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Back Pain-Child

Variant: 1   Child. Back pain. No clinical red flags. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography complete spine Usually Not Appropriate ☢☢☢
US spine area of interest Usually Not Appropriate O
Radiography spine area of interest Usually Not Appropriate Varies
MRI complete spine with IV contrast Usually Not Appropriate O
MRI complete spine without and with IV contrast Usually Not Appropriate O
MRI complete spine without IV contrast Usually Not Appropriate O
MRI spine area of interest with 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 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 Varies
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   Child. Back pain. With at least one clinical red flag. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography spine area of interest Usually Appropriate Varies
Radiography complete spine May Be Appropriate ☢☢☢
MRI complete spine without and with IV contrast May Be Appropriate O
MRI complete spine without IV contrast May Be Appropriate (Disagreement) O
MRI spine area of interest without and with IV contrast May Be Appropriate (Disagreement) O
MRI spine area of interest without IV contrast May Be Appropriate (Disagreement) O
CT spine area of interest with IV contrast May Be Appropriate Varies
CT spine area of interest without IV contrast May Be Appropriate Varies
US spine area of interest Usually Not Appropriate O
MRI complete spine with IV contrast Usually Not Appropriate O
MRI spine area of interest with IV contrast Usually Not Appropriate O
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 Varies
CT spine area of interest without and with IV contrast Usually Not Appropriate Varies

Variant: 3   Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
Procedure Appropriateness Category Peds Relative Radiation Level
MRI spine area of interest without and with IV contrast Usually Appropriate O
MRI spine area of interest without IV contrast Usually Appropriate O
MRI complete spine with IV contrast May Be Appropriate (Disagreement) O
MRI complete spine without and with IV contrast May Be Appropriate (Disagreement) O
MRI complete spine without IV contrast May Be Appropriate (Disagreement) O
MRI spine area of interest with IV contrast May Be Appropriate (Disagreement) O
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 Varies
CT spine area of interest without IV contrast May Be Appropriate Varies
US spine area of interest Usually Not Appropriate O
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 Varies
CT spine area of interest without and with IV contrast Usually Not Appropriate Varies

Variant: 4   Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
MRI complete spine without and with IV contrast Usually Appropriate O
Radiography complete spine May Be Appropriate (Disagreement) ☢☢☢
Radiography spine area of interest May Be Appropriate (Disagreement) Varies
MRI complete spine with IV contrast May Be Appropriate (Disagreement) O
MRI complete spine without IV contrast May Be Appropriate O
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) Varies
CT spine area of interest without and with IV contrast May Be Appropriate (Disagreement) Varies
CT spine area of interest without IV contrast May Be Appropriate Varies
US spine area of interest Usually Not Appropriate O
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 Varies

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 Peds Relative Radiation Level
MRI complete spine without and with IV contrast Usually Appropriate O
MRI spine area of interest without and with IV contrast Usually Appropriate O
MRI complete spine without IV contrast May Be Appropriate (Disagreement) O
MRI spine area of interest with IV contrast May Be Appropriate (Disagreement) O
MRI spine area of interest without IV contrast May Be Appropriate (Disagreement) O
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 Varies
CT spine area of interest without IV contrast May Be Appropriate Varies
US spine area of interest Usually Not Appropriate O
MRI complete spine with IV contrast Usually Not Appropriate O
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 Varies
CT spine area of interest without and with IV contrast Usually Not Appropriate Varies

Variant: 6   Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography spine area of interest Usually Appropriate Varies
Radiography complete spine May Be Appropriate (Disagreement) ☢☢☢
MRI spine area of interest without IV contrast May Be Appropriate (Disagreement) O
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 Varies
US spine area of interest Usually Not Appropriate O
MRI complete spine with IV contrast Usually Not Appropriate O
MRI complete spine without and with IV contrast Usually Not Appropriate O
MRI complete spine without IV contrast Usually Not Appropriate O
MRI spine area of interest with IV contrast Usually Not Appropriate O
MRI spine area of interest without and with IV contrast Usually Not Appropriate O
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 Varies
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: 7   Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
US spine area of interest Usually Appropriate O
MRI spine area of interest without and with IV contrast Usually Appropriate O
MRI spine area of interest without IV contrast Usually Appropriate O
MRI complete spine without and with IV contrast May Be Appropriate (Disagreement) O
MRI complete spine without IV contrast May Be Appropriate (Disagreement) O
MRI spine area of interest with IV contrast May Be Appropriate (Disagreement) O
Radiography complete spine Usually Not Appropriate ☢☢☢
Radiography spine area of interest Usually Not Appropriate Varies
MRI complete spine with IV contrast Usually Not Appropriate O
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 Varies
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

Panel Members
Hisham Dahmoush, MBBCha; Durga Sivacharan Gaddam, MDb; Mai-Lan Ho, MDc; David F. Bauer, MD, MPHd; Thangamadhan Bosemani, MDe; Jeffrey Buchhalter, MD, PhDf; Roshni A. Dasgupta, MDg; Orit A. Glenn, MDh; Carolina V. Guimaraes, MDi; Helen R. Nadel, MDj; Cory M. Pfeifer, MD, MS, MPH, MBAk; Rupa Radhakrishnan, MBBS, MSl; Charles Reitman, MDm; Anna K. Thomas, MDn; Unni K. Udayasankar, MDo; Jessica J. Wall, MD, MPH, MSCEp; Jason N. Wright, MDq; Courtney J. Wusthoff, MD, MSr; Sumit Pruthi, MD, MBBSs.
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)

OR

  • 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: Child. Back pain. No clinical red flags. Initial imaging.
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT area of interest
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
B. Bone scan whole body with SPECT or SPECT/CT complete spine
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
C. CT complete spine with IV contrast
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
D. CT complete spine without and with IV contrast
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
E. CT complete spine without IV contrast
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
F. CT myelography complete spine
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
G. CT myelography spine area of interest
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
H. CT spine area of interest with IV contrast
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
I. CT spine area of interest without and with IV contrast
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
J. CT spine area of interest without IV contrast
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
K. MRI complete spine with IV contrast
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
L. MRI complete spine without and with IV contrast
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
M. MRI complete spine without IV contrast
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
N. MRI spine area of interest with IV contrast
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
O. MRI spine area of interest without and with IV contrast
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
P. MRI spine area of interest without IV contrast
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
Q. Radiography complete spine
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
R. Radiography spine area of interest
Variant 1: Child. Back pain. No clinical red flags. Initial imaging.
S. US spine area of interest
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT area of interest
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
B. Bone scan whole body with SPECT or SPECT/CT complete spine
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
C. CT complete spine with IV contrast
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
D. CT complete spine without and with IV contrast
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
E. CT complete spine without IV contrast
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
F. CT myelography complete spine
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
G. CT myelography spine area of interest
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
H. CT spine area of interest with IV contrast
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
I. CT spine area of interest without and with IV contrast
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
J. CT spine area of interest without IV contrast
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
K. MRI complete spine with IV contrast
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
L. MRI complete spine without and with IV contrast
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
M. MRI complete spine without IV contrast
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
N. MRI spine area of interest with IV contrast
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
O. MRI spine area of interest without and with IV contrast
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
P. MRI spine area of interest without IV contrast
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
Q. Radiography complete spine
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
R. Radiography spine area of interest
Variant 2: Child. Back pain. With at least one clinical red flag. Initial imaging.
S. US spine area of interest
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
A. Bone scan whole body with SPECT or SPECT/CT area of interest
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
B. Bone scan whole body with SPECT or SPECT/CT complete spine
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
C. CT complete spine with IV contrast
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
D. CT complete spine without and with IV contrast
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
E. CT complete spine without IV contrast
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
F. CT myelography complete spine
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
G. CT myelography spine area of interest
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
H. CT spine area of interest with IV contrast
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
I. CT spine area of interest without and with IV contrast
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
J. CT spine area of interest without IV contrast
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
K. MRI complete spine with IV contrast
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
L. MRI complete spine without and with IV contrast
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
M. MRI complete spine without IV contrast
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
N. MRI spine area of interest with IV contrast
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
O. MRI spine area of interest without and with IV contrast
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
P. MRI spine area of interest without IV contrast
Variant 3: Child. Back pain. With at least one clinical red flag. Negative radiographs. Next imaging study.
Q. US spine area of interest
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT area of interest
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
B. Bone scan whole body with SPECT or SPECT/CT complete spine
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
C. CT complete spine with IV contrast
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
D. CT complete spine without and with IV contrast
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
E. CT complete spine without IV contrast
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
F. CT myelography complete spine
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
G. CT myelography spine area of interest
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
H. CT spine area of interest with IV contrast
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
I. CT spine area of interest without and with IV contrast
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
J. CT spine area of interest without IV contrast
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
K. MRI complete spine with IV contrast
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
L. MRI complete spine without and with IV contrast
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
M. MRI complete spine without IV contrast
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
N. Radiography complete spine
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
O. Radiography spine area of interest
Variant 4: Child. Back pain. Known or suspected inflammation, infection, or neoplasm. Initial imaging.
P. US spine area of interest
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
A. Bone scan whole body with SPECT or SPECT/CT area of interest
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
B. Bone scan whole body with SPECT or SPECT/CT complete spine
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
C. CT complete spine with IV contrast
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
D. CT complete spine without and with IV contrast
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
E. CT complete spine without IV contrast
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
F. CT myelography complete spine
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
G. CT myelography spine area of interest
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
H. CT spine area of interest with IV contrast
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
I. CT spine area of interest without and with IV contrast
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
J. CT spine area of interest without IV contrast
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
K. FDG-PET/CT whole body
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
L. MRI complete spine with IV contrast
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
M. MRI complete spine without and with IV contrast
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
N. MRI complete spine without IV contrast
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
O. MRI spine area of interest with IV contrast
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
P. MRI spine area of interest without and with IV contrast
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
Q. MRI spine area of interest without IV contrast
Variant 5: Child. Back pain. With at least one clinical red flag. Suspected infection, inflammation, or malignancy on radiography. Next imaging study.
R. US spine area of interest
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT area of interest
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
B. Bone scan whole body with SPECT or SPECT/CT complete spine
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
C. CT complete spine with IV contrast
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
D. CT complete spine without and with IV contrast
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
E. CT complete spine without IV contrast
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
F. CT myelography complete spine
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
G. CT myelography spine area of interest
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
H. CT spine area of interest with IV contrast
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
I. CT spine area of interest without and with IV contrast
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
J. CT spine area of interest without IV contrast
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
K. MRI complete spine with IV contrast
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
L. MRI complete spine without and with IV contrast
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
M. MRI complete spine without IV contrast
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
N. MRI spine area of interest with IV contrast
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
O. MRI spine area of interest without and with IV contrast
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
P. MRI spine area of interest without IV contrast
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
Q. Radiography complete spine
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
R. Radiography spine area of interest
Variant 6: Child. Chronic mechanical back pain associated with overuse or repetitive activity. Initial imaging.
S. US spine area of interest
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
A. Bone scan whole body with SPECT or SPECT/CT area of interest
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
B. Bone scan whole body with SPECT or SPECT/CT complete spine
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
C. CT complete spine with IV contrast
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
D. CT complete spine without and with IV contrast
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
E. CT complete spine without IV contrast
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
F. CT myelography complete spine
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
G. CT myelography spine area of interest
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
H. CT spine area of interest with IV contrast
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
I. CT spine area of interest without and with IV contrast
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
J. CT spine area of interest without IV contrast
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
K. MRI complete spine with IV contrast
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
L. MRI complete spine without and with IV contrast
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
M. MRI complete spine without IV contrast
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
N. MRI spine area of interest with IV contrast
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
O. MRI spine area of interest without and with IV contrast
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
P. MRI spine area of interest without IV contrast
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
Q. Radiography complete spine
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
R. Radiography spine area of interest
Variant 7: Child. Back pain with palpable lump or skin discoloration or hairy patch or draining sinus. Initial imaging.
S. 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.

Gender Equality and Inclusivity Clause
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 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. Borenstein DG, Balague F. Low Back Pain in Adolescent and Geriatric Populations. [Review]. Rheum Dis Clin North Am. 47(2):149-163, 2021 05.
2. Nolte MT, Harada GK, LeDuc R, et al. Pediatric Back Pain: A Scoring System to Guide Use of Magnetic Resonance Imaging. J Pediatr Orthop. 42(2):116-122, 2022 Feb 01.
3. Rodriguez DP, Poussaint TY. Imaging of back pain in children. AJNR. American journal of neuroradiology 2010;31:787-802.
4. Watson KD, Papageorgiou AC, Jones GT, et al. Low back pain in schoolchildren: occurrence and characteristics. Pain 2002;97:87-92.
5. Hebert JJ, Leboeuf-Yde C, Franz C, et al. Pubertal development and growth are prospectively associated with spinal pain in young people (CHAMPS study-DK). European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 2019;28:1565-71.
6. Shymon SJ, Yaszay B, Dwek JR, Proudfoot JA, Donohue M, Hargens AR. Altered disc compression in children with idiopathic low back pain: an upright magnetic resonance imaging backpack study. Spine 2014;39:243-8.
7. Palmer AJ, Poveda JL, Martinez-Laguna D, et al. Childhood overweight and obesity and back pain risk: a cohort study of 466 997 children. BMJ Open 2020;10:e036023.
8. Applegate KE, Cost NG. Image Gently: a campaign to reduce children's and adolescents' risk for cancer during adulthood. J Adolesc Health 2013;52:S93-7.
9. MacDonald J, Stuart E, Rodenberg R. Musculoskeletal Low Back Pain in School-aged Children: A Review. JAMA Pediatr 2017;171:280-87.
10. Kadom N, Palasis S, Pruthi S, et al. ACR Appropriateness Criteria® Suspected Spine Trauma-Child. J Am Coll Radiol 2019;16:S286-S99.
11. Jones JY, Saigal G, Palasis S, et al. ACR Appropriateness Criteria® Scoliosis-Child. J Am Coll Radiol 2019;16:S244-S51.
12. Achar S, Yamanaka J. Back Pain in Children and Adolescents. Am Fam Physician. 102(1):19-28, 2020 07 01.
13. de Bruin F, ter Horst S, Bloem HL, et al. Prevalence of degenerative changes of the spine on magnetic resonance images and radiographs in patients aged 16-45 years with chronic back pain of short duration in the Spondyloarthritis Caught Early (SPACE) cohort. Rheumatology (Oxford). 55(1):56-65, 2016 Jan.
14. Haidar R, Saad S, Khoury NJ, Musharrafieh U. Practical approach to the child presenting with back pain. European journal of pediatrics 2011;170:149-56.
15. 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.
16. Calloni SF, Huisman TA, Poretti A, Soares BP. Back pain and scoliosis in children: When to image, what to consider. [Review]. Neuroradiol. j.. 30(5):393-404, 2017 Oct.
17. Ramirez N, Flynn JM, Hill BW, et al. Evaluation of a systematic approach to pediatric back pain: the utility of magnetic resonance imaging. Journal of pediatric orthopedics 2015;35:28-32.
18. Costelloe CM, Madewell JE. Radiography in the initial diagnosis of primary bone tumors. AJR Am J Roentgenol 2013;200:3-7.
19. Gosangi B, Mandell JC, Weaver MJ, et al. Bone Marrow Edema at Dual-Energy CT: A Game Changer in the Emergency Department. Radiographics. 40(3):859-874, 2020 May-Jun.
20. Maamari J, Tande AJ, Diehn F, Tai DBG, Berbari EF. Diagnosis of vertebral osteomyelitis. J Bone Jt Infect 2022;7:23-32.
21. Dhanjani S, Marrache M, Puvanesarajah V, Pakpoor J, Jain A. Annual Trends and Geographic Variation in the Utilization of Imaging in Pediatric Patients with Low Back Pain in the United States. World Neurosurgery. 146:e972-e978, 2021 02.
22. Shih RY, Koeller KK. Intramedullary Masses of the Spinal Cord: Radiologic-Pathologic Correlation. Radiographics 2020;40:1125-45.
23. Trout AT, Sharp SE, Anton CG, Gelfand MJ, Mehlman CT. Spondylolysis and Beyond: Value of SPECT/CT in Evaluation of Low Back Pain in Children and Young Adults. [Review]. Radiographics. 35(3):819-34, 2015 May-Jun.
24. Jaramillo D, Dormans JP, Delgado J, Laor T, St Geme JW 3rd. Hematogenous Osteomyelitis in Infants and Children: Imaging of a Changing Disease. [Review]. Radiology. 283(3):629-643, 2017 06.
25. Patel DM, Weinberg BD, Hoch MJ. CT Myelography: Clinical Indications and Imaging Findings. Radiographics 2020;40:470-84.
26. Ozsoy-Unubol T, Yagci I. Is ultrasonographic enthesitis evaluation helpful for diagnosis of non-radiographic axial spondyloarthritis?. Rheumatology International. 38(11):2053-2061, 2018 11.
27. Garg S, Dormans JP. Tumors and tumor-like conditions of the spine in children. The Journal of the American Academy of Orthopaedic Surgeons 2005;13:372-81.
28. Huisman TA. Pediatric tumors of the spine. Cancer imaging : the official publication of the International Cancer Imaging Society 2009;9 Spec No A:S45-8.
29. Batouli A, Gholamrezanezhad A, Petrov D, Rudkin S, Matcuk G, Jadvar H. Management of Primary Osseous Spinal Tumors with PET. [Review]. PET clinics. 14(1):91-101, 2019 Jan.
30. Kaneko H, Murakami M, Nishizawa K. Prevalence and clinical features of sports-related lumbosacral stress injuries in the young. Arch Orthop Trauma Surg. 137(5):685-691, 2017 May.
31. Schroeder GD, LaBella CR, Mendoza M, et al. The role of intense athletic activity on structural lumbar abnormalities in adolescent patients with symptomatic low back pain. Eur Spine J. 25(9):2842-8, 2016 09.
32. Yoshimizu R, Nakase J, Yoshioka K, et al. Incidence and temporal changes in lumbar degeneration and low back pain in child and adolescent weightlifters: A prospective 5-year cohort study. PLoS ONE. 17(6):e0270046, 2022.
33. Gaddikeri S, Matesan M, Alvarez J, Hippe DS, Vesselle HJ. MDP-SPECT Versus Hybrid MDP-SPECT/CT in the Evaluation of Suspected Pars Interarticularis Fracture in Young Athletes. Journal of Neuroimaging. 28(6):635-639, 2018 11.
34. Sanpera I, Jr., Beguiristain-Gurpide JL. Bone scan as a screening tool in children and adolescents with back pain. Journal of pediatric orthopedics 2006;26:221-5.
35. Yang J, Servaes S, Edwards K, Zhuang H. Prevalence of stress reaction in the pars interarticularis in pediatric patients with new-onset lower back pain. Clinical nuclear medicine 2013;38:110-4.
36. Lohani S, Rodriguez DP, Lidov HG, Scott RM, Proctor MR. Intrasacral meningocele in the pediatric population. Journal of neurosurgery. Pediatrics 2013;11:615-22.
37. National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Committee on National Statistics; Committee on Measuring Sex, Gender Identity, and Sexual Orientation. Measuring Sex, Gender Identity, and Sexual Orientation. In: Becker T, Chin M, Bates N, eds. Measuring Sex, Gender Identity, and Sexual Orientation. Washington (DC): National Academies Press (US) Copyright 2022 by the National Academy of Sciences. All rights reserved.; 2022.
38. 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.