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Inflammatory Back Pain: Known or Suspected Axial Spondyloarthropathy

Variant: 1   Inflammatory back pain. Suspected axial spondyloarthritis. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography sacroiliac joints Usually Appropriate ☢☢
Radiography sacroiliac joints and spine area of interest Usually Appropriate ☢☢☢
US sacroiliac joints Usually Not Appropriate O
US spine area of interest Usually Not Appropriate O
MRI sacroiliac joints without and with IV contrast Usually Not Appropriate O
MRI sacroiliac joints without IV contrast Usually Not Appropriate O
MRI spine area of interest without and with IV contrast Usually Not Appropriate O
MRI spine area of interest without IV contrast Usually Not Appropriate O
Bone scan with SPECT or SPECT/CT sacroiliac joints Usually Not Appropriate ☢☢☢
Bone scan with SPECT or SPECT/CT spine area of interest Usually Not Appropriate ☢☢☢
CT sacroiliac joints with IV contrast Usually Not Appropriate ☢☢☢
CT sacroiliac joints without IV contrast Usually Not Appropriate ☢☢☢
CT sacroiliac joints without and with IV contrast Usually Not Appropriate ☢☢☢☢
Fluoride PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢
CT spine area of interest with IV contrast Usually Not Appropriate Varies
CT spine area of interest without and with IV contrast Usually Not Appropriate Varies
CT spine area of interest without IV contrast Usually Not Appropriate Varies

Variant: 2   Inflammatory back pain. Suspected axial spondyloarthritis. Additional imaging following radiographs. Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
MRI sacroiliac joints and spine area of interest without and with IV contrast Usually Appropriate O
MRI sacroiliac joints and spine area of interest without IV contrast Usually Appropriate O
MRI sacroiliac joints without and with IV contrast Usually Appropriate O
MRI sacroiliac joints without IV contrast Usually Appropriate O
CT sacroiliac joints without IV contrast May Be Appropriate ☢☢☢
CT sacroiliac joints and spine area of interest without IV contrast May Be Appropriate Varies
US sacroiliac joints Usually Not Appropriate O
US sacroiliac joints and spine area of interest Usually Not Appropriate O
Bone scan with SPECT or SPECT/CT sacroiliac joints Usually Not Appropriate ☢☢☢
Bone scan with SPECT or SPECT/CT sacroiliac joints and spine area of interest Usually Not Appropriate ☢☢☢
CT sacroiliac joints with IV contrast Usually Not Appropriate ☢☢☢
CT sacroiliac joints without and with IV contrast Usually Not Appropriate ☢☢☢☢
Fluoride PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢
CT sacroiliac joints and spine area of interest with IV contrast Usually Not Appropriate Varies
CT sacroiliac joints and spine area of interest without and with IV contrast Usually Not Appropriate Varies

Variant: 3   Inflammatory back pain. Suspected axial spondyloarthritis. Negative radiographs and negative MRI of the sacroiliac joints. Next imaging study.
Procedure Appropriateness Category Relative Radiation Level
Radiography spine area of interest Usually Appropriate Varies
MRI spine area of interest without and with IV contrast Usually Appropriate O
MRI spine area of interest without IV contrast Usually Appropriate O
CT spine area of interest without IV contrast Usually Appropriate Varies
US spine area of interest Usually Not Appropriate O
Bone scan with SPECT or SPECT/CT spine area of interest Usually Not Appropriate ☢☢☢
Fluoride PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢
CT spine area of interest with IV contrast Usually Not Appropriate Varies
CT spine area of interest without and with IV contrast Usually Not Appropriate Varies

Variant: 4   Known axial spondyloarthritis. Follow-up for treatment response or disease progression.
Procedure Appropriateness Category Relative Radiation Level
Radiography sacroiliac joints Usually Appropriate ☢☢
Radiography sacroiliac joints and spine area of interest Usually Appropriate ☢☢☢
MRI sacroiliac joints and spine area of interest without and with IV contrast May Be Appropriate O
MRI sacroiliac joints and spine area of interest without IV contrast May Be Appropriate O
MRI sacroiliac joints without and with IV contrast May Be Appropriate O
MRI sacroiliac joints without IV contrast May Be Appropriate O
US sacroiliac joints Usually Not Appropriate O
US sacroiliac joints and spine area of interest Usually Not Appropriate O
Bone scan with SPECT or SPECT/CT sacroiliac joints Usually Not Appropriate ☢☢☢
Bone scan with SPECT or SPECT/CT sacroiliac joints and spine area of interest Usually Not Appropriate ☢☢☢
CT sacroiliac joints with IV contrast Usually Not Appropriate ☢☢☢
CT sacroiliac joints without IV contrast Usually Not Appropriate ☢☢☢
CT sacroiliac joints without and with IV contrast Usually Not Appropriate ☢☢☢☢
Fluoride PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢
CT sacroiliac joints and spine area of interest with IV contrast Usually Not Appropriate Varies
CT sacroiliac joints and spine area of interest without and with IV contrast Usually Not Appropriate Varies
CT sacroiliac joints and spine area of interest without IV contrast Usually Not Appropriate Varies

Variant: 5   Axial spondyloarthritis with spine ankylosis. Suspected fracture. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography spine area of interest Usually Appropriate Varies
MRI spine area of interest without IV contrast Usually Appropriate O
CT spine area of interest without IV contrast Usually Appropriate Varies
US spine area of interest Usually Not Appropriate O
MRI spine area of interest without and with IV contrast Usually Not Appropriate O
Bone scan with SPECT or SPECT/CT spine area of interest Usually Not Appropriate ☢☢☢
Fluoride PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢
CT spine area of interest with IV contrast Usually Not Appropriate Varies
CT spine area of interest without and with IV contrast Usually Not Appropriate Varies

Panel Members
Connie C. So, a.
Summary of Literature Review
Introduction/Background
Initial Imaging Definition
Discussion of Procedures by Variant
Variant 1: Inflammatory back pain. Suspected axial spondyloarthritis. Initial imaging.
Variant 1: Inflammatory back pain. Suspected axial spondyloarthritis. Initial imaging.
A. Bone scan with SPECT or SPECT/CT sacroiliac joints
Variant 1: Inflammatory back pain. Suspected axial spondyloarthritis. Initial imaging.
B. Bone scan with SPECT or SPECT/CT spine area of interest
Variant 1: Inflammatory back pain. Suspected axial spondyloarthritis. Initial imaging.
C. CT sacroiliac joints
Variant 1: Inflammatory back pain. Suspected axial spondyloarthritis. Initial imaging.
D. CT spine area of interest
Variant 1: Inflammatory back pain. Suspected axial spondyloarthritis. Initial imaging.
E. Fluoride PET/CT skull base to mid-thigh
Variant 1: Inflammatory back pain. Suspected axial spondyloarthritis. Initial imaging.
F. MRI sacroiliac joints
Variant 1: Inflammatory back pain. Suspected axial spondyloarthritis. Initial imaging.
G. MRI spine area of interest
Variant 1: Inflammatory back pain. Suspected axial spondyloarthritis. Initial imaging.
H. Radiography sacroiliac joints
Variant 1: Inflammatory back pain. Suspected axial spondyloarthritis. Initial imaging.
I. Radiography sacroiliac joints and spine area of interest
Variant 1: Inflammatory back pain. Suspected axial spondyloarthritis. Initial imaging.
J. US sacroiliac joints
Variant 1: Inflammatory back pain. Suspected axial spondyloarthritis. Initial imaging.
K. US spine area of interest
Variant 2: Inflammatory back pain. Suspected axial spondyloarthritis. Additional imaging following radiographs. Next imaging study.
Variant 2: Inflammatory back pain. Suspected axial spondyloarthritis. Additional imaging following radiographs. Next imaging study.
A. Bone scan with SPECT or SPECT/CT sacroiliac joints
Variant 2: Inflammatory back pain. Suspected axial spondyloarthritis. Additional imaging following radiographs. Next imaging study.
B. Bone scan with SPECT or SPECT/CT sacroiliac joints and spine area of interest
Variant 2: Inflammatory back pain. Suspected axial spondyloarthritis. Additional imaging following radiographs. Next imaging study.
C. CT sacroiliac joints
Variant 2: Inflammatory back pain. Suspected axial spondyloarthritis. Additional imaging following radiographs. Next imaging study.
D. CT sacroiliac joints and spine area of interest
Variant 2: Inflammatory back pain. Suspected axial spondyloarthritis. Additional imaging following radiographs. Next imaging study.
E. Fluoride PET/CT skull base to mid-thigh
Variant 2: Inflammatory back pain. Suspected axial spondyloarthritis. Additional imaging following radiographs. Next imaging study.
F. MRI sacroiliac joints
Variant 2: Inflammatory back pain. Suspected axial spondyloarthritis. Additional imaging following radiographs. Next imaging study.
G. MRI sacroiliac joints and spine area of interest
Variant 2: Inflammatory back pain. Suspected axial spondyloarthritis. Additional imaging following radiographs. Next imaging study.
H. US sacroiliac joints
Variant 2: Inflammatory back pain. Suspected axial spondyloarthritis. Additional imaging following radiographs. Next imaging study.
I. US sacroiliac joints and spine area of interest
Variant 3: Inflammatory back pain. Suspected axial spondyloarthritis. Negative radiographs and negative MRI of the sacroiliac joints. Next imaging study.
Variant 3: Inflammatory back pain. Suspected axial spondyloarthritis. Negative radiographs and negative MRI of the sacroiliac joints. Next imaging study.
A. Bone scan with SPECT or SPECT/CT spine area of interest
Variant 3: Inflammatory back pain. Suspected axial spondyloarthritis. Negative radiographs and negative MRI of the sacroiliac joints. Next imaging study.
B. CT spine area of interest
Variant 3: Inflammatory back pain. Suspected axial spondyloarthritis. Negative radiographs and negative MRI of the sacroiliac joints. Next imaging study.
C. Fluoride PET/CT skull base to mid-thigh
Variant 3: Inflammatory back pain. Suspected axial spondyloarthritis. Negative radiographs and negative MRI of the sacroiliac joints. Next imaging study.
D. MRI spine area of interest
Variant 3: Inflammatory back pain. Suspected axial spondyloarthritis. Negative radiographs and negative MRI of the sacroiliac joints. Next imaging study.
E. Radiography spine area of interest
Variant 3: Inflammatory back pain. Suspected axial spondyloarthritis. Negative radiographs and negative MRI of the sacroiliac joints. Next imaging study.
F. US spine area of interest
Variant 4: Known axial spondyloarthritis. Follow-up for treatment response or disease progression.
Variant 4: Known axial spondyloarthritis. Follow-up for treatment response or disease progression.
A. Bone scan with SPECT or SPECT/CT sacroiliac joints
Variant 4: Known axial spondyloarthritis. Follow-up for treatment response or disease progression.
B. Bone scan with SPECT or SPECT/CT sacroiliac joints and spine area of interest
Variant 4: Known axial spondyloarthritis. Follow-up for treatment response or disease progression.
C. CT sacroiliac joints
Variant 4: Known axial spondyloarthritis. Follow-up for treatment response or disease progression.
D. CT sacroiliac joints and spine area of interest
Variant 4: Known axial spondyloarthritis. Follow-up for treatment response or disease progression.
E. Fluoride PET/CT skull base to mid-thigh
Variant 4: Known axial spondyloarthritis. Follow-up for treatment response or disease progression.
F. MRI sacroiliac joints
Variant 4: Known axial spondyloarthritis. Follow-up for treatment response or disease progression.
G. MRI sacroiliac joints and spine area of interest
Variant 4: Known axial spondyloarthritis. Follow-up for treatment response or disease progression.
H. Radiography sacroiliac joints
Variant 4: Known axial spondyloarthritis. Follow-up for treatment response or disease progression.
I. Radiography sacroiliac joints and spine area of interest
Variant 4: Known axial spondyloarthritis. Follow-up for treatment response or disease progression.
J. US sacroiliac joints
Variant 4: Known axial spondyloarthritis. Follow-up for treatment response or disease progression.
K. US sacroiliac joints and spine area of interest
Variant 5: Axial spondyloarthritis with spine ankylosis. Suspected fracture. Initial imaging.
Variant 5: Axial spondyloarthritis with spine ankylosis. Suspected fracture. Initial imaging.
A. Bone scan with SPECT or SPECT/CT spine area of interest
Variant 5: Axial spondyloarthritis with spine ankylosis. Suspected fracture. Initial imaging.
B. CT spine area of interest
Variant 5: Axial spondyloarthritis with spine ankylosis. Suspected fracture. Initial imaging.
C. Fluoride PET/CT skull base to mid-thigh
Variant 5: Axial spondyloarthritis with spine ankylosis. Suspected fracture. Initial imaging.
D. MRI spine area of interest
Variant 5: Axial spondyloarthritis with spine ankylosis. Suspected fracture. Initial imaging.
E. Radiography spine area of interest
Variant 5: Axial spondyloarthritis with spine ankylosis. Suspected fracture. Initial imaging.
F. US spine area of interest
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.”
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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