For most indications MRI is the preferred exam
If MRI is Preferred CT cannot be authorized without a statement that MRI is not available, has been done but was not diagnostic, or that the patient cannot tolerate an MR examination.
Abnormal CBC, Sed Rate, etc
Bladder and Bowel dysfunction
Fever
Cancer, History of
Immunocompromised state
IV drug use
Major weakness of a limb
Pain increased at rest
Saddle anesthesia
Severe pain, not repsonding to opiates after two days
Trauma
Unexplained weight loss
Urinary tract infections
1. Nonsteroidal anti-inflammatory drugs for at least three weeks (Requirement is waived if NSAIDS are not tolerated or contraindicated, or if condition worsens while under treatment.)
2. Activity modification or physical therapy if appropriate
1.1 Bilateral radiculopathy SEE MYELOPATHY
1.2 Bladder dysfunction This is a RED FLAG. No conservative management is required
1.3.1 Failed Conservative Management
1.4 Bowel incontinence This is a RED FLAG. No conservative management is required
1.5 Clumsiness, increasing with time
1.6.1 Myelopathy suspected
1.7.1 Failed Conservative Management
1.8.1.1 Failed conservative management
1.8.1.2 Known malignancy elsewhere This is a RED FLAG. No conservative management is required
1.8.2.1 No RED FLAGS, Failed conservative management
1.8.2.2.1 AIDS
1.8.2.2.2 ESR elevated
1.8.2.2.3 Fever
1.8.2.2.4 Immunosuppressed
1.8.2.2.5 White count elevated
AS Baker, RG Ojemann, MN Swartz, and EP Richardson Spinal epidural abscess; N. Engl. J. Med., Sep 1975; 293: 463 – 468.
1.8.2.2.6.2 Davis DP; Wold RM; Patel RJ; Tran AJ; Tokhi RN; Chan TC; Vilke GM The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med 2004 Apr;26(3):285-91.
1.8.2.2.6.3 Darouiche RO; Hamill RJ; Greenberg SB; Weathers SW; Musher DM; Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 1992 Nov;71(6):369-85 [abstract]
1.8.2.2.6.4 David T Durack, MD, DPhil Daniel J Sexton, MD Epidural abscess UpToDate 15.2 accessed 07/09/07
1.8.3 Severe pain, not repsonding to opiates or worsening, This is a RED FLAG. No conservative management is required
1.8.4.1 Radiculopathy or disc disease suspected. Failed conservative management
1.9 Paralysis of upper extremity
1.10.1 Failed Conservative Management
1.11.1 Failed Conservative Management
1.12.1 Failed Conservative Management
2.1.1.1.1 Loss of bowel or bladder control
2.1.1.1.2 Muscle weakness
2.1.1.1.3 Pain, local to spine or radiating in root patte
2.1.1.1.4 Paralysis
2.1.1.1.5 Sensory abnormality confirmed by examination
2.1.1.1.6 Tenderness over spine
2.1.1.2.1 AIDS
2.1.1.2.2 ESR Elevated
2.1.1.2.3 Fever
2.1.1.2.4 Immunosuppressed
2.1.1.2.5 Infection elsewhere
2.1.1.2.6 Positive blood culture
2.1.1.2.7 Recent spinal surgery or procedure
2.1.1.2.8 WBC elevated
2.1.2.1 Interval Follow up
2.1.2.2 Recurrent or worsening symptoms
2.1.3.1 AS Baker, RG Ojemann, MN Swartz, and EP Richardson Spinal epidural abscess; N. Engl. J. Med., Sep 1975; 293: 463 – 468.
2.1.3.2 Davis DP; Wold RM; Patel RJ; Tran AJ; Tokhi RN; Chan TC; Vilke GM The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med 2004 Apr;26(3):285-91.
2.1.3.3 Darouiche RO; Hamill RJ; Greenberg SB; Weathers SW; Musher DM; Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 1992 Nov;71(6):369-85 [abstract]
2.1.3.4 David T Durack, MD, DPhil Daniel J Sexton, MD Epidural abscess UpToDate 15.2 accessed 07/09/07
2.2.1 Focal Pain
2.2.2 Neurologic findings
2.2.3 Suspicious findings on other imaging
2.3.1.1.1 Current Rheumatology Diagnosis & Treatment, 2nd Edition John B. Imboden, David B. Hellmann, John H. Stone > Chapter 9. Approach to the Patient with Neck Pain David Borenstein, MD
2.3.2 Atrophy of upper extremity musculature
2.3.3 Bladder dysfunction This is a RED FLAG. No conservative management is required
2.3.4 Bowel incontinence This is a RED FLAG. No conservative management is required
2.3.5 Burning sensations (dysesthesias)
2.3.6 Clumsiness, increasing with time
2.3.7 Gait disturbances
2.3.8 Hyporeflexia
2.3.9 Numbness, in nerve root distribution
2.3.10 Sensory abnormality objectively observed
2.3.11 Shooting pain, in nerve root distribution
2.3.12 Tingling sensations (paresthesias)
2.3.13 Weakness, in nerve root distribution
2.3.14 Weakness in upper and lower extremities Failed conservative management
2.3.15.1 Rao, Raj D., Gourab, Krishnaj, David, Kenny S. Operative Treatment of Cervical Spondylotic Myelopathy J Bone Joint Surg Am 2006 88: 1619-1640
2.3.15.2 Rao R. Neck pain, cervical radiculopathy, and cervical myelopathy: pathophysiology, natural history, and clinical evaluation. J Bone Joint Surg Am.2002; 84:1872 -81
2.4.1.1 C reactive Protein elevated
2.4.1.2 Elevated ESR
2.4.1.3 Fever
2.4.1.4 Leukocytosis
2.4.1.5 Positive Blood Cultures
2.4.2.1 Parsonnet Jeffrey, “Chapter 120. Osteomyelitis” (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison’s Principles of Internal Medicine, 17th Edition: http://www.accessmedicine.com/content.aspx?aID=2893649.
2.4.2.2 Alok Kapoor, Stephanie Page, Michael LaValley, Daniel R. Gale, and David T. Felson Magnetic Resonance Imaging for Diagnosing Foot Osteomyelitis: A Meta-analysis Arch Intern Med, Jan 2007; 167: 125 – 132.
2.4.2.3 J. Herman Kan, Melissa A. Hilmes, Jeffrey E. Martus, Chang Yu, and Marta Hernanz-Schulman Value of MRI After Recent Diagnostic or Surgical Intervention in Children with Suspected Osteomyelitis Am. J. Roentgenol., Nov 2008; 191: 1595 – 1600.
2.4.2.4 Kuo-Chen Lee, Yi-Ting Tsai, Chih-Yuan Lin, and Chien-Sung Tsai Vertebral osteomyelitis combined streptococcal viridans endocarditis Eur. J. Cardiothorac. Surg., Jan 2003; 23: 125.
2.4.2.5 D Allen, S Ng, K Beaton, and D Taussig Sternal osteomyelitis caused by Aspergillus fumigatus in a patient with previously treated Hodgkin’s disease J. Clin. Pathol., Aug 2002; 55: 616 – 618.
2.4.2.6 M Ida, H Watanabe, A Tetsumura, and T Kurabayashi CT findings as a significant predictive factor for the curability of mandibular osteomyelitis: multivariate analysis Dentomaxillofac. Radiol., Mar 2005; 34: 86 – 90.
2.4.2.7 Jyri K. Koort, Tatu J. Mäkinen, Juhani Knuuti, Jari Jalava, and Hannu T. Aro Comparative 18F-FDG PET of Experimental Staphylococcus aureus Osteomyelitis and Normal Bone Healing J. Nucl. Med., Aug 2004; 45: 1406 – 1411.
2.4.2.8 Susan A. Connolly, Leonard P. Connolly, Laura A. Drubach, David Zurakowski, and Diego Jaramillo MRI for Detection of Abscess in Acute Osteomyelitis of the Pelvis in Children Am. J. Roentgenol., Oct 2007; 189: 867 – 872.
2.5.1.1 Atrophy of upper extremity musculature
2.5.1.2 Burning sensations (dysesthesias)
2.5.1.3 Hyporeflexia
2.5.1.4 Numbness, in nerve root distribution
2.5.1.5 Shooting pain, in nerve root distribution
2.5.1.6 Tingling sensations (paresthesias),
2.5.1.7 Weakness, in nerve root distribution
2.5.2.1 Schwartz’s Principles of Surgery, 8th Edition F. Charles Brunicardi, et al opyright © 2005, The McGraw-Hill Companies, Inc. Chapter 41. Neurosurgery Michael L. Smith, M. Sean Grady
2.5.2.2 Douglas-Akinwande, Annette C., Rydberg, Jonas, Shah, Mitesh V., Phillips, Michael D., Caldemeyer, Karen S., Lurito, Joseph T., Ying, Jun, Mathews, Vincent P. Accuracy of Contrast-Enhanced MDCT and MRI for Identifying the Severity and Cause of Neural Foraminal Stenosis in Cervical Radiculopathy: A Prospective Study Am. J. Roentgenol. 2010 194: 55-61
2.5.2.3 Michael T. Modic, Nancy A. Obuchowski, Jeffrey S. Ross, Michael N. Brant-Zawadzki, Paul N. Grooff, Daniel J. Mazanec, and Edward C. Benzel Acute Low Back Pain and Radiculopathy: MR Imaging Findings and Their Prognostic Role and Effect on Outcome Radiology November 2005 237:597-604
2.6 Spinal Stenosis SEE Radiculopathy
2.7 Suspected Fracture
2.8.1 Hyperreflexia
2.8.2 Weakness of the upper or lower extremity
2.8.3 Spasticity
2.8.4 Bladder or bowel dysfunction
2.8.5 Lhermitte’s sign
2.8.6 Sensory deficit
2.8.7 New onset scoliosis or kyphosis
2.8.8 Spastic gait
2.8.9 Radiculopathy
2.8.10 Localized tenderness over the cervical spine
2.8.11 CSF cytology positive for malignant cells
3.1.1 Failed conservative management
3.2.1 Note Plexopathy refers to an abnormality of the complex of nerve roots exiting the spine and organizing into the nerves serving the arm, trunk or legs. Symptoms may include burning, tingling, or numbness in a circumferential or dermatomal distribution. The symptoms may radiate to the hand or remain localized in the neck.
3.2.2.1.1.1 Aliya Qayyum, A. David MacVicar, Anwar R. Padhani, Patrick Revell, and Janet E. S. Husband Symptomatic Brachial Plexopathy following Treatment for Breast Cancer: Utility of MR Imaging with Surface-Coil Techniques Radiology March 2000 214:837-842
Bowen, BC, Verma, A, Brandon, AH, Fiedler, JA Radiation-induced brachial plexopathy: MR and clinical findings AJNR Am J Neuroradiol 1996 17: 1932-1936
3.2.2.1.3 Palpable mass in neck or shoulder area
3.2.2.1.4 Truama, including at birth
Numbness
3.2.2.2.2 Paresthesias
3.2.2.2.3 Radiating pain
3.2.2.2.4 Weakness
3.2.2.3.1 ACR Appropriateness Criteria Plexopathy p10 Accessed 12/28/08
3.2.2.3.2 Aliya Qayyum, A. David MacVicar, Anwar R. Padhani, Patrick Revell, and Janet E. S. Husband Symptomatic Brachial Plexopathy following Treatment for Breast Cancer: Utility of MR Imaging with Surface-Coil Techniques Radiology 2000 214: 837-842.
3.2.2.3.3 BC Bowen, A Verma, AH Brandon, and JA Fiedler Radiation-induced brachial plexopathy: MR and clinical findings AJNR Am. J. Neuroradiol., Nov 1996; 17: 1932 – 1936. Neurosurgical Focus Posted 04/02/2007 Accessed 1/4/09 @ http://www.medscape.com/viewarticle/553963_1
3.2.2.3.4 Bowen B, Seidenwurm DJ, Davis P, et al, Expert Panel on Neurologic Imaging, American College of Radiology, Appropriateness Criteria, Plexopathy, accessed at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/PlexopathyDoc12.asp 12/28/08
3.2.2.3.5 Devin K. Binder, M.D., Ph.D.; Justin S. Smith, M.D., Ph.D.; Nicholas M. Barbaro, M.D Primary Brachial Plexus Tumors: Imaging, Surgical, and Pathological Findings in 25 Patients Neurosurgical Focus Medscape Radiology accessed 12/28/08
3.2.2.3.6 Edward Fathers, David Thrush, Susan M Huson, and Andrew Norman Radiation-induced brachial plexopathy in women treated for carcinoma of the breast Clinical Rehabilitation, Feb 2002; 16: 160 – 165.
3.2.2.3.7 Neoplastic Brachial Plexopathy Author: Mark A Wren, MD, MPH, Medical Director, Department of Physical Medicine and Rehabilitation, HealthSouth Rehabilitation Hospital of Texarkana eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy Updated: Jan 19, 2010 Accesed 3/15/10
3.2.2.3.8 Vincent J. Miele, M.D.; John A. Norwig, A.T.C.; Julian E. Bailes, M.D. Sideline and Ringside Evaluation for Brain and Spinal Injuries
3.2.2.3.9 Walker, AT, Chaloupka, JC, de Lotbiniere, AC, Wolfe, SW, Goldman, R, Kier, EL Detection of nerve rootlet avulsion on CT myelography in patients with birth palsy and brachial plexus injury after trauma Am. J. Roentgenol. 1996 167: 1283-1287
3.2.2.3.10 T. Yoshikawa, N. Hayashi, S. Yamamoto, Y. Tajiri, N. Yoshioka, T. Masumoto, H. Mori, O. Abe, S. Aoki, and K. Ohtomo Brachial Plexus Injury: Clinical Manifestations, Conventional Imaging Findings, and the Latest Imaging Techniques RadioGraphics, October 1, 2006; 26(suppl_1): S133 – S143.
3.2.2.3.11 A. TAVAKKOLIZADEH, A. SAIFUDDIN, and R. BIRCH Imaging of Adult Brachial Plexus Traction Injuries J Hand Surg Eur Vol., June 1, 2001; 26(3): 183 – 191
3.3.1 Myelopathy suspected
3.4.1 Radiculopathy or disc disease suspected. Failed conservative management
3.5.1 Myelopathy suspected
3.5.2 Radiculopathy or disc disease suspected. Failed conservative management
4.1 Fracture seen or suspected on recent x-ray
4.2 Suspected Fracture
5.1.1.1.1 Loss of bowel or bladder control
5.1.1.1.2 Muscle weakness
5.1.1.1.3 Pain, local to spine or radiating in root pattern
5.1.1.1.4 Paralysis
5.1.1.1.5 Sensory abnormality confirmed by examination
5.1.1.1.6 Tenderness over spine
5.1.1.2.1 AIDS
5.1.1.2.2 ESR Elevated
5.1.1.2.3 Fever
5.1.1.2.4 Immunosuppressed
5.1.1.2.5 Infection elsewhere
5.1.1.2.6 Positive blood culture
5.1.1.2.7 Recent spinal surgery or procedure
5.1.1.2.8 WBC elevated
5.1.2.1 Interval Follow up
5.1.2.2 Recurrent or worsening symptoms
5.1.3.1 AS Baker, RG Ojemann, MN Swartz, and EP Richardson Spinal epidural abscess; N. Engl. J. Med., Sep 1975; 293: 463 – 468.
5.1.3.2 Davis DP; Wold RM; Patel RJ; Tran AJ; Tokhi RN; Chan TC; Vilke GM The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med 2004 Apr;26(3):285-91.
5.1.3.3 Darouiche RO; Hamill RJ; Greenberg SB; Weathers SW; Musher DM; Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 1992 Nov;71(6):369-85 [abstract]
5.1.3.4 David T Durack, MD, DPhil Daniel J Sexton, MD Epidural abscess UpToDate 15.2 accessed 07/09/07
5.2 Infection or abscess, after treatment
5.3 Management and assessment of spinal injury
5.4.1 With symptoms attributable to a specific level. Not indicated for asymptomatic patients
5.4.2.1 Adams and Victor’s Neurology > Part 4. Major Categories of Neurologic Disease > Chapter 36. Multiple Sclerosis and Allied Demyelinative Diseases < Multiple Sclerosis < Pathologic Findings <
5.4.2.2 Multiple sclerosis. T2-weighted MRIs demonstrating multiple plaques in the periventricular white matter (left), emanating radially from the corpus callosum (“Dawson fingers”) (middle), and cervical spinal cord (right). The radial orientation and periventricular location of cerebral lesions is typical of the disease.
5.5.1 Interval follow up during and after treatment
5.5.2 Preoperative
5.5.3 Worsening clinical situation
5.5.4.1 Parsonnet Jeffrey, “Chapter 120. Osteomyelitis” (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison’s Principles of Internal Medicine, 17th Edition: http://www.accessmedicine.com/content.aspx?aID=2893649.
5.5.4.2 Alok Kapoor, Stephanie Page, Michael LaValley, Daniel R. Gale, and David T. Felson Magnetic Resonance Imaging for Diagnosing Foot Osteomyelitis: A Meta-analysis Arch Intern Med, Jan 2007; 167: 125 – 132.
5.5.4.3 J. Herman Kan, Melissa A. Hilmes, Jeffrey E. Martus, Chang Yu, and Marta Hernanz-Schulman Value of MRI After Recent Diagnostic or Surgical Intervention in Children with Suspected Osteomyelitis Am. J. Roentgenol., Nov 2008; 191: 1595 – 1600.
5.5.4.4 Kuo-Chen Lee, Yi-Ting Tsai, Chih-Yuan Lin, and Chien-Sung Tsai Vertebral osteomyelitis combined streptococcal viridans endocarditis Eur. J. Cardiothorac. Surg., Jan 2003; 23: 125.
5.5.4.5 D Allen, S Ng, K Beaton, and D Taussig Sternal osteomyelitis caused by Aspergillus fumigatus in a patient with previously treated Hodgkin’s disease J. Clin. Pathol., Aug 2002; 55: 616 – 618.
5.5.4.6 M Ida, H Watanabe, A Tetsumura, and T Kurabayashi CT findings as a significant predictive factor for the curability of mandibular osteomyelitis: multivariate analysis Dentomaxillofac. Radiol., Mar 2005; 34: 86 – 90.
5.5.4.7 Jyri K. Koort, Tatu J. Mäkinen, Juhani Knuuti, Jari Jalava, and Hannu T. Aro Comparative 18F-FDG PET of Experimental Staphylococcus aureus Osteomyelitis and Normal Bone Healing J. Nucl. Med., Aug 2004; 45: 1406 – 1411.
5.5.4.8 Susan A. Connolly, Leonard P. Connolly, Laura A. Drubach, David Zurakowski, and Diego Jaramillo MRI for Detection of Abscess in Acute Osteomyelitis of the Pelvis in Children Am. J. Roentgenol., Oct 2007; 189: 867 – 872.
5.6 Prior to Surgical Intervention, as a road map for the surgeon
5.7.1.1 This includes inability to visualize lower cervical vertebrae or T1 on x-rays
5.7.2 Midline cervical spinal tenderness
5.7.3 New onset of neurologic findings
5.7.4.1 A Gardner, S Grannum and KM Porter Cervical spine trauma Trauma [London] 2005; 7: 109-121 American College of Surgeons Committee on Trauma. 1997.
5.7.4.2 Advanced trauma life support for doctors. British Trauma Society. 2002. Guidelines for initial management and assessment of spinal injury. Int J Care Injured 34: 405-25.
5.8.1 Preoperative evaluation
5.8.2 Neurologic finding
5.8.3 Atypical curve pattern
5.8.4 Congenital scoliosis
5.8.5 Neurofibromatosis
Kim HJ, Tetreault LA, Massicotte EM, Arnold PM, Skelly AC, Brodt ED, Riew KD.
Spine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S78-88. doi: 10.1097/BRS.0b013e3182a7eb06.
Orguc S, Arkun R.
Semin Musculoskelet Radiol. 2014 Jul;18(3):280-99. doi: 10.1055/s-0034-1375570. Epub 2014 Jun 4.