Date of origin: 1999 Last review date: 2012
American College of Radiology ACR Appropriateness Criteria® Clinical Condition:
Suspected Spine Trauma
Variant 1:
Cervical spine imaging not indicated by NEXUS or CCR clinical criteria. Patient meets lowrisk criteria. Radiologic Procedure
Rating
Comments
RRL* ☢☢
X-ray cervical spine
1
CT cervical spine without IV contrast
1
CT cervical spine with IV contrast
1
☢☢☢
1
☢☢☢
1
☢☢☢☢
CTA head and neck with IV contrast
1
☢☢☢
MRI cervical spine without IV contrast MRI cervical spine without and with IV contrast MRA neck without and with IV contrast
1
O
1
O
1
O
MRA neck without IV contrast
1
O
Arteriography cervicocerebral
1
☢☢☢
CT cervical spine without and with IV contrast Myelography and post myelography CT cervical spine
With sagittal and coronal reformat.
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
Variant 2:
☢☢☢
*Relative Radiation Level
Suspected acute cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Not otherwise specified. Radiologic Procedure
CT cervical spine without IV contrast
Rating
Comments
RRL* ☢☢☢
9
With sagittal and coronal reformat.
X-ray cervical spine
6
Lateral view only. Useful if CT reconstructions are not optimal.
CT cervical spine with IV contrast
1
☢☢☢
1
☢☢☢
1
☢☢☢☢
CT cervical spine without and with IV contrast Myelography and post myelography CT cervical spine
☢☢
CTA head and neck with IV contrast
1
See variant 6.
☢☢☢
MRI cervical spine without IV contrast MRI cervical spine without and with IV contrast MRA neck without and with IV contrast
1
See variant 3.
O
1
See variant 3.
O
1
See variant 6.
O
MRA neck without IV contrast
1
See variant 6.
O
Arteriography cervicocerebral
1
See variant 6.
☢☢☢
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
ACR Appropriateness Criteria®
1
*Relative Radiation Level
Suspected Spine Trauma
Clinical Condition:
Suspected Spine Trauma
Variant 3:
Suspected acute cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Myelopathy. Radiologic Procedure
Rating
Comments
RRL*
With sagittal and coronal reformat. MRI and CT provide complementary information. It is appropriate to perform both examinations. MRI and CT provide complementary information. It is appropriate to perform both examinations. Lateral view only. Useful if CT reconstructions are not optimal.
☢☢☢
CT cervical spine without IV contrast
9
MRI cervical spine without IV contrast
9
X-ray cervical spine
6
Myelography and post myelography CT cervical spine
5
CT cervical spine with IV contrast
1
☢☢☢
1
☢☢☢
1
O
CT cervical spine without and with IV contrast MRI cervical spine without and with IV contrast
If MRI is contraindicated or inconclusive.
O ☢☢ ☢☢☢☢
CTA head and neck with IV contrast
1
See variant 6.
☢☢☢
MRA neck without and with IV contrast
1
See variant 6.
O
MRA neck without IV contrast
1
See variant 6.
O
Arteriography cervicocerebral
1
See variant 6.
☢☢☢
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
ACR Appropriateness Criteria®
2
*Relative Radiation Level
Suspected Spine Trauma
Clinical Condition:
Suspected Spine Trauma
Variant 4:
Acute cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Treatment planning for mechanically unstable spine. Radiologic Procedure
Rating
Comments
RRL* ☢☢☢
CT cervical spine without IV contrast
9
MRI cervical spine without IV contrast
8
X-ray cervical spine
6
Myelography and post myelography CT cervical spine
4
☢☢☢☢
CT cervical spine with IV contrast
1
☢☢☢
1
☢☢☢
1
O
CT cervical spine without and with IV contrast MRI cervical spine without and with IV contrast
With sagittal and coronal reformat. Useful for thorough evaluation of ligamentous injury. Either lateral views only or AP, lateral, open-mouth, and oblique views may be appropriate. Individualized in consultation with ordering physician for surgical planning.
O
☢☢
CTA head and neck with IV contrast
1
See variant 6.
☢☢☢
MRA neck without and with IV contrast
1
See variant 6.
O
MRA neck without IV contrast
1
See variant 6.
O
Arteriography cervicocerebral
1
See variant 6.
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
ACR Appropriateness Criteria®
3
☢☢☢ *Relative Radiation Level
Suspected Spine Trauma
Clinical Condition:
Suspected Spine Trauma
Variant 5:
Suspected acute cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Patient persistently clinically unevaluable for >48 hours. Radiologic Procedure
Rating
Comments
RRL* ☢☢☢
CT cervical spine without IV contrast
9
MRI cervical spine without IV contrast
8
X-ray cervical spine
4
CT cervical spine with IV contrast
1
☢☢☢
1
☢☢☢
1
O
1
☢☢☢☢
CTA head and neck with IV contrast
1
☢☢☢
MRA neck without and with IV contrast
1
O
MRA neck without IV contrast
1
O
Arteriography cervicocerebral
1
☢☢☢
CT cervical spine without and with IV contrast MRI cervical spine without and with IV contrast Myelography and post myelography CT cervical spine
To look for ligamentous injury, cord pathology, and edema. May be complementary to MDCT (see narrative). Limited use when there are motion artifacts on CT.
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
ACR Appropriateness Criteria®
4
O ☢☢
*Relative Radiation Level
Suspected Spine Trauma
Clinical Condition:
Suspected Spine Trauma
Variant 6:
Suspected acute cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Clinical or imaging findings suggest arterial injury. Radiologic Procedure
Rating
Comments
RRL*
With sagittal and coronal reformat. Another CT is not needed if already done on initial evaluation. Either CTA or MRA can be performed depending on institutional preference. Either CTA or MRA can be performed depending on institutional preference.
☢☢☢
CT cervical spine without IV contrast
9
CTA head and neck with IV contrast
9
MRA neck without and with IV contrast
9
MRI cervical spine without IV contrast
8
If neurological deficit is present.
Arteriography cervicocerebral
5
For treatment planning or problem solving.
CT cervical spine with IV contrast
1
☢☢☢
CT cervical spine without and with IV contrast
1
☢☢☢
MRA neck without IV contrast
1
O
MRI cervical spine without and with IV contrast
1
O
X-ray cervical spine
1
☢☢
Myelography and post myelography CT cervical spine
1
☢☢☢☢
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
ACR Appropriateness Criteria®
5
☢☢☢ O O ☢☢☢
*Relative Radiation Level
Suspected Spine Trauma
Clinical Condition:
Suspected Spine Trauma
Variant 7:
Suspected acute cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Clinical or imaging findings suggest ligamentous injury. Radiologic Procedure
Rating
Comments
RRL* ☢☢☢
CT cervical spine without IV contrast
9
Should be initial study.
MRI cervical spine without IV contrast
9
Procedure of choice for ligament damage.
O
X-ray cervical spine
4
Flexion/extension views are not helpful in acute stage because of spasm.
☢☢
CT cervical spine with IV contrast
1
☢☢☢
1
☢☢☢
1
O
1
☢☢☢☢
CTA head and neck with IV contrast
1
☢☢☢
MRA neck without and with IV contrast
1
O
MRA neck without IV contrast
1
O
Arteriography cervicocerebral
1
☢☢☢
CT cervical spine without and with IV contrast MRI cervical spine without and with IV contrast Myelography and post myelography CT cervical spine
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
ACR Appropriateness Criteria®
6
*Relative Radiation Level
Suspected Spine Trauma
Clinical Condition:
Suspected Spine Trauma
Variant 8:
Suspected cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Follow-up imaging on patient with no unstable injury demonstrated initially, but kept in collar for neck pain. Returns for evaluation. Radiologic Procedure
Rating
Comments
RRL*
AP, lateral, open-mouth, oblique, and flexion/extension views. Individualized based on clinical findings. With sagittal and coronal reformat. Not indicated unless follow-up radiographs or clinical examination suggest an abnormality.
☢☢
X-ray cervical spine
7
CT cervical spine without IV contrast
1
CT cervical spine with IV contrast
1
☢☢☢
1
☢☢☢
1
☢☢☢☢
CT cervical spine without and with IV contrast Myelography and post myelography CT cervical spine CTA head and neck with IV contrast
☢☢☢
☢☢☢
1 May be appropriate if radiographs suggest a further problem. Not indicated unless follow-up radiographs or clinical examination suggest an abnormality.
MRI cervical spine without IV contrast
1
MRI cervical spine without and with IV contrast
1
O
MRA neck without and with IV contrast
1
O
MRA neck without IV contrast
1
O
Arteriography cervicocerebral
1
☢☢☢
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
ACR Appropriateness Criteria®
O
7
*Relative Radiation Level
Suspected Spine Trauma
Clinical Condition:
Suspected Spine Trauma
Variant 9:
Blunt trauma meeting criteria for thoracic and lumbar imaging. With or without localizing signs. Radiologic Procedure
CT thoracic and lumbar spine without IV contrast MRI thoracic and lumbar spine without IV contrast Myelography and post myelography CT thoracic and lumbar spine X-ray thoracic and lumbar spine CT thoracic and lumbar spine with IV contrast CT thoracic and lumbar spine without and with IV contrast MRI thoracic and lumbar spine without and with IV contrast
Rating
Comments
RRL*
Dedicated images with sagittal and coronal reformat or derived from TAP (thorax-abdomen-pelvis) scan.
9 5
O
3
If MRI is contraindicated.
☢☢☢☢
3
Useful for localizing signs.
☢☢☢
1
☢☢☢
1
☢☢☢☢
1
O *Relative Radiation Level
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
Variant 10:
☢☢☢
Blunt trauma meeting criteria for thoracic and lumbar imaging. Neurologic abnormalities. Radiologic Procedure
Rating
Comments Dedicated images with sagittal and coronal reformat or derived from TAP scan. CT and MRI are complementary examinations, and both should be performed. For cord abnormalities. CT and MRI are complementary examinations, and both should be performed.
CT thoracic and lumbar spine without IV contrast
9
MRI thoracic and lumbar spine without IV contrast
9
Myelography and post myelography CT thoracic and lumbar spine
7
If MRI is not possible.
X-ray thoracic and lumbar spine
4
For surgical planning purposes.
CT thoracic and lumbar spine with IV contrast CT thoracic and lumbar spine without and with IV contrast MRI thoracic and lumbar spine without and with IV contrast
☢☢☢
O ☢☢☢☢ ☢☢☢
1
☢☢☢
1
☢☢☢☢
1
O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
ACR Appropriateness Criteria®
RRL*
8
*Relative Radiation Level
Suspected Spine Trauma
Clinical Condition:
Suspected Spine Trauma
Variant 11:
Child age
