPECT or SPECT/CT complete spine	Usually Not Appropriate	☢☢☢
CT lumbar spine with IV contrast	Usually Not Appropriate	☢☢☢
Discography and post-discography CT lumbar spine	Usually Not Appropriate	☢☢☢
CT lumbar spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢

Variant: 6 Low back pain with or without radiculopathy. One or more of the following: low-velocity trauma, osteoporosis, elderly individual, or chronic steroid use. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography lumbar spine	Usually Appropriate	☢☢☢
MRI lumbar spine without IV contrast	Usually Appropriate	O
CT lumbar spine without IV contrast	Usually Appropriate	☢☢☢
MRI lumbar spine without and with IV contrast	May Be Appropriate	O
CT myelography lumbar spine	May Be Appropriate	☢☢☢☢
MRI lumbar spine with IV contrast	Usually Not Appropriate	O
Bone scan whole body with SPECT or SPECT/CT complete spine	Usually Not Appropriate	☢☢☢
CT lumbar spine with IV contrast	Usually Not Appropriate	☢☢☢
Discography and post-discography CT lumbar spine	Usually Not Appropriate	☢☢☢
CT lumbar spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢

Variant: 7 Low back pain with or without radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI lumbar spine without and with IV contrast	Usually Appropriate	O
MRI lumbar spine without IV contrast	Usually Appropriate	O
Radiography lumbar spine	May Be Appropriate (Disagreement)	☢☢☢
CT lumbar spine with IV contrast	May Be Appropriate	☢☢☢
CT lumbar spine without IV contrast	May Be Appropriate	☢☢☢
CT myelography lumbar spine	May Be Appropriate	☢☢☢☢
MRI lumbar spine with IV contrast	Usually Not Appropriate	O
Bone scan whole body with SPECT or SPECT/CT complete spine	Usually Not Appropriate	☢☢☢
Discography and post-discography CT lumbar spine	Usually Not Appropriate	☢☢☢
CT lumbar spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢

Panel Members

Troy A. Hutchins, MD^a; Miriam Peckham, MD^b; Lubdha M. Shah, MD^c; Matthew S. Parsons, MD^d; Vikas Agarwal, MD^e; Daniel J. Boulter, MD^f; Judah Burns, MD^g; R. Carter Cassidy, MD^h; Melissa A. Davis, MD, MBAⁱ; Langston T. Holly, MD^j; Christopher H. Hunt, MD^k; Majid A. Khan, MBBS, BS^l; Toshio Moritani, MD, PhD^m; A. Orlando Ortiz, MD, MBAⁿ; John E. O'Toole, MD, MS^o; William J. Powers, MD^p; Susan B. Promes, MD, MBA^q; Charles Reitman, MD^r; Vinil N. Shah, MD^s; Simranjit Singh, MD^t; Vincent M. Timpone, MD^u; Amanda S. Corey, MD^v.

Summary of Literature Review

Introduction/Background

Initial Imaging Definition

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).

Discussion of Procedures by Variant

Variant 1: Acute low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.

Variant 1: Acute low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT complete spine

Variant 1: Acute low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
B. CT lumbar spine with IV contrast

Variant 1: Acute low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
C. CT lumbar spine without and with IV contrast

Variant 1: Acute low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
D. CT lumbar spine without IV contrast

Variant 1: Acute low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
E. CT myelography lumbar spine

Variant 1: Acute low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
F. Discography and post-discography CT lumbar spine

Variant 1: Acute low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
G. FDG-PET/CT whole body

Variant 1: Acute low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
H. MRI lumbar spine with IV contrast

Variant 1: Acute low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
I. MRI lumbar spine without and with IV contrast

Variant 1: Acute low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
J. MRI lumbar spine without IV contrast

Variant 1: Acute low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
K. Radiography lumbar spine

Variant 2: Subacute or chronic low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.

Variant 2: Subacute or chronic low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT complete spine

Variant 2: Subacute or chronic low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
B. CT lumbar spine with IV contrast

Variant 2: Subacute or chronic low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
C. CT lumbar spine without and with IV contrast

Variant 2: Subacute or chronic low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
D. CT lumbar spine without IV contrast

Variant 2: Subacute or chronic low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
E. CT myelography lumbar spine

Variant 2: Subacute or chronic low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
F. Discography and post-discography CT lumbar spine

Variant 2: Subacute or chronic low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
G. FDG-PET/CT whole body

Variant 2: Subacute or chronic low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
H. MRI lumbar spine with IV contrast

Variant 2: Subacute or chronic low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
I. MRI lumbar spine without and with IV contrast

Variant 2: Subacute or chronic low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
J. MRI lumbar spine without IV contrast

Variant 2: Subacute or chronic low back pain with or without radiculopathy. No red flags. No prior management. Initial imaging.
K. Radiography lumbar spine

Variant 3: Subacute or chronic low back pain with or without radiculopathy. Surgery or intervention candidate with persistent or progressive symptoms during or following 6 weeks of optimal medical management. Initial imaging.

Variant 4: Low back pain with suspected cauda equina syndrome. Initial imaging.

Variant 4: Low back pain with suspected cauda equina syndrome. Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT complete spine

Variant 4: Low back pain with suspected cauda equina syndrome. Initial imaging.
B. CT lumbar spine with IV contrast

Variant 4: Low back pain with suspected cauda equina syndrome. Initial imaging.
C. CT lumbar spine without and with IV contrast

Variant 4: Low back pain with suspected cauda equina syndrome. Initial imaging.
D. CT lumbar spine without IV contrast

Variant 4: Low back pain with suspected cauda equina syndrome. Initial imaging.
E. CT myelography lumbar spine

Variant 4: Low back pain with suspected cauda equina syndrome. Initial imaging.
F. Discography and post-discography CT lumbar spine

Variant 4: Low back pain with suspected cauda equina syndrome. Initial imaging.
G. FDG-PET/CT whole body

Variant 4: Low back pain with suspected cauda equina syndrome. Initial imaging.
H. MRI lumbar spine with IV contrast

Variant 4: Low back pain with suspected cauda equina syndrome. Initial imaging.
I. MRI lumbar spine without and with IV contrast

Variant 4: Low back pain with suspected cauda equina syndrome. Initial imaging.
J. MRI lumbar spine without IV contrast

Variant 4: Low back pain with suspected cauda equina syndrome. Initial imaging.
K. Radiography lumbar spine

Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging.

Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT complete spine

Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging.
B. CT lumbar spine with IV contrast

Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging.
C. CT lumbar spine without and with IV contrast

Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging.
D. CT lumbar spine without IV contrast

Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging.
E. CT myelography lumbar spine

Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging.
F. Discography and post-discography CT lumbar spine

Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging.
G. FDG-PET/CT whole body

Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging.
H. MRI lumbar spine with IV contrast

Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging.
I. MRI lumbar spine without and with IV contrast

Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging.
J. MRI lumbar spine without IV contrast

Variant 5: Low back pain with history of prior lumbar surgery and with or without radiculopathy. New or progressing symptoms or clinical findings. Initial imaging.
K. Radiography lumbar spine

Variant 6: Low back pain with or without radiculopathy. One or more of the following: low-velocity trauma, osteoporosis, elderly individual, or chronic steroid use. Initial imaging.

Variant 6: Low back pain with or without radiculopathy. One or more of the following: low-velocity trauma, osteoporosis, elderly individual, or chronic steroid use. Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT complete spine

Variant 6: Low back pain with or without radiculopathy. One or more of the following: low-velocity trauma, osteoporosis, elderly individual, or chronic steroid use. Initial imaging.
F. Discography and post-discography CT lumbar spine

Variant 7: Low back pain with or without radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.

Variant 7: Low back pain with or without radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT complete spine

Variant 7: Low back pain with or without radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.
B. CT lumbar spine with IV contrast

Variant 7: Low back pain with or without radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.
C. CT lumbar spine without and with IV contrast

Variant 7: Low back pain with or without radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.
D. CT lumbar spine without IV contrast

Variant 7: Low back pain with or without radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.
E. CT myelography lumbar spine

Variant 7: Low back pain with or without radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.
F. Discography and post-discography CT lumbar spine

Variant 7: Low back pain with or without radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.
G. FDG-PET/CT whole body

Variant 7: Low back pain with or without radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.
H. MRI lumbar spine with IV contrast

Variant 7: Low back pain with or without radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.
I. MRI lumbar spine without and with IV contrast

Variant 7: Low back pain with or without radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.
J. MRI lumbar spine without IV contrast

Variant 7: Low back pain with or without radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.
K. Radiography lumbar spine

Summary of Highlights

Supporting Documents

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 go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

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.

Relative Radiation Level Information

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.”

References

1.	Murray CJ, Lopez AD. Measuring the global burden of disease. N Engl J Med. 2013;369(5):448-457.
2.	Johnson SM, Shah LM. Imaging of Acute Low Back Pain. [Review]. Radiologic Clinics of North America. 57(2):397-413, 2019 Mar.
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.
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.
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/.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
19.	Last AR, Hulbert K. Chronic low back pain: evaluation and management. American Family Physician. 79(12):1067-74, 2009 Jun 15.
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.
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.
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.
23.	Nazarian S, Beinart R, Halperin HR. Magnetic resonance imaging and implantable devices. Circ Arrhythm Electrophysiol 2013;6:419-28.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
36.	Butt S, Saifuddin A. The imaging of lumbar spondylolisthesis. Clin Radiol 2005;60:533-46.
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.
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.
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.
40.	American College of Radiology. ACR Appropriateness Criteria®: Myelopathy. Available at: https://acsearch.acr.org/docs/69484/Narrative/.
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.
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.
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.
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.
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.
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.
47.	Darouiche RO. Spinal epidural abscess. N Engl J Med 2006;355:2012-20.
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.
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.
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.
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.
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.
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.
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.
55.	Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137(7):586-597.
56.	Beckmann NM, West OC, Nunez D, Jr., et al. ACR Appropriateness Criteria® Suspected Spine Trauma. J Am Coll Radiol 2019;16:S264-S85.
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.
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.
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.
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.
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.
62.	Shah LM, Salzman KL. Imaging of spinal metastatic disease. International Journal of Surgical Oncology Print. 2011:769753, 2011.
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.
64.	Edelstyn GA, Gillespie PJ, Grebbell FS. The radiological demonstration of osseous metastases. Experimental observations. Clinical Radiology. 18(2):158-62, 1967 Apr.
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.
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.
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.
68.	Jarvik JG. Imaging of adults with low back pain in the primary care setting. Neuroimaging Clin N Am. 2003;13(2):293-305.
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.
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.
71.	American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

Disclaimer

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.