Joint Pain: Idiopathic Arthritis-Child

Variant: 1 Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Radiography area of interest	Usually Appropriate	Varies
US area of interest	May Be Appropriate	O
MRI area of interest without and with IV contrast	May Be Appropriate	O
MRI area of interest without IV contrast	May Be Appropriate	O
US area of interest with IV contrast	Usually Not Appropriate	O
MRI whole body without and with IV contrast	Usually Not Appropriate	O
MRI whole body without IV contrast	Usually Not Appropriate	O
Bone scan whole body	Usually Not Appropriate	☢☢☢☢
Bone scan whole body with SPECT or SPECT/CT area of interest	Usually Not Appropriate	☢☢☢☢
Bone scan with SPECT or SPECT/CT area of interest	Usually Not Appropriate	☢☢☢☢
FDG-PET/MRI whole body	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢
CT area of interest with IV contrast	Usually Not Appropriate	Varies
CT area of interest without and with IV contrast	Usually Not Appropriate	Varies
CT area of interest without IV contrast	Usually Not Appropriate	Varies

Variant: 2 Child. Back pain. Suspected idiopathic arthritis. Initial imaging.

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
Radiography complete spine	May Be Appropriate	☢☢☢
Radiography spine area of interest	May Be Appropriate	Varies
MRI complete spine without IV contrast	May Be Appropriate	O
MRI spine area of interest without IV contrast	May Be Appropriate	O
US spine area of interest	Usually Not Appropriate	O
Bone scan whole body	Usually Not Appropriate	☢☢☢☢
Bone scan whole body with SPECT or SPECT/CT area of interest	Usually Not Appropriate	☢☢☢☢
Bone scan with SPECT or SPECT/CT area of interest	Usually Not Appropriate	☢☢☢☢
FDG-PET/MRI whole body	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	☢☢☢☢
FDG-PET/CT whole body	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: 3 Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRI sacroiliac joints without IV contrast	Usually Appropriate	O
Radiography pelvis	May Be Appropriate (Disagreement)	☢☢
Radiography sacroiliac joints	May Be Appropriate	☢☢
MRI sacroiliac joints and lumbar spine without and with IV contrast	May Be Appropriate	O
MRI sacroiliac joints and lumbar spine without IV contrast	May Be Appropriate	O
US sacroiliac joints	Usually Not Appropriate	O
MRI sacroiliac joints without and with IV contrast	Usually Not Appropriate	O
Bone scan whole body	Usually Not Appropriate	☢☢☢☢
Bone scan with SPECT or SPECT/CT sacroiliac joints	Usually Not Appropriate	☢☢☢☢
CT pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/MRI whole body	Usually Not Appropriate	☢☢☢☢
CT pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢

Variant: 4 Child. Temporomandibular joint pain. Suspected idiopathic arthritis. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRI temporomandibular joint without and with IV contrast	Usually Appropriate	O
Radiography temporomandibular joint	Usually Not Appropriate	☢☢
US head and neck	Usually Not Appropriate	O
MRI temporomandibular joint without IV contrast	Usually Not Appropriate	O
CT maxillofacial with IV contrast	Usually Not Appropriate	☢☢☢
CT maxillofacial without IV contrast	Usually Not Appropriate	☢☢☢
Bone scan whole body	Usually Not Appropriate	☢☢☢☢
Bone scan with SPECT or SPECT/CT maxillofacial	Usually Not Appropriate	☢☢☢☢
CT maxillofacial without and with IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/MRI whole body	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢

Variant: 5 Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US area of interest	Usually Appropriate	O
MRI area of interest without and with IV contrast	Usually Appropriate	O
Radiography area of interest	May Be Appropriate (Disagreement)	Varies
MRI area of interest without IV contrast	May Be Appropriate	O
US area of interest with IV contrast	Usually Not Appropriate	O
MRI whole body without and with IV contrast	Usually Not Appropriate	O
MRI whole body without IV contrast	Usually Not Appropriate	O
Bone scan whole body	Usually Not Appropriate	☢☢☢☢
Bone scan whole body with SPECT or SPECT/CT area of interest	Usually Not Appropriate	☢☢☢☢
Bone scan with SPECT or SPECT/CT area of interest	Usually Not Appropriate	☢☢☢☢
FDG-PET/MRI whole body	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢
CT area of interest with IV contrast	Usually Not Appropriate	Varies
CT area of interest without and with IV contrast	Usually Not Appropriate	Varies
CT area of interest without IV contrast	Usually Not Appropriate	Varies

Variant: 6 Child. Back pain. Idiopathic arthritis. Follow-up imaging.

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	O
MRI spine area of interest without IV contrast	May Be Appropriate	O
Radiography complete spine	Usually Not Appropriate	☢☢☢
US spine area of interest	Usually Not Appropriate	O
Radiography spine area of interest	Usually Not Appropriate	Varies
Bone scan whole body	Usually Not Appropriate	☢☢☢☢
Bone scan whole body with SPECT or SPECT/CT area of interest	Usually Not Appropriate	☢☢☢☢
Bone scan with SPECT or SPECT/CT area of interest	Usually Not Appropriate	☢☢☢☢
FDG-PET/MRI whole body	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	☢☢☢☢
FDG-PET/CT whole body	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: 7 Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRI sacroiliac joints without IV contrast	Usually Appropriate	O
MRI sacroiliac joints and lumbar spine without and with IV contrast	May Be Appropriate	O
MRI sacroiliac joints and lumbar spine without IV contrast	May Be Appropriate	O
US sacroiliac joints	Usually Not Appropriate	O
Radiography pelvis	Usually Not Appropriate	☢☢
Radiography sacroiliac joints	Usually Not Appropriate	☢☢
MRI sacroiliac joints without and with IV contrast	Usually Not Appropriate	O
Bone scan whole body	Usually Not Appropriate	☢☢☢☢
Bone scan with SPECT or SPECT/CT sacroiliac joints	Usually Not Appropriate	☢☢☢☢
CT pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/MRI whole body	Usually Not Appropriate	☢☢☢☢
CT pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢

Variant: 8 Child. Temporomandibular joint pain. Idiopathic arthritis. Follow-up imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRI temporomandibular joint without and with IV contrast	Usually Appropriate	O
CT maxillofacial without IV contrast	May Be Appropriate	☢☢☢
Radiography temporomandibular joint	Usually Not Appropriate	☢☢
US head and neck	Usually Not Appropriate	O
MRI temporomandibular joint without IV contrast	Usually Not Appropriate	O
CT maxillofacial with IV contrast	Usually Not Appropriate	☢☢☢
Bone scan whole body	Usually Not Appropriate	☢☢☢☢
Bone scan with SPECT or SPECT/CT maxillofacial	Usually Not Appropriate	☢☢☢☢
CT maxillofacial without and with IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/MRI whole body	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT whole body	Usually Not Appropriate	☢☢☢☢

Panel Members

Nancy A. Chauvin, MD^a; Anh-Vu H. Ngo, MD^b; Sherwin S. Chan, MD, PhD^c; Brandon P. Brown, MD, MA^d; Scott R. Dorfman, MD^e; Marla Guzman, MD^f; George Koberlein, MD^g; Morgan P. McBee, MD^h; HaiThuy N. Nguyen, MDⁱ; Karen Brandt Onel, MD^j; Emily S. Orscheln, MD^k; Elizabeth J. Snyder, MD^l; Andrew T. Trout, MD^m; Muhammad Waseem, MD, MSⁿ; Kirsten L. Weltmer, MD^o; George S. Wu, MD^p; Ramesh S. Iyer, MD, MBA^q.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

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: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.

Variant 1: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.
A. Bone scan whole body

Variant 1: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.
B. Bone scan whole body with SPECT or SPECT/CT area of interest

Variant 1: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.
C. Bone scan with SPECT or SPECT/CT area of interest

Variant 1: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.
D. CT area of interest with IV contrast

Variant 1: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.
E. CT area of interest without and with IV contrast

Variant 1: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.
F. CT area of interest without IV contrast

Variant 1: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.
G. FDG-PET/CT whole body

Variant 1: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.
H. FDG-PET/MRI whole body

Variant 1: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.
I. MRI area of interest without and with IV contrast

Variant 1: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.
J. MRI area of interest without IV contrast

Variant 1: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.
K. MRI whole body without and with IV contrast

Variant 1: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.
L. MRI whole body without IV contrast

Variant 1: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.
M. Radiography area of interest

Variant 1: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.
N. US area of interest

Variant 1: Child. Appendicular joint pain or swelling. Suspected idiopathic arthritis. Initial imaging.
O. US area of interest with IV contrast

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
A. Bone scan whole body

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
B. Bone scan whole body with SPECT or SPECT/CT area of interest

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
C. Bone scan with SPECT or SPECT/CT area of interest

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
D. CT complete spine with IV contrast

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
E. CT complete spine without and with IV contrast

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
F. CT complete spine without IV contrast

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
G. CT spine area of interest with IV contrast

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
H. CT spine area of interest without and with IV contrast

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
I. CT spine area of interest without IV contrast

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
J. FDG-PET/CT whole body

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
K. FDG-PET/MRI whole body

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
L. MRI complete spine without and with IV contrast

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
M. MRI complete spine without IV contrast

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
N. MRI spine area of interest without and with IV contrast

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
O. MRI spine area of interest without IV contrast

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
P. Radiography complete spine

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
Q. Radiography spine area of interest

Variant 2: Child. Back pain. Suspected idiopathic arthritis. Initial imaging.
R. US spine area of interest

Variant 3: Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.

Variant 3: Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.
A. Bone scan whole body

Variant 3: Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.
B. Bone scan with SPECT or SPECT/CT sacroiliac joints

Variant 3: Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.
C. CT pelvis with IV contrast

Variant 3: Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.
D. CT pelvis without and with IV contrast

Variant 3: Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.
E. CT pelvis without IV contrast

Variant 3: Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.
F. FDG-PET/CT whole body

Variant 3: Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.
G. FDG-PET/MRI whole body

Variant 3: Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.
H. MRI sacroiliac joints and lumbar spine without and with IV contrast

Variant 3: Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.
I. MRI sacroiliac joints and lumbar spine without IV contrast

Variant 3: Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.
J. MRI sacroiliac joints without and with IV contrast

Variant 3: Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.
K. MRI sacroiliac joints without IV contrast

Variant 3: Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.
L. Radiography pelvis

Variant 3: Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.
M. Radiography sacroiliac joints

Variant 3: Child. Sacroiliac joint pain. Suspected idiopathic arthritis. Initial imaging.
N. US sacroiliac joints

Variant 4: Child. Temporomandibular joint pain. Suspected idiopathic arthritis. Initial imaging.

Variant 4: Child. Temporomandibular joint pain. Suspected idiopathic arthritis. Initial imaging.
A. Bone scan whole body

Variant 4: Child. Temporomandibular joint pain. Suspected idiopathic arthritis. Initial imaging.
B. Bone scan with SPECT or SPECT/CT maxillofacial

Variant 4: Child. Temporomandibular joint pain. Suspected idiopathic arthritis. Initial imaging.
C. CT maxillofacial with IV contrast

Variant 4: Child. Temporomandibular joint pain. Suspected idiopathic arthritis. Initial imaging.
D. CT maxillofacial without and with IV contrast

Variant 4: Child. Temporomandibular joint pain. Suspected idiopathic arthritis. Initial imaging.
E. CT maxillofacial without IV contrast

Variant 4: Child. Temporomandibular joint pain. Suspected idiopathic arthritis. Initial imaging.
F. FDG-PET/CT whole body

Variant 4: Child. Temporomandibular joint pain. Suspected idiopathic arthritis. Initial imaging.
G. FDG-PET/MRI whole body

Variant 4: Child. Temporomandibular joint pain. Suspected idiopathic arthritis. Initial imaging.
H. MRI temporomandibular joint without and with IV contrast

Variant 4: Child. Temporomandibular joint pain. Suspected idiopathic arthritis. Initial imaging.
I. MRI temporomandibular joint without IV contrast

Variant 4: Child. Temporomandibular joint pain. Suspected idiopathic arthritis. Initial imaging.
J. Radiography temporomandibular joint

Variant 4: Child. Temporomandibular joint pain. Suspected idiopathic arthritis. Initial imaging.
K. US head and neck

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.
A. Bone scan whole body

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.
B. Bone scan whole body with SPECT or SPECT/CT area of interest

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.
C. Bone scan with SPECT or SPECT/CT area of interest

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.
D. CT area of interest with IV contrast

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.
E. CT area of interest without and with IV contrast

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.
F. CT area of interest without IV contrast

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.
G. FDG-PET/CT whole body

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.
H. FDG-PET/MRI whole body

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.
I. MRI area of interest without and with IV contrast

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.
J. MRI area of interest without IV contrast

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.
K. MRI whole body without and with IV contrast

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.
L. MRI whole body without IV contrast

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.
M. Radiography area of interest

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.
N. US area of interest

Variant 5: Child. Appendicular joint pain or swelling. Idiopathic arthritis. Follow-up imaging.
O. US area of interest with IV contrast

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
A. Bone scan whole body

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
B. Bone scan whole body with SPECT or SPECT/CT area of interest

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
C. Bone scan with SPECT or SPECT/CT area of interest

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
D. CT complete spine with IV contrast

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
E. CT complete spine without and with IV contrast

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
F. CT complete spine without IV contrast

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
G. CT spine area of interest with IV contrast

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
H. CT spine area of interest without and with IV contrast

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
I. CT spine area of interest without IV contrast

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
J. FDG-PET/CT whole body

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
K. FDG-PET/MRI whole body

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
L. MRI complete spine without and with IV contrast

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
M. MRI complete spine without IV contrast

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
N. MRI spine area of interest without and with IV contrast

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
O. MRI spine area of interest without IV contrast

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
P. Radiography complete spine

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
Q. Radiography spine area of interest

Variant 6: Child. Back pain. Idiopathic arthritis. Follow-up imaging.
R. US spine area of interest

Variant 7: Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.

Variant 7: Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.
A. Bone scan whole body

Variant 7: Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.
B. Bone scan with SPECT or SPECT/CT sacroiliac joints

Variant 7: Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.
C. CT pelvis with IV contrast

Variant 7: Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.
D. CT pelvis without and with IV contrast

Variant 7: Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.
E. CT pelvis without IV contrast

Variant 7: Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.
F. FDG-PET/CT whole body

Variant 7: Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.
G. FDG-PET/MRI whole body

Variant 7: Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.
H. MRI sacroiliac joints and lumbar spine without and with IV contrast

Variant 7: Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.
I. MRI sacroiliac joints and lumbar spine without IV contrast

Variant 7: Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.
J. MRI sacroiliac joints without and with IV contrast

Variant 7: Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.
K. MRI sacroiliac joints without IV contrast

Variant 7: Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.
L. Radiography pelvis

Variant 7: Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.
M. Radiography sacroiliac joints

Variant 7: Child. Sacroiliac joint pain. Idiopathic arthritis. Follow-up imaging.
N. US sacroiliac joints

Variant 8: Child. Temporomandibular joint pain. Idiopathic arthritis. Follow-up imaging.

Variant 8: Child. Temporomandibular joint pain. Idiopathic arthritis. Follow-up imaging.
A. Bone scan whole body

Variant 8: Child. Temporomandibular joint pain. Idiopathic arthritis. Follow-up imaging.
B. Bone scan with SPECT or SPECT/CT maxillofacial

Variant 8: Child. Temporomandibular joint pain. Idiopathic arthritis. Follow-up imaging.
C. CT maxillofacial with IV contrast

Variant 8: Child. Temporomandibular joint pain. Idiopathic arthritis. Follow-up imaging.
D. CT maxillofacial without and with IV contrast

Variant 8: Child. Temporomandibular joint pain. Idiopathic arthritis. Follow-up imaging.
E. CT maxillofacial without IV contrast

Variant 8: Child. Temporomandibular joint pain. Idiopathic arthritis. Follow-up imaging.
F. FDG-PET/CT whole body

Variant 8: Child. Temporomandibular joint pain. Idiopathic arthritis. Follow-up imaging.
G. FDG-PET/MRI whole body

Variant 8: Child. Temporomandibular joint pain. Idiopathic arthritis. Follow-up imaging.
H. MRI temporomandibular joint without and with IV contrast

Variant 8: Child. Temporomandibular joint pain. Idiopathic arthritis. Follow-up imaging.
I. MRI temporomandibular joint without IV contrast

Variant 8: Child. Temporomandibular joint pain. Idiopathic arthritis. Follow-up imaging.
J. Radiography temporomandibular joint

Variant 8: Child. Temporomandibular joint pain. Idiopathic arthritis. Follow-up imaging.
K. US head and neck

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.	Chauvin NA, Doria AS. Ultrasound imaging of synovial inflammation in juvenile idiopathic arthritis. [Review]. Pediatric Radiology. 47(9):1160-1170, 2017 Aug.
2.	Basra HAS, Humphries PD. Juvenile idiopathic arthritis: what is the utility of ultrasound?. [Review]. British Journal of Radiology. 90(1073):20160920, 2017 May.
3.	Malattia C, Rinaldi M, Martini A. The role of imaging in juvenile idiopathic arthritis. [Review]. Expert Review of Clinical Immunology. 14(8):681-694, 2018 08.
4.	Hemke R, Herregods N, Jaremko JL, et al. Imaging assessment of children presenting with suspected or known juvenile idiopathic arthritis: ESSR-ESPR points to consider. [Review]. European Radiology. 30(10):5237-5249, 2020 Oct.
5.	Sheybani EF, Khanna G, White AJ, Demertzis JL. Imaging of juvenile idiopathic arthritis: a multimodality approach. Radiographics. 33(5):1253-73, 2013 Sep-Oct.
6.	Collado P, Malattia C. Imaging in paediatric rheumatology: Is it time for imaging?. [Review]. Best Practice & Research in Clinical Rheumatology. 30(4):720-735, 2016 08.
7.	Tarsia M, Zajc Avramovic M, Gazikalovic A, Kljucevsek D, Avcin T. A clinical perspective on imaging in juvenile idiopathic arthritis. Pediatr Radiol 2023.
8.	Ording Muller LS, Boavida P, Avenarius D, et al. MRI of the wrist in juvenile idiopathic arthritis: erosions or normal variants? A prospective case-control study. Pediatric Radiology. 43(7):785-95, 2013 Jul.
9.	Herregods N, Maksymowych WP, Jans L, et al. Atlas of MRI findings of sacroiliitis in pediatric sacroiliac joints to accompany the updated preliminary OMERACT pediatric JAMRIS (Juvenile Idiopathic Arthritis MRI Score) scoring system: Part I: Active lesions. Seminars in Arthritis & Rheumatism. 51(5):1089-1098, 2021 10.
10.	Herregods N, Maksymowych WP, Jans L, et al. Atlas of MRI findings of sacroiliitis in pediatric sacroiliac joints to accompany the updated preliminary OMERACT pediatric JAMRIS (Juvenile Idiopathic Arthritis MRI Score) scoring system: Part II: Structural damage lesions. Seminars in Arthritis & Rheumatism. 51(5):1099-1107, 2021 10.
11.	Kellenberger CJ, Junhasavasdikul T, Tolend M, Doria AS. Temporomandibular joint atlas for detection and grading of juvenile idiopathic arthritis involvement by magnetic resonance imaging. [Review]. Pediatric Radiology. 48(3):411-426, 2018 03.
12.	Restrepo R, Lee EY, Babyn PS. Juvenile idiopathic arthritis: current practical imaging assessment with emphasis on magnetic resonance imaging. [Review]. Radiologic Clinics of North America. 51(4):703-19, 2013 Jul.
13.	Hemke R, van Rossum MA, van Veenendaal M, et al. Reliability and responsiveness of the Juvenile Arthritis MRI Scoring (JAMRIS) system for the knee. European Radiology. 23(4):1075-83, 2013 Apr.
14.	Malattia C, Consolaro A, Pederzoli S, et al. MRI versus conventional measures of disease activity and structural damage in evaluating treatment efficacy in juvenile idiopathic arthritis. Annals of the Rheumatic Diseases. 72(3):363-8, 2013 Mar.
15.	Porter-Young FM, Offiah AC, Broadley P, et al. Inter- and intra-observer reliability of contrast-enhanced magnetic resonance imaging parameters in children with suspected juvenile idiopathic arthritis of the hip. Pediatric Radiology. 48(13):1891-1900, 2018 12.
16.	Hemke R, Kuijpers TW, van den Berg JM, et al. The diagnostic accuracy of unenhanced MRI in the assessment of joint abnormalities in juvenile idiopathic arthritis. European Radiology. 23(7):1998-2004, 2013 Jul.
17.	Nusman CM, Hemke R, Benninga MA, et al. Contrast-enhanced MRI of the knee in children unaffected by clinical arthritis compared to clinically active juvenile idiopathic arthritis patients. European Radiology. 26(4):1141-8, 2016 Apr.
18.	Nusman CM, Ording Muller LS, Hemke R, et al. Current Status of Efforts on Standardizing Magnetic Resonance Imaging of Juvenile Idiopathic Arthritis: Report from the OMERACT MRI in JIA Working Group and Health-e-Child. [Review]. Journal of Rheumatology. 43(1):239-44, 2016 Jan.
19.	Nusman CM, Rosendahl K, Maas M. MRI Protocol for the Assessment of Juvenile Idiopathic Arthritis of the Wrist: Recommendations from the OMERACT MRI in JIA Working Group and Health-e-Child. J Rheumatol 2016;43:1257-8.
20.	Barendregt AM, van Gulik EC, Lavini C, et al. Diffusion-weighted imaging for assessment of synovial inflammation in juvenile idiopathic arthritis: a promising imaging biomarker as an alternative to gadolinium-based contrast agents. European Radiology. 27(11):4889-4899, 2017 Nov.
21.	Vo Chieu VD, Vo Chieu V, Dressler F, et al. Juvenile idiopathic arthritis of the knee: is contrast needed to score disease activity when using an augmented MRI protocol comprising PD-weighted sequences?. European Radiology. 33(5):3775-3784, 2023 May.
22.	Marteau P, Adamsbaum C, Rossi-Semerano L, et al. Conventional radiography in juvenile idiopathic arthritis: Joint recommendations from the French societies for rheumatology, radiology and paediatric rheumatology. [Review]. European Radiology. 28(9):3963-3976, 2018 Sep.
23.	Pracon G, Aparisi Gomez MP, Simoni P, Gietka P, Sudol-Szopinska I. Conventional Radiography and Ultrasound Imaging of Rheumatic Diseases Affecting the Pediatric Population. Seminars in Musculoskeletal Radiology. 25(1):68-81, 2021 Feb.
24.	Onel KB, Horton DB, Lovell DJ, et al. 2021 American College of Rheumatology Guideline for the Treatment of Juvenile Idiopathic Arthritis: Recommendations for Nonpharmacologic Therapies, Medication Monitoring, Immunizations, and Imaging. Arthritis Rheumatol 2022;74:570-85.
25.	Rodriguez-Lozano AL, Giancane G, Pignataro R, et al. Agreement among musculoskeletal pediatric specialists in the assessment of radiographic joint damage in juvenile idiopathic arthritis. Arthritis care & research. 66(1):34-9, 2014 Jan.
26.	Borocco C, Anselmi F, Rossi-Semerano L. Contribution of Ultrasound in Current Practice for Managing Juvenile Idiopathic Arthritis. J Clin Med 2022;12.
27.	Rossi-Semerano L, Breton S, Semerano L, et al. Application of the OMERACT synovitis ultrasound scoring system in juvenile idiopathic arthritis: a multicenter reliability exercise. Rheumatology (Oxford) 2021;60:3579-87.
28.	Collado P, Martire MV, Lanni S, et al. OMERACT International Consensus for Ultrasound Definitions of Tenosynovitis in Juvenile Idiopathic Arthritis: Systematic Literature Review and Delphi Process. Arthritis Care Res (Hoboken) 2023;75:2277-84.
29.	Rossi-Semerano L, Ravagnani V, Collado P, et al. Validity of ultrasonography in detecting enthesitis in children: A systematic literature review. Joint, Bone, Spine: Revue du Rhumatisme. 90(4):105538, 2023 Jul.
30.	Ventura-Rios L, Faugier E, Barzola L, et al. Reliability of ultrasonography to detect inflammatory lesions and structural damage in juvenile idiopathic arthritis. Pediatric Rheumatology Online Journal. 16(1):58, 2018 Sep 17.
31.	Vega-Fernandez P, Esteban Y, Oberle E, et al. Reliability of the Pediatric Specific Musculoskeletal Ultrasound Scoring Systems for the Elbow, Wrist, and Finger Joints. Journal of Rheumatology. 50(2):236-239, 2023 02.
32.	De Lucia O, Ravagnani V, Pregnolato F, et al. Baseline ultrasound examination as possible predictor of relapse in patients affected by juvenile idiopathic arthritis (JIA). Annals of the Rheumatic Diseases. 77(10):1426-1431, 2018 10.
33.	Ntoulia A, Barnewolt CE, Doria AS, et al. Contrast-enhanced ultrasound for musculoskeletal indications in children. [Review]. Pediatric Radiology. 51(12):2303-2323, 2021 Nov.
34.	Hospach T, Maier J, Muller-Abt P, Patel A, Horneff G, von Kalle T. Cervical spine involvement in patients with juvenile idiopathic arthritis - MRI follow-up study. Pediatric Rheumatology Online Journal. 12:9, 2014 Mar 04.
35.	Demir S, Ergen FB, Taydas O, et al. Spinal involvement in juvenile idiopathic arthritis: what do we miss without imaging?. Rheumatology International. 42(3):519-527, 2022 03.
36.	Srinivasalu H, Sikora KA, Colbert RA. Recent Updates in Juvenile Spondyloarthritis. [Review]. Rheumatic Diseases Clinics of North America. 47(4):565-583, 2021 11.
37.	Naveen R, Guleria S, Aggarwal A. Recent updates in enthesitis-related arthritis. Rheumatol Int 2023;43:409-20.
38.	Weiss PF, Xiao R, Biko DM, Johnson AM, Chauvin NA. Detection of inflammatory sacroiliitis in children with magnetic resonance imaging: is gadolinium contrast enhancement necessary? Arthritis Rheumatol 2015;67:2250-6.
39.	Tsoi C, Griffith JF, Lee RKL, Wong PCH, Tam LS. Imaging of sacroiliitis: Current status, limitations and pitfalls. Quant Imaging Med Surg 2019;9:318-35.
40.	Bray TJ, Amies T, Vendhan K, et al. Discordant inflammatory changes in the apophyseal and sacroiliac joints: serial observations in enthesitis-related arthritis. Br J Radiol 2016;89:20160353.
41.	Herregods N, Jaremko JL, Baraliakos X, et al. Limited role of gadolinium to detect active sacroiliitis on MRI in juvenile spondyloarthritis. Skeletal Radiology. 44(11):1637-46, 2015 Nov.
42.	Wagle S, Gu JT, Courtier JL, Phelps AS, Lin C, MacKenzie JD. Value of dedicated small-field-of-view sacroiliac versus large-field-of-view pelvic magnetic resonance imaging for evaluating pediatric sacroiliitis. Pediatr Radiol 2019;49:933-40.
43.	Weiss PF, Xiao R, Brandon TG, et al. Radiographs in screening for sacroiliitis in children: what is the value?. Arthritis Res Ther. 20(1):141, 2018 07 11.
44.	Rongo R, Alstergren P, Ammendola L, et al. Temporomandibular joint damage in juvenile idiopathic arthritis: Diagnostic validity of diagnostic criteria for temporomandibular disorders. Journal of Oral Rehabilitation. 46(5):450-459, 2019 May.
45.	Inarejos Clemente EJ, Tolend M, Navallas M, Doria AS, Meyers AB. MRI of the temporomandibular joint in children with juvenile idiopathic arthritis: protocol and findings. [Review]. Pediatric Radiology. 53(8):1498-1512, 2023 07.
46.	Miller E, Inarejos Clemente EJ, Tzaribachev N, et al. Imaging of temporomandibular joint abnormalities in juvenile idiopathic arthritis with a focus on developing a magnetic resonance imaging protocol. [Review]. Pediatric Radiology. 48(6):792-800, 2018 06.
47.	Rosa VLM, Zwir LMF, Dutra MEP, Russo GCS, Rodrigues WDR, Terreri MT. Does the use of panoramic radiography add information in the temporomandibular joint evaluation in Juvenile Idiopathic Arthritis patients? A case control study. Advances in Rheumatology. 63(1):6, 2023 02 13.
48.	Zwir LF, Terreri MT, do Amaral E Castro A, Rodrigues WDR, Fernandes ARC. Is power Doppler ultrasound useful to evaluate temporomandibular joint inflammatory activity in juvenile idiopathic arthritis?. Clinical Rheumatology. 39(4):1237-1240, 2020 Apr.
49.	Tateishi U, Imagawa T, Kanezawa N, et al. PET assessment of disease activity in children with juvenile idiopathic arthritis. Pediatr Radiol 2010;40:1781-8.
50.	Mazzoni M, Pistorio A, Magnaguagno F, et al. Predictive Value of Magnetic Resonance Imaging in Patients With Juvenile Idiopathic Arthritis in Clinical Remission. Arthritis care & research. 75(1):198-205, 2023 01.
51.	Panwar J, Tolend M, Redd B, et al. Consensus-driven conceptual development of a standardized whole body-MRI scoring system for assessment of disease activity in juvenile idiopathic arthritis: MRI in JIA OMERACT working group. Seminars in Arthritis & Rheumatism. 51(6):1350-1359, 2021 12.
52.	Saoussen M, Yasmine M, Hiba B, Alia F, Kawther BA, Ahmed L. The role of ultrasonography in assessing remission in juvenile idiopathic arthritis: a systematic review. [Review]. European Journal of Pediatrics. 182(7):2989-2997, 2023 Jul.
53.	Vega-Fernandez P, Oberle EJ, Henrickson M, et al. Musculoskeletal Ultrasound and the Assessment of Disease Activity in Juvenile Idiopathic Arthritis. Arthritis care & research. 75(8):1815-1820, 2023 08.
54.	Kotecki M, Gietka P, Posadzy M, Sudol-Szopinska I. Radiographs and MRI of the Cervical Spine in Juvenile Idiopathic Arthritis: A Cross-Sectional Retrospective Study. J Clin Med 2021;10.
55.	Vendhan K, Sen D, Fisher C, Ioannou Y, Hall-Craggs MA. Inflammatory changes of the lumbar spine in children and adolescents with enthesitis-related arthritis: magnetic resonance imaging findings. Arthritis Care Res (Hoboken) 2014;66:40-6.
56.	Al-Shwaikh H, Urtane I, Pirttiniemi P, et al. Radiologic features of temporomandibular joint osseous structures in children with juvenile idiopathic arthritis. Cone beam computed tomography study. Stomatologija. 18(2):51-60, 2016.
57.	Hara GF, de Souza-Pinto GN, Brasil DM, et al. What is the image appearance of juvenile idiopathic arthritis in MRI, CT, and CBCT of TMJ? A systematic review. Clinical Oral Investigations. 27(5):2321-2333, 2023 May.
58.	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.
59.	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.