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 notndiagnostic, 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
Note: If the criteria indicate that 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
Knee pain, predominantly anterior, not responding to conservative management.
McMahon Patrick J, Kaplan Lee D, “Chapter 4. Sports Medicine” (Chapter). Skinner HB: CURRENT Diagnosis & Treatment in Orthopedics, 4e: http://www.accessmedicine.com/content.aspx?aID=2318624.
Gagliardi, JA, Chung, EM, Chandnani, VP, Kesling, KL, Christensen, KP, Null, RN, Radvany, MG, Hansen, MF Detection and staging of chondromalacia patellae: relative efficacies of conventional MR imaging, MR arthrography, and CT arthrography Am. J. Roentgenol. 1994 163: 629-636
Osteochondritis Dissecans MRI PREFERRED
Loose body by X-ray MRI PREFERRED
X-rays nondiagostic
Hauger, O, Moinard, M, Lasalarie, JC, Chauveaux, D, Diard, F Anterolateral compartment of the ankle in the lateral impingement syndrome: appearance on CT arthrography Am. J. Roentgenol. 1999 173: 685-690 Cochet, Hubert, Pele, Eric, Amoretti, Nicolas, Brunot, Sebastien, Lafenetre, Olivier, Hauger, Olivier Anterolateral Ankle Impingement: Diagnostic Performance of MDCT Arthrography and Sonography Am. J. Roentgenol. 2010 194: 1575-1580 Molloy, S., Solan, M. C., Bendall, S. P. Synovial impingement in the ankle: A NEW PHYSICAL SIGN J Bone Joint Surg Br 2003 85-B: 330-333
Akle unstable, X-ray nondiagnostic MRI PREFERRED
Normal or nondiagnostic X-ray No response to conservative treatment
Akle unstable, X-ray nondiagnostic MRI PREFERRED
Reference ACR Appropriateness Criteria
1.1.1 Prior imaging nondiagnostic (US or X-ray)
1.2 Pain post trauma
2.1.1 Pain with passive stretching of muscle
2.1.2 Pain, more severe than expected from trauma
2.1.3 Paresthesias
2.1.4 Plulseless Paralysis
2.1.5.1 Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 6th Edition; Judith Tintinalli et al Eds. Chapter 278 Compartment Syndromes Paul R Haller
2.2.1.1 x-ray nondiagnostic
2.3.1.1 C reactive Protein elevated
2.3.1.2 Elevated ESR
2.3.1.3 Fever
2.3.1.4 Leukocytosis
2.3.1.5 Positive Blood Cultures
2.3.2.1 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.
2.3.2.2 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.
2.3.2.3 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.
2.3.2.4 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.
2.3.2.5 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.
2.3.2.6 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.
2.3.2.7 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.
2.3.2.8 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.
2.4.1 Pain
2.4.2 Swelling
2.4.3 Fever
2.4.4 Warm, shiny or discolored skin over the affected area
2.4.5 Elevated WBC count (Leukocytoisis)
2.4.6 Lymphangitis and/or Lymphadenitis.
2.4.7.1 Tubbs Robert J, Savitt Daniel L, Suner Selim, “Chapter 12. Extremity Conditions” (Chapter). Knoop KJ, Stack LB, Storrow AB, Thurman RJ: The Atlas of Emergency Medicine, 3e: http://www.accessmedicine.com/content.aspx?aID=6003337.
2.4.7.2 Fugitt JB, Puckett ML, Quigley MM, Kerr SM. Necrotizing fasciitis. RadioGraphics 2004;24 : 1472-1476
2.5 Pes Planum (flat foot)
2.6.1 Localized Pain
2.6.2 Nondiagnostic Repeat X-ray at least 7 days after onset of symptoms
2.6.3.1 Gaeta, Michele, Minutoli, Fabio, Vinci, Sergio, Salamone, Ignazio, D’Andrea, Letterio, Bitto, Linda, Magaudda, Ludovico, Blandino, Alfredo; High-Resolution CT Grading of Tibial Stress Reactions in Distance Runners; Am. J. Roentgenol. 2006 187: 789-793
2.6.3.2 Gaeta M, Minutoli F, Scribano E, et al. CT and MRI findings in athletes with early tibial stress injuries: comparison with bone scintigraphy and emphasis on cortical abnormalities. Radiology2005; 235:553 -561
2.6.3.3 Current Diagnosis & Treatment in Family Medicine; Jeannette E. South-Paul, et al editors Chapter 36. Common Upper & Lower Extremity Fractures David A. Nikovits, MD, Richard E. Rodenberg, Jr., MD, Thomas D. Armsey, & Robert G. Hosey, MD
2.7.1 foot pain, valgus heel, and decreased subtalar motion
2.7.2.1 Lomasney, LM, Demos, TC, Harris, EJ; Computed tomographic imaging of the foot and ankle. Developmental and congenital anomalies; J Am Podiatr Med Assoc 2000 90: 223-233
2.7.2.2 Jack, E. A.; BONE ANOMALIES OF THE TARSUS IN RELATION TO “PERONEAL SPASTIC FLAT FOOT”; J Bone Joint Surg Br 1954 36-B: 530-542 [a paper from well before the CT era, with an excellent description of tarsal coalition and radiographs to illustrate.]
2.8.1 Lesion on prior imaging
2.8.2 Pain
3.1 Palpable gap in muscle or tendon MRI PREFERRED
3.2 Pulseless paralysis MRI PREFERRED
4 Abnormal Lab or Imaging presented as primary indication
5.1 Congenital foot anomalies for evaluation
5.2.1 For treatment planning
5.2.2.1 Movement at fracture site by PE, x-ray or statement of patient
5.2.2.2 No evidence of healing for at least 3 months
5.2.2.3 Pain
5.3.1 Interval follow up during and after treatment
5.3.2 Preoperative
5.3.3 Worsening clinical situation
5.3.4.1 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.
5.3.4.2 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.
5.3.4.3 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.
5.3.4.4 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.
5.3.4.5 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.
5.3.4.6 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.
5.3.4.7 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.
5.3.4.8 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.
5.4 Pes Planum (flat foot)
5.5.1 X-ray nondiagnostic
5.6.1 Interval routine follow up of primary or meastatic tumor
5.6.2 New or worsening symptoms