Thoracic Back Pain

Variant: 1 Adult. Acute thoracic back pain without myelopathy or radiculopathy. No red flags. No prior management. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography thoracic spine	Usually Not Appropriate	☢☢☢
MRI thoracic spine with IV contrast	Usually Not Appropriate	O
MRI thoracic spine without and with IV contrast	Usually Not Appropriate	O
MRI thoracic spine without IV contrast	Usually Not Appropriate	O
Bone scan whole body	Usually Not Appropriate	☢☢☢
Bone scan with SPECT or SPECT/CT thoracic spine	Usually Not Appropriate	☢☢☢
CT thoracic spine with IV contrast	Usually Not Appropriate	☢☢☢
CT thoracic spine without IV contrast	Usually Not Appropriate	☢☢☢
CT myelography thoracic spine	Usually Not Appropriate	☢☢☢☢
CT thoracic spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 2 Adult. Subacute or chronic thoracic back pain without myelopathy or radiculopathy. No red flags. Failed conservative management. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography thoracic spine	May Be Appropriate (Disagreement)	☢☢☢
MRI thoracic spine with IV contrast	Usually Not Appropriate	O
MRI thoracic spine without and with IV contrast	Usually Not Appropriate	O
MRI thoracic spine without IV contrast	Usually Not Appropriate	O
Bone scan whole body	Usually Not Appropriate	☢☢☢
Bone scan with SPECT or SPECT/CT thoracic spine	Usually Not Appropriate	☢☢☢
CT thoracic spine with IV contrast	Usually Not Appropriate	☢☢☢
CT thoracic spine without IV contrast	Usually Not Appropriate	☢☢☢
CT myelography thoracic spine	Usually Not Appropriate	☢☢☢☢
CT thoracic spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 3 Adult. Thoracic back pain with myelopathy or radiculopathy. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI thoracic spine without IV contrast	Usually Appropriate	O
Radiography thoracic spine	May Be Appropriate	☢☢☢
MRI thoracic spine without and with IV contrast	May Be Appropriate (Disagreement)	O
CT thoracic spine without IV contrast	May Be Appropriate (Disagreement)	☢☢☢
CT myelography thoracic spine	May Be Appropriate	☢☢☢☢
MRI thoracic spine with IV contrast	Usually Not Appropriate	O
Bone scan whole body	Usually Not Appropriate	☢☢☢
Bone scan with SPECT or SPECT/CT thoracic spine	Usually Not Appropriate	☢☢☢
CT thoracic spine with IV contrast	Usually Not Appropriate	☢☢☢
CT thoracic spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 4 Adult. Thoracic back pain without or with myelopathy or 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 thoracic spine	Usually Appropriate	☢☢☢
MRI thoracic spine without IV contrast	Usually Appropriate	O
CT thoracic spine without IV contrast	Usually Appropriate	☢☢☢
MRI thoracic spine without and with IV contrast	May Be Appropriate	O
Bone scan whole body	May Be Appropriate	☢☢☢
Bone scan with SPECT or SPECT/CT thoracic spine	May Be Appropriate	☢☢☢
MRI thoracic spine with IV contrast	Usually Not Appropriate	O
CT thoracic spine with IV contrast	Usually Not Appropriate	☢☢☢
CT myelography thoracic spine	Usually Not Appropriate	☢☢☢☢
CT thoracic spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 5 Adult. Thoracic back pain without or with myelopathy or radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI thoracic spine without and with IV contrast	Usually Appropriate	O
MRI thoracic spine without IV contrast	Usually Appropriate	O
Radiography thoracic spine	May Be Appropriate	☢☢☢
CT thoracic spine without IV contrast	May Be Appropriate	☢☢☢
CT myelography thoracic spine	May Be Appropriate	☢☢☢☢
MRI thoracic spine with IV contrast	Usually Not Appropriate	O
Bone scan whole body	Usually Not Appropriate	☢☢☢
Bone scan with SPECT or SPECT/CT thoracic spine	Usually Not Appropriate	☢☢☢
CT thoracic spine with IV contrast	Usually Not Appropriate	☢☢☢
CT thoracic spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 6 Adult. Thoracic back pain without or with myelopathy or radiculopathy. Radiograph shows bone destruction or fracture or spinal deformity. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
MRI thoracic spine without and with IV contrast	Usually Appropriate	O
MRI thoracic spine without IV contrast	Usually Appropriate	O
CT thoracic spine without IV contrast	Usually Appropriate	☢☢☢
CT myelography thoracic spine	May Be Appropriate	☢☢☢☢
MRI thoracic spine with IV contrast	Usually Not Appropriate	O
Bone scan whole body	Usually Not Appropriate	☢☢☢
Bone scan with SPECT or SPECT/CT thoracic spine	Usually Not Appropriate	☢☢☢
CT thoracic spine with IV contrast	Usually Not Appropriate	☢☢☢
CT thoracic spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 7 Adult. Thoracic back pain without or with myelopathy or radiculopathy. Post thoracic spine surgery. Follow-up imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography thoracic spine	Usually Appropriate	☢☢☢
MRI thoracic spine without and with IV contrast	Usually Appropriate	O
MRI thoracic spine without IV contrast	Usually Appropriate	O
CT thoracic spine without IV contrast	Usually Appropriate	☢☢☢
CT myelography thoracic spine	May Be Appropriate	☢☢☢☢
MRI thoracic spine with IV contrast	Usually Not Appropriate	O
Bone scan whole body	Usually Not Appropriate	☢☢☢
Bone scan with SPECT or SPECT/CT thoracic spine	Usually Not Appropriate	☢☢☢
CT thoracic spine with IV contrast	Usually Not Appropriate	☢☢☢
CT thoracic spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Panel Members

Vinil N. Shah, MD^a; Matthew S. Parsons, MD^b; Daniel J. Boulter, MD^c; Judah Burns, MD^d; Brian Callaghan, MD, MS^e; Rami W. Eldaya, MD^f; Michael Hanak, MD^g; Alvand Hassankhani, MD^h; Troy A. Hutchins, MDⁱ; Christopher D. Jackson, MD^j; Majid A. Khan, MD^k; Jeff Mullin, MD, MBA^l; A. Orlando Ortiz, MD, MBA^m; Charles Reitman, MDⁿ; Christopher Sampson, MD^o; Claire K. Sandstrom, MD^p; Vincent M. Timpone, MD^q; Andrew T. Trout, MD^r; Bruno Policeni, MD, MBA^s.

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: Adult. Acute thoracic back pain without myelopathy or radiculopathy. No red flags. No prior management. Initial imaging.

Variant 1: Adult. Acute thoracic back pain without myelopathy or radiculopathy. No red flags. No prior management. Initial imaging.
A. Bone scan whole body

Variant 1: Adult. Acute thoracic back pain without myelopathy or radiculopathy. No red flags. No prior management. Initial imaging.
B. Bone scan with SPECT or SPECT/CT thoracic spine

Variant 1: Adult. Acute thoracic back pain without myelopathy or radiculopathy. No red flags. No prior management. Initial imaging.
C. CT myelography thoracic spine

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

Variant 1: Adult. Acute thoracic back pain without myelopathy or radiculopathy. No red flags. No prior management. Initial imaging.
E. CT thoracic spine without and with IV contrast

Variant 1: Adult. Acute thoracic back pain without myelopathy or radiculopathy. No red flags. No prior management. Initial imaging.
F. CT thoracic spine without IV contrast

Variant 1: Adult. Acute thoracic back pain without myelopathy or radiculopathy. No red flags. No prior management. Initial imaging.
G. FDG-PET/CT skull base to mid-thigh

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

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

Variant 1: Adult. Acute thoracic back pain without myelopathy or radiculopathy. No red flags. No prior management. Initial imaging.
J. MRI thoracic spine without IV contrast

Variant 1: Adult. Acute thoracic back pain without myelopathy or radiculopathy. No red flags. No prior management. Initial imaging.
K. Radiography thoracic spine

Variant 2: Adult. Subacute or chronic thoracic back pain without myelopathy or radiculopathy. No red flags. Failed conservative management. Initial imaging.

Variant 2: Adult. Subacute or chronic thoracic back pain without myelopathy or radiculopathy. No red flags. Failed conservative management. Initial imaging.
A. Bone scan whole body

Variant 2: Adult. Subacute or chronic thoracic back pain without myelopathy or radiculopathy. No red flags. Failed conservative management. Initial imaging.
B. Bone scan with SPECT or SPECT/CT thoracic spine

Variant 2: Adult. Subacute or chronic thoracic back pain without myelopathy or radiculopathy. No red flags. Failed conservative management. Initial imaging.
C. CT myelography thoracic spine

Variant 2: Adult. Subacute or chronic thoracic back pain without myelopathy or radiculopathy. No red flags. Failed conservative management. Initial imaging.
D. CT thoracic spine with IV contrast

Variant 2: Adult. Subacute or chronic thoracic back pain without myelopathy or radiculopathy. No red flags. Failed conservative management. Initial imaging.
E. CT thoracic spine without and with IV contrast

Variant 2: Adult. Subacute or chronic thoracic back pain without myelopathy or radiculopathy. No red flags. Failed conservative management. Initial imaging.
F. CT thoracic spine without IV contrast

Variant 2: Adult. Subacute or chronic thoracic back pain without myelopathy or radiculopathy. No red flags. Failed conservative management. Initial imaging.
G. FDG-PET/CT skull base to mid-thigh

Variant 2: Adult. Subacute or chronic thoracic back pain without myelopathy or radiculopathy. No red flags. Failed conservative management. Initial imaging.
H. MRI thoracic spine with IV contrast

Variant 2: Adult. Subacute or chronic thoracic back pain without myelopathy or radiculopathy. No red flags. Failed conservative management. Initial imaging.
I. MRI thoracic spine without and with IV contrast

Variant 2: Adult. Subacute or chronic thoracic back pain without myelopathy or radiculopathy. No red flags. Failed conservative management. Initial imaging.
J. MRI thoracic spine without IV contrast

Variant 2: Adult. Subacute or chronic thoracic back pain without myelopathy or radiculopathy. No red flags. Failed conservative management. Initial imaging.
K. Radiography thoracic spine

Variant 3: Adult. Thoracic back pain with myelopathy or radiculopathy. Initial imaging.

Variant 3: Adult. Thoracic back pain with myelopathy or radiculopathy. Initial imaging.
A. Bone scan whole body

Variant 3: Adult. Thoracic back pain with myelopathy or radiculopathy. Initial imaging.
B. Bone scan with SPECT or SPECT/CT thoracic spine

Variant 3: Adult. Thoracic back pain with myelopathy or radiculopathy. Initial imaging.
C. CT myelography thoracic spine

Variant 3: Adult. Thoracic back pain with myelopathy or radiculopathy. Initial imaging.
D. CT thoracic spine with IV contrast

Variant 3: Adult. Thoracic back pain with myelopathy or radiculopathy. Initial imaging.
E. CT thoracic spine without and with IV contrast

Variant 3: Adult. Thoracic back pain with myelopathy or radiculopathy. Initial imaging.
F. CT thoracic spine without IV contrast

Variant 3: Adult. Thoracic back pain with myelopathy or radiculopathy. Initial imaging.
G. FDG-PET/CT skull base to mid-thigh

Variant 3: Adult. Thoracic back pain with myelopathy or radiculopathy. Initial imaging.
H. MRI thoracic spine with IV contrast

Variant 3: Adult. Thoracic back pain with myelopathy or radiculopathy. Initial imaging.
I. MRI thoracic spine without and with IV contrast

Variant 3: Adult. Thoracic back pain with myelopathy or radiculopathy. Initial imaging.
J. MRI thoracic spine without IV contrast

Variant 3: Adult. Thoracic back pain with myelopathy or radiculopathy. Initial imaging.
K. Radiography thoracic spine

Variant 4: Adult. Thoracic back pain without or with myelopathy or radiculopathy. One or more of the following: low-velocity trauma, osteoporosis, elderly individual, or chronic steroid use. Initial imaging.

Variant 5: Adult. Thoracic back pain without or with myelopathy or radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.

Variant 5: Adult. Thoracic back pain without or with myelopathy or radiculopathy. One or more of the following: suspicion of cancer, infection, or immunosuppression. Initial imaging.
A. Bone scan whole body

Variant 6: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Radiograph shows bone destruction or fracture or spinal deformity. Next imaging study.

Variant 6: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Radiograph shows bone destruction or fracture or spinal deformity. Next imaging study.
A. Bone scan whole body

Variant 7: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Post thoracic spine surgery. Follow-up imaging.

Variant 7: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Post thoracic spine surgery. Follow-up imaging.
A. Bone scan whole body

Variant 7: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Post thoracic spine surgery. Follow-up imaging.
B. Bone scan with SPECT or SPECT/CT thoracic spine

Variant 7: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Post thoracic spine surgery. Follow-up imaging.
C. CT myelography thoracic spine

Variant 7: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Post thoracic spine surgery. Follow-up imaging.
D. CT thoracic spine with IV contrast

Variant 7: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Post thoracic spine surgery. Follow-up imaging.
E. CT thoracic spine without and with IV contrast

Variant 7: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Post thoracic spine surgery. Follow-up imaging.
F. CT thoracic spine without IV contrast

Variant 7: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Post thoracic spine surgery. Follow-up imaging.
G. FDG-PET/CT skull base to mid-thigh

Variant 7: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Post thoracic spine surgery. Follow-up imaging.
H. MRI thoracic spine with IV contrast

Variant 7: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Post thoracic spine surgery. Follow-up imaging.
I. MRI thoracic spine without and with IV contrast

Variant 7: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Post thoracic spine surgery. Follow-up imaging.
J. MRI thoracic spine without IV contrast

Variant 7: Adult. Thoracic back pain without or with myelopathy or radiculopathy. Post thoracic spine surgery. Follow-up imaging.
K. Radiography thoracic 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.”

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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