ADVANCED IMAGING CLINICAL APPROPRIATENESS GUIDELINES. Appropriate Use Criteria: Imaging of the Spine. EFFECTIVE JANUARY 1, 2019 Proprietary

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1 CLINICAL APPROPRIATENESS GUIDELINES ADVANCED IMAGING Apprpriate Use Criteria: Imaging f the Spine EFFECTIVE JANUARY 1, 2019 Prprietary 8600 West Bryn Mawr Avenue Suth Twer Suite 800 Chicag, IL Apprpriate.Safe.Affrdable AIM Specialty Health

2 Imaging f the Spine Table f Cntents Descriptin and Applicatin f the Guidelines... 4 Administrative Guidelines... 5 Ordering f Multiple Studies... 5 Simultaneus Ordering f Multiple Studies... 5 Repeated Imaging... 5 Pre-Test Requirements... 6 Histry... 6 Imaging f the Spine... 7 General Infrmatin/Overview... 7 Scpe... 7 Technlgy Cnsideratins... 7 Definitins... 7 Clinical Indicatins... 9 Cngenital and Develpmental Cnditins... 9 Chiari malfrmatin... 9 Cngenital spinal crd anmalies nt listed... 9 Cngenital vertebral defects Cranicervical junctin abnrmalities Sclisis Spinal dysraphism Tethered crd Infectius and Inflammatry Cnditins Juvenile idipathic arthritis (Pediatric nly) Multiple sclersis r ther white matter disease Rheumatid arthritis (Adult nly) Spinal infectin Spndylarthrpathy Trauma Cervical injury Thracic r lumbar injury Tumr Tumr Miscellaneus Cnditins f the Spine Osteprsis and stepenia Spinal crd infarctin Spndyllysis and spndyllisthesis Syringmyelia Signs and Symptms Cauda equina syndrme Myelpathy Cpyright AIM Specialty Health. All Rights Reserved. 2

3 Imaging f the Spine Neck pain (cervical) Mid-back pain (thracic) Lw back pain (lumbar) References Cdes Histry Cpyright AIM Specialty Health. All Rights Reserved. 3

4 Imaging f the Spine Descriptin and Applicatin f the Guidelines The AIM Clinical Apprpriateness Guidelines (hereinafter the AIM Clinical Apprpriateness Guidelines r the Guidelines ) are designed t assist prviders in making the mst apprpriate treatment decisin fr a specific clinical cnditin fr an individual. As used by AIM, the Guidelines establish bjective and evidence-based criteria fr medical necessity determinatins where pssible. In the prcess, multiple functins are accmplished: T establish criteria fr when services are medically necessary T assist the practitiner as an educatinal tl T encurage standardizatin f medical practice patterns T curtail the perfrmance f inapprpriate and/r duplicate services T advcate fr patient safety cncerns T enhance the quality f health care T prmte the mst efficient and cst-effective use f services The AIM guideline develpment prcess cmplies with applicable accreditatin standards, including the requirement that the Guidelines be develped with invlvement frm apprpriate prviders with current clinical expertise relevant t the Guidelines under review and be based n the mst up-t-date clinical principles and best practices. Relevant citatins are included in the References sectin attached t each Guideline. AIM reviews all f its Guidelines at least annually. AIM makes its Guidelines publicly available n its website twenty-fur hurs a day, seven days a week. Cpies f the AIM Clinical Apprpriateness Guidelines are als available upn ral r written request. Althugh the Guidelines are publicly-available, AIM cnsiders the Guidelines t be imprtant, prprietary infrmatin f AIM, which cannt be sld, assigned, leased, licensed, reprduced r distributed withut the written cnsent f AIM. AIM applies bjective and evidence-based criteria, and takes individual circumstances and the lcal delivery system int accunt when determining the medical apprpriateness f health care services. The AIM Guidelines are just guidelines fr the prvisin f specialty health services. These criteria are designed t guide bth prviders and reviewers t the mst apprpriate services based n a patient s unique circumstances. In all cases, clinical judgment cnsistent with the standards f gd medical practice shuld be used when applying the Guidelines. Guideline determinatins are made based n the infrmatin prvided at the time f the request. It is expected that medical necessity decisins may change as new infrmatin is prvided r based n unique aspects f the patient s cnditin. The treating clinician has final authrity and respnsibility fr treatment decisins regarding the care f the patient and fr justifying and demnstrating the existence f medical necessity fr the requested service. The Guidelines are nt a substitute fr the experience and judgment f a physician r ther health care prfessinals. Any clinician seeking t apply r cnsult the Guidelines is expected t use independent medical judgment in the cntext f individual clinical circumstances t determine any patient s care r treatment. The Guidelines d nt address cverage, benefit r ther plan specific issues. If requested by a health plan, AIM will review requests based n health plan medical plicy/guidelines in lieu f the AIM Guidelines. The Guidelines may als be used by the health plan r by AIM fr purpses f prvider educatin, r t review the medical necessity f services by any prvider wh has been ntified f the need fr medical necessity review, due t billing practices r claims that are nt cnsistent with ther prviders in terms f frequency r sme ther manner. Cpyright AIM Specialty Health. All Rights Reserved. 4

5 Imaging f the Spine Administrative Guidelines Ordering f Multiple Studies Requests fr multiple imaging studies t evaluate a suspected r identified cnditin and requests fr repeated imaging f the same anatmic area are subject t additinal review t avid unnecessary r inapprpriate imaging. Simultaneus Ordering f Multiple Studies In many situatins, rdering multiple imaging studies at the same time is nt clinically apprpriate because: Current literature and/r standards f medical practice supprt that ne f the requested imaging studies is mre apprpriate in the clinical situatin presented; r One f the imaging studies requested is mre likely t imprve patient utcmes based n current literature and/r standards f medical practice; r Apprpriateness f additinal imaging is dependent n the results f the lead study. When multiple imaging studies are rdered, the request will ften require a peer-t-peer cnversatin t understand the individual circumstances that supprt the medically necessity f perfrming all imaging studies simultaneusly. Examples f multiple imaging studies that may require a peer-t-peer cnversatin include: CT brain and CT sinus fr headache MRI brain and MRA brain fr headache MRI cervical spine and MRI shulder fr pain indicatins MRI lumbar spine and MRI hip fr pain indicatins MRI r CT f multiple spine levels fr pain r radicular indicatins MRI ft and MRI ankle fr pain indicatins Bilateral exams, particularly cmparisn studies There are certain clinical scenaris where simultaneus rdering f multiple imaging studies is cnsistent with current literature and/r standards f medical practice. These include: Onclgic imaging Cnsideratins include the type f malignancy and the pint alng the care cntinuum at which imaging is requested Cnditins which span multiple anatmic regins Examples include certain gastrintestinal indicatins r cngenital spinal anmalies Repeated Imaging In general, repeated imaging f the same anatmic area shuld be limited t evaluatin fllwing an interventin, r when there is a change in clinical status such that imaging is required t determine next steps in management. At times, repeated imaging dne with different techniques r cntrast regimens may be necessary t clarify a finding seen n the riginal study. Repeated imaging f the same anatmic area (with same r similar technlgy) may be subject t additinal review in the fllwing scenaris: Repeated imaging at the same facility due t mtin artifact r ther technical issues Repeated imaging requested at a different facility due t prvider preference r quality cncerns Repeated imaging f the same anatmic area (MRI r CT) based n persistent symptms with n clinical change, treatment, r interventin since the previus study Repeated imaging f the same anatmical area by different prviders fr the same member ver a shrt perid f time Cpyright AIM Specialty Health. All Rights Reserved. 5

6 Imaging f the Spine Pre-Test Requirements Critical t any finding f clinical apprpriateness under the guidelines fr specific imaging exams is a determinatin that the fllwing are true with respect t the imaging request: A clinical evaluatin has been perfrmed prir t the imaging request (which shuld include a cmplete histry and physical exam and review f results frm relevant labratry studies, prir imaging and supplementary testing) t identify suspected r established diseases r cnditins. Fr suspected diseases r cnditins: Based n the clinical evaluatin, there is a reasnable likelihd f disease prir t imaging; and Current literature and standards f medical practice supprt that the requested imaging study is the mst apprpriate methd f narrwing the differential diagnsis generated thrugh the clinical evaluatin and can be reasnably expected t lead t a change in management f the patient; and The imaging requested is reasnably expected t imprve patient utcmes based n current literature and standards f medical practice. Fr established diseases r cnditins: Advanced imaging is needed t determine whether the extent r nature f the disease r cnditin has changed; and Current literature and standards f medical practice supprt that the requested imaging study is the mst apprpriate methd f determining this and can be reasnably expected t lead t a change in management f the patient; and The imaging requested is reasnably expected t imprve patient utcmes based n current literature and standards f medical practice. If these elements are nt established with respect t a given request, the determinatin f apprpriateness will mst likely require a peer-t-peer cnversatin t understand the individual and unique facts that wuld supersede the pre-test requirements set frth abve. During the peert-peer cnversatin, factrs such as patient acuity and setting f service may als be taken int accunt. Histry Status Date Actin Reviewed and revised 07/26/2016 Independent Multispecialty Physician Panel review and revisin Created 03/30/2005 Original effective date Cpyright AIM Specialty Health. All Rights Reserved. 6

7 Imaging f the Spine Imaging f the Spine General Infrmatin/Overview Scpe These guidelines address advanced imaging f the spine in bth adult and pediatric ppulatins. Fr interpretatin f the guidelines, and where nt therwise nted, adult refers t persns age 19 and lder, and pediatric refers t persns age 18 and yunger. Where separate indicatins exist, they are specified as Adult r Pediatric. Where nt specified, indicatins and prerequisite infrmatin apply t persns f all ages. See the Cding sectin fr a list f mdalities included in these guidelines. Technlgy Cnsideratins Cmputed tmgraphy (CT) is the preferred imaging mdality fr bny abnrmalities f the spine when radigraphs d nt prvide sufficient detail fr management. Cmmn indicatins include fracture, vertebral anmalies, and sseus tumrs. Spine CT is als utilized fr CT myelgraphy, in which radigraphically paque dye is injected int the thecal sac t image nerve detail. CT myelgraphy is invasive, but is cmparable t MRI in detectin f neural impingement and stensis, and can als be used in diagnsis f cerebrspinal fluid leak and nerve rt avulsin. Cnventinal myelgraphy, in which radigraphs are btained rather than using CT imaging, is less cmmnly perfrmed. Disadvantages f CT include expsure t inizing radiatin and risks assciated with idinated cntrast, including allergy and impaired renal functin. Magnetic resnance imaging (MRI) is the preferred mdality fr the majrity f sft tissue indicatins in the spine due t its superir reslutin and lack f inizing radiatin. MRI can be perfrmed with r withut cntrast; cntrast may be necessary fr infectin, tumr, and pst-surgical evaluatin. Cntrast MRI may als be useful fr imaging herniated discs particularly if herniatin needs t be distinguished frm pst-surgical epidural scarring and diagnsing tumrs in the intramedullary, extramedullary, and extradural spaces. Cntraindicatins t MRI may include implanted devices unsafe fr use in an MRI scanner such as pacemakers r implantable cardiverter-defibrillatrs and claustrphbia. CT discgraphy determines the available vlume f discs and can be used t lcalize annulus fibrsis fissures r herniated discs. Discgraphy can als cnfirm the surce f back pain by reprducing the symptms assciated with disc herniatin. MR discgraphy may be perfrmed in the event that CT is cntraindicated. False psitives, infectin, and neural injury are pssible with discgraphy, and it shuld be used primarily t cnfirm an initial diagnsis. Definitins Phases f the care cntinuum are bradly defined as fllws: Screening testing in the absence f signs r symptms f disease Diagnsis testing based n a reasnable suspicin f a particular cnditin r disrder, usually due t the presence f signs r symptms Management testing t direct therapy f an established cnditin, which may include preperative r pstperative imaging, r imaging perfrmed t evaluate the respnse t nnsurgical interventin Surveillance peridic assessment fllwing cmpletin f therapy, r fr mnitring knwn disease that is stable r asymptmatic Cpyright AIM Specialty Health. All Rights Reserved. 7

8 Statistical terminlgy 1 Imaging f the Spine Cnfidence interval (CI) range f values which is likely t cntain the cited statistic. Fr example, 92% sensitivity (95% CI, 89%-95%) means that, while the sensitivity was calculated at 92% n the current study, there is a 95% chance that, if a study were t be repeated, the sensitivity n the repeat study wuld be in the range f 89%-95%. Diagnstic accuracy ability f a test t discriminate between the target cnditin and health. Diagnstic accuracy is quantified using sensitivity and specificity, predictive values, and likelihd ratis. Hazard rati dds that an individual in the grup with the higher hazard reaches the utcme first. Hazard rati is analgus t dds rati and is reprted mst cmmnly in time-t-event analysis r survival analysis. A hazard rati f 1 means that the hazard rates f the 2 grups are equivalent. A hazard rati f greater than 1 r less than 1 means that there are differences in the hazard rates between the 2 grups. Likelihd rati rati f an expected test result (psitive r negative) in patients with the disease t an expected test result (psitive r negative) in patients withut the disease. Psitive likelihd ratis, especially thse greater than 10, help rule in a disease (i.e., they substantially raise the pst-test prbability f the disease, and hence make it very likely and the test very useful in identifying the disease). Negative likelihd ratis, especially thse less than 0.1, help rule ut a disease (i.e., they substantially decrease the pst-test prbability f disease, and hence make it very unlikely and the test very useful in excluding the disease). Odds rati dds that an utcme will ccur given a particular expsure, cmpared t the dds f the utcme ccurring in the absence f that expsure. An dds rati f 1 means that the expsure des nt affect the dds f the utcme. An dds rati greater than 1 means that the expsure is assciated with higher dds f the utcme. An dds rati less than 1 means that the expsure is assciated with lwer dds f the utcme. Predictive value likelihd that a given test result crrelates with the presence r absence f disease. Psitive predictive value is defined as the number f true psitives divided by the number f test psitives. Negative predictive value is defined as the number f true negatives divided by the number f test negative patients. Predictive value is dependent n the prevalence f the cnditin. Pretest prbability prbability that a given patient has a disease prir t testing. May be divided int very lw (less than 5%), lw (less than 20%), mderate (20%-75%), and high (greater than 75%) althugh these numbers may vary by cnditin. Relative risk prbability f an utcme when an expsure is present relative t the prbability f the utcme ccurring when the expsure is absent. Relative risk is analgus t dds rati; hwever, relative risk is calculated by using percentages instead f dds. A relative risk f 1 means that there is n difference in risk between the 2 grups. A relative risk f greater than 1 means that the utcme is mre likely t happen in the expsed grup cmpared t the cntrl grup. A relative risk less than 1 means that the utcme is less likely t happen in the expsed grup cmpared t the cntrl grup. Sensitivity cnditinal prbability that the test is psitive, given that the patient has the disease. Defined as the true psitive rate (number f true psitives divided by the number f patients with disease). Excellent r high sensitivity is usually greater than 90%. Specificity cnditinal prbability that the test is negative, given that the patient des nt have the disease. Defined as the true negative rate (number f true negatives divided by the number f patients withut the disease). Excellent r high specificity is usually greater than 90%. Cpyright AIM Specialty Health. All Rights Reserved. 8

9 General prerequisites fr spine imaging: Imaging f the Spine Evidence f nerve rt r crd cmpressin bjective muscle weakness r sensry abnrmality crrespnding t a specific dermatme/mytme, reflex changes r spasticity Cnservative management a cmbinatin f strategies t reduce inflammatin, alleviate pain, and imprve functin, including but nt limited t the fllwing: Prescriptin strength anti-inflammatry medicatins and analgesics Adjunctive medicatins such as nerve membrane stabilizers r muscle relaxants Physician-supervised therapeutic exercise prgram r physical therapy Manual therapy r spinal manipulatin Alternative therapies such as acupuncture Apprpriate management f underlying r assciated cgnitive, behaviral r addictin disrders Clinical Indicatins The fllwing sectin includes indicatins fr which advanced imaging f the spine is cnsidered medically necessary, alng with prerequisite infrmatin and supprting evidence where available. Indicatins, diagnses, r imaging mdalities nt specifically addressed are cnsidered nt medically necessary. It is recgnized that imaging ften detects abnrmalities unrelated t the cnditin being evaluated. Such findings must be cnsidered within the cntext f the clinical situatin when determining whether additinal imaging is required. General prerequisites fr spine imaging include evidence f nerve rt r crd cmpressin and cnservative management, as defined abve. Dcumentatin f cmpliance with a plan f therapy that includes elements f cnservative management may be required. Exceptins may be cnsidered n a case-by-case basis. Cngenital and Develpmental Cnditins Chiari malfrmatin Advanced imaging f the spine is cnsidered medically necessary fr diagnsis and management when the results f imaging will impact treatment decisins. - CT r MRI cervical spine Cngenital spinal crd anmalies nt listed Advanced imaging f the spine is cnsidered medically necessary fr diagnsis and management when the results f imaging will impact treatment decisins. - CT r MRI all spinal levels Nte: Spina bifida cculta is a cmmn incidental finding in pediatric patients. Imaging shuld nt be perfrmed unless the patient is symptmatic and there is a cncern fr tethered crd. Cpyright AIM Specialty Health. All Rights Reserved. 9

10 Imaging f the Spine Cngenital vertebral defects Includes skeletal dysplasia as well as segmentatin and fusin anmalies Advanced imaging f the spine is cnsidered medically necessary fr diagnsis and management when results f imaging will impact treatment. - CT r MRI all spinal levels Cranicervical junctin abnrmalities Includes atlantaxial and ccipital instability as well as basilar invaginatin Advanced imaging f the spine is cnsidered medically necessary fr diagnsis and management in persns with ANY f the fllwing high-risk cnditins: Dwn syndrme Grisel syndrme Skeletal dysplasia Sclisis - Radigraphs required - CT r MRI cervical spine when radigraphs are nt sufficient t guide treatment Advanced imaging f the spine is cnsidered medically necessary in ANY f the fllwing scenaris: Evaluatin f sclisis fllwing initial radigraphs in the fllwing grups: Cngenital sclisis Idipathic sclisis with ANY f the fllwing atypical features: Early nset (prir t 10 years f age) Unusual curvature (left thracic r right lumbar) Neurlgical signs r symptms Rapidly prgressive sclisis Significant pain Sclisis related t ther pathlgic prcesses such as neurfibrmatsis Surgical planning Pst-surgical evaluatin - Radigraphs required fr initial evaluatin in pediatric patients - CT r MRI f all spinal levels Nte: Fr pediatric patients wh may require imaging f a significant prtin f the spine r the entire spine, MRI shuld be cnsidered t minimize radiatin expsure. Ratinale Idipathic sclisis is a lateral curvature f the spine f unknwn etilgy, ccurring at any time befre the end f grwth in therwise healthy children. 2 Idipathic sclisis is classified by age f nset as infantile befre three years f Cpyright AIM Specialty Health. All Rights Reserved. 10

11 Imaging f the Spine age, juvenile between 3 and 10 years f age r befre puberty (bth early nset), and adlescent when detected after 10 years f age r pst puberty. 3 Sclisis is usually defined as a lateral curvature f the spine f > 10 degrees, and it is estimated that 2% f children are affected at sme stage f their life. The etilgy f the spinal defrmity may be idipathic (80% f cases), particularly in adlescents. Hwever, it may be assciated with underlying systemic syndrmes, secndary t a neurmuscular cnditin (10% f cases), skeletal dysplasia, r secndary t cngenital spinal defrmity (10% f cases). Sclisis is classified as early nset when clinical and radilgical symptms ccur befre 10 years f age. 3 Radigraphy is the first and primary mdality t evaluate sclisis in pediatric patients. It can be used t make the diagnsis f sclisis, evaluate prgressin, and perfrm fllw-up treatment. Radigraphy can evaluate fr changes in the Cbb angle, which is the primary metric fr evaluating sclisis. 4 Adlescent sclisis is cmmn (2%-4% prevalence) and usually idipathic. 5 The typical patient has a right thracic r thraclumbar curve (S-shaped) and n neurlgical findings, and imaging is nt generally indicated. 4 Imaging is indicated in patients with sclisis and atypical findings, as atypical patients are mre likely t have cngenital anmalies f the vertebrae r spinal crd. The degree f sclisis is nt assciated with an increase in imaging abnrmalities and is therefre nt an atypical feature. 6 Cngenital sclisis is ften assciated with additinal develpment anmalies including Chiari malfrmatin (30%), diastematmyelia (20%), spinal segmentatin anmalies and systemic develpmental anmalies (VACTERL), and cnnective tissue disease (Marfan s). 3 Spinal dysraphism Includes clsed spinal dysraphism (lipmyelcele, lipmyelmeningcele, r dermal sinus) as well as pen spinal dysraphism (meningcele, myelcele, r myelmeningcele) Advanced imaging f the spine is cnsidered medically necessary fr diagnsis and management when results f imaging will impact treatment. - Ultrasund required fr initial evaluatin in infants age 5 mnths r yunger - MRI cervical, thracic, r lumbar spine - CT thracic r lumbar spine when MRI cntraindicated Ratinale Spinal dysraphism is a term used t describe a brad spectrum f disrders characterized by incmplete r absent midline fusin f the drsal spinal elements (spina bifida), neural structures, r bth. Examples include pen (cmmunicating with the nerve rts) and clsed dysraphisms including myelcele, myelmeningcele, spina bifida, and drsal dermal sinus. 7 Ultrasund f the spine can be perfrmed in nenates prir t ssificatin f the cartilaginus spine 7 and is a useful screening test in newbrns and in uter, 8 helping t select patients wh require further evaluatin with MRI, which has higher diagnstic accuracy but is mre time intensive and which may require sedatin. 9 Tethered crd Advanced imaging f the spine is cnsidered medically necessary fr diagnsis and management when results f imaging will impact treatment. - CT r MRI lumbar spine Ratinale Ultrasund is preferred as the initial imaging mdality t screen fr tethered crd in infants under 5 mnths, with a sensitivity f 80% and specificity f 89%. 10 Ultrasund is limited in lder nenates. As the cartilaginus psterir elements f the spine ssify frm caudally t cranially, reduced sund penetratin in the lumbar spine by apprximately 3-4 mnths f age usually renders this mdality subptimal as a screening tl beynd this perid. 7 Cpyright AIM Specialty Health. All Rights Reserved. 11

12 Imaging f the Spine Infectius and Inflammatry Cnditins Juvenile idipathic arthritis (Pediatric nly) Als see juvenile idipathic arthritis in Extremity Imaging guidelines. Advanced imaging f the spine is cnsidered medically necessary fr management f established juvenile idipathic arthritis when radigraphs are insufficient t determine apprpriate curse f therapy. - MRI all spinal levels - CT when MRI is cntraindicated r expected t be nndiagnstic Ratinale Juvenile idipathic arthritis (JIA), the mst cmmn rheumatic disease f children and adlescents, is an umbrella term that encmpasses all frms f arthritis that begin befre age 16, persist fr mre than 6 weeks, and are f unknwn etilgy. Specific examples f JIA include ligarthritis, plyarthritis, systemic arthritis, psriatic arthritis, and enthesisrelated arthritis. JIA is the mst cmmn childhd rheumatic entity, with a prevalence f 0.6 t 1.9 in 1000 children. 11 JIA is primarily a clinical diagnsis. General practitiners shuld base diagnsis f JIA (and differential diagnsis) n histry and clinical examinatin, with strng suspicin f JIA indicated by pain and swelling f single r multiple jints, persistent r wrsening lss f functin, fever f at least 10 days with unknwn cause (ften assciated with transient erythematus rash), decreased range f mtin, and jint warmth r effusin. 12 Labratry assessment with apprpriate tests can assist in increasing diagnstic certainty, excluding differential diagnses, and predicting patients likely t prgress t ersive disease. Base investigatins usually include erythrcyte sedimentatin rate r C-reactive prtein and full bld cunt, with cnsideratin given t rheumatid factr, antinuclear antibdy, and human leukcyte antigen B When there is clinical diagnstic dubt, cnventinal radigraphs (CR), ultrasund, r MRI can be used t imprve the certainty f a diagnsis f JIA abve clinical features alne. 13 MRI is the mst sensitive nninvasive imaging mdality t evaluate fr inflammatin f the jints, tendns, and entheses, and is the nly mdality that can depict bne marrw edema. Currently, MRI with cntrast is the mst sensitive tl fr determining active synvitis. 14 When the imaging mdalities were directly cmpared, MRI and US detected mre jint damage than CR, but primarily at the hip (MRI vs CR detectin rate, mean [range] 1.54-fld [ fld]; ultrasund vs CR detectin rate, mean 2.29-fld), and at the wrist (MRI vs CR detectin rate, 1.36-fld [ fld]). 13 Imaging studies help identify children with a high likelihd f early ersive jint damage, prviding an pprtunity t implement aggressive therapy at an early stage in an attempt t reduce mrbidity. 14 Multiple sclersis r ther white matter disease Advanced imaging f the spine is cnsidered medically necessary when required t establish a diagnsis r guide management. - MRI cervical r thracic spine Rheumatid arthritis (Adult nly) Advanced imaging f the spine is cnsidered medically necessary fr evaluatin f suspected cervical subluxatin in persns with cnfirmed rheumatid arthritis. - CT r MRI cervical spine Ratinale Rheumatid arthritis is a systemic inflammatry disease that affects the cervical spine in up t 80% f cases resulting in cranicervical instability, mst cmmnly frm atlantaxial subluxatin. MRI is the mst sensitive exam t establish the diagnsis, 15 which carries an increased risk f mrtality and mrbidity in rheumatid arthritis patients, 16 and lifetime radilgical fllw up may be required. Cpyright AIM Specialty Health. All Rights Reserved. 12

13 Imaging f the Spine Spinal infectin Advanced imaging f the spine is cnsidered medically necessary fr diagnsis and management f spinal infectin, including but nt limited t epidural abscess, arachniditis, discitis, and stemyelitis. - CT r MRI all spinal levels - FDG-PET fr chrnic stemyelitis Spndylarthrpathy Includes ankylsing spndylitis, reactive arthritis, psriatic arthritis, spndylarthrpathy assciated with inflammatry bwel disease, and juvenile-nset spndylarthritis Advanced imaging f the spine is cnsidered medically necessary fr diagnsis fllwing standard evaluatin with radigraphs and/r labratry evaluatin. - CT r MRI all spinal levels Ratinale Axial spndylarthritis (SpA) includes a grup f rare (estimated 0.25% t 1% prevalence) disrders that may be human leukcyte antigen B27 (HLA-B27) psitive and that manifest with inflammatry changes arund the enthesis. SpA includes ankylsing spndylitis (AS), reactive arthritis, psriatic arthritis, arthrpathy assciated with inflammatry bwel disease, and undifferentiated SpA. The Assessment f Spndylarthritis Internatinal Sciety (ASAS) has develped and validated criteria (ASAS chrt) fr spndylarthritis, as well as fr their subsets, axial SpA and peripheral SpA. 17 While sacriliitis is the mst cmmn MRI manifestatin f axial spndylarthrpathy, bne marrw edema can be seen in the vertebra as well and characteristic patterns have been described. 18 Cnsensus amng guidelines that radigraphy f the pelvis and/r spine is the preferred imaging mdality fr initial evaluatin f SpA: The first-line imaging mdality is radigraphy. We recmmend imaging the whle spine. 19 Offer plain film X-ray f the sacriliac jints fr peple with suspected axial spndylarthritis, unless the persn is likely t have an immature skeletn. 20 In patients with ankylsing spndylitis (nt nn-radigraphic axial SpA), initial cnventinal radigraphy f the lumbar and cervical spine is recmmended t detect syndesmphytes, which are predictive f develpment f new syndesmphytes. 21 ASAS criteria fr axial spndylarthritis have a high diagnstic accuracy (sensitivity 82%, specificity 88%) based n a systematic review f 9 papers and 5739 patients. 17 Patients that d nt meet the ASAS criteria are a lw pretest prbability grup unlikely t have axial spndylarthrpathy. ASAS criteria fr axial spndylarthritis include: Age less than 45 years Back pain f at least 3 mnths duratin Sacriliitis n imaging (either definitive changes n radigraphy r evidence frm MRI) and ne characteristic feature HLA-B27 psitive and at least tw characteristic clinical features, which include arthritis, uveitis, dactylitis, psriasis, Crhn s disease, psitive NSAID respnse, and family histry. Diagnstic criteria fr axial spndylarthrpathy (ASAS) are based n MRI f the sacriliac jints, nt the spine. MRI f the spine has a lw yield in patients with a negative sacriliac jint MRI and shuld nt be rutinely perfrmed. Retrspective study f 1191 patients under age 45 with chrnic lwer back pain (apprximately 7%) were fund t have sacriliitis. Less than 2% f patients with a negative sacriliac jint MRI had a psitive spine MRI. Spine MRI changed management (reclassified patients frm negative t psitive axial SPA) in nly 0.16% f cases. 22 MRI can demnstrate edema f the vertebral bdy crners (als knwn as crner inflammatry lesins) and bne marrw edema. A psitive MRI spine is defined as 3 r mre lesins present n 2 r mre slices, but this definitin is used primarily fr research purpses. 22 There is cnsensus amng guidelines that MRI shuld be btained in patients with persistent clinical suspicin when radigraphy is negative r indeterminate: Cpyright AIM Specialty Health. All Rights Reserved. 13

14 Imaging f the Spine If a diagnsis f axial spndylarthritis cannt be cnfirmed and clinical suspicin remains high, cnsider a fllwup MRI 23 In case f negative radigraphs in patients with a suspicin f SpA, MRI is mandatry t lk fr early inflammatry lesins 24 Cnsider plain film X-rays, ultrasund and/r MRI f ther peripheral and axial symptmatic sites 20 A negative/indeterminate radigraph meets BOTH f the fllwing criteria: Des nt satisfy the New Yrk Criteria fr Ankylsing Spndylitis bilateral grade 2 4 r unilateral grade 3 4 sacriliitis (evidence f ersins, sclersis, jint space widening, narrwing r ankylses) Des nt therwise explain the back pain MRI f the SI jints and/r the spine may be used t assess and mnitr disease activity in axial SpA, prviding additinal infrmatin n tp f clinical and bichemical assessments. The decisin n when t repeat MRI depends n the clinical circumstances. In general, STIR sequences are sufficient t detect inflammatin and the use f cntrast medium is nt needed. 21 Trauma Cervical injury Advanced imaging is cnsidered medically necessary in the fllwing scenaris: Acute significant trauma Neurlgic deficit suggestive f crd injury Prgressively wrsening pain fllwing an injury Suspected fracture r cranicervical instability when radigraphs are nndiagnstic - CT r MRI cervical spine Ratinale Multiple guidelines recmmend use f CT in patients with acute significant cervical trauma. 25, 26 While the diagnstic yield in the acute trauma setting is lw, 27 the mrbidity and mrtality f a missed fracture are high. 28 After initial evaluatin with CT, MRI may be a helpful add-n test in select patient ppulatins such as thse with spinal crd injury withut radigraphic abnrmality, 29, 30 neurlgical signs and symptms, r prgressive symptms unexplained by radigraphy r CT. MRI is mre sensitive than CT fr the detectin f crd edema and hemrrhage r epidural hematmas that may require surgical decmpressin. Hwever, there is a very lw likelihd that MRI will change management r identify clinically significant injuries in unselected acute trauma patients with a nrmal cervical spine CT. 31 Thracic r lumbar injury Advanced imaging is cnsidered medically necessary in the fllwing scenaris: Acute significant trauma Neurlgic deficit suggestive f crd injury Fllwing nndiagnstic radigraphs when EITHER f the fllwing is present: Suspected fracture Prgressive pain withut neurlgic findings - CT r MRI f thracic r lumbar spine Ratinale Guidelines recmmend selective use f CT in high-risk trauma patients. Patients withut cmplaints f thraclumbar spine (TLS) pain that have nrmal mental status as well as nrmal neurlgical and physical examinatins may be Cpyright AIM Specialty Health. All Rights Reserved. 14

15 Imaging f the Spine excluded frm TLS injury by clinical examinatin alne (withut radigraphic imaging) prvided that there is n suspicin f high-energy mechanism r intxicatin with alchl r drugs. 32 X-ray shuld be perfrmed as the first-line investigatin fr peple with suspected spinal clumn injury withut abnrmal neurlgical signs r symptms in the thracic r lumbsacral regins. 26 Patients with back pain, TLS tenderness n examinatin, neurlgic deficits referable t the TLS, altered mental status, intxicatin, distracting injuries, r knwn r suspected high-energy mechanisms shuld be screened fr TLS injury with CT scan. 32 Tumr Tumr Fr management f dcumented malignancy, please refer t the Onclgic Imaging guidelines. Advanced imaging f the spine is cnsidered medically necessary fr diagnsis r management f a mass in the spinal crd, vertebrae, r adjacent sft tissue. - CT r MRI all spinal levels Miscellaneus Cnditins f the Spine Osteprsis and stepenia Advanced imaging f the spine is cnsidered medically necessary fr diagnsis r management in the fllwing scenaris: Screening and Diagnstic indicatins Screening in menpausal r pst-menpausal wmen and men age 70 r lder Persns being treated with medicatins assciated with develpment f steprsis Anyne presenting with a fragility r pathlgic fracture Persns with a disease r cnditin assciated with develpment f steprsis including the fllwing: Anrexia nervsa Chrnic liver disease Chrnic renal failure Cushing syndrme Delayed menarche r untreated premature menpause Heavy alchl cnsumptin Hypercalciuria Hypgnadism Inflammatry bwel disease Lw trauma fractures r vertebral fractures Malabsrptin syndrmes Primary hyperparathyridism Prlnged immbilizatin Radigraphic evidence f stepenia Rheumatid arthritis Thyrid disease Cpyright AIM Specialty Health. All Rights Reserved. 15

16 Imaging f the Spine Anyne cnsidering therapy fr steprsis, if bne mineral densitmetry will facilitate decisin making Management indicatins Testing at 2- t 3-year intervals in persns being treated fr steprsis r stepenia Testing at 3- t 5-year intervals in untreated individuals wh met the criteria fr initial evaluatin, withut significant stepenia n the prir study r interval develpment f risk factrs fr accelerated bne lss - CT bne density fr all indicatins listed - CT r MRI spine fr suspected cmpressin fracture with nndiagnstic radigraphs Spinal crd infarctin Advanced imaging f the spine is cnsidered medically necessary fr diagnsis and management when the results f imaging will impact treatment. - MRI all spinal levels - CT all spinal levels when MRI is cntraindicated r expected t be nndiagnstic Spndyllysis and spndyllisthesis Advanced imaging f the spine is cnsidered medically necessary in ANY f the fllwing scenaris: Suspected spndyllysis with nndiagnstic lumbar spine radigraphs Fllwing radigraphs dcumenting spndyllisthesis Preperative planning when lumbar spine radigraphs are nt sufficient t guide treatment - Radigraphs required - CT r MRI lumbar spine Syringmyelia Includes syrinx, hydrmyelia, and hydrsyringmyelia Advanced imaging f the spine is cnsidered medically necessary fr diagnsis and peridic surveillance when results f imaging will impact treatment. - MRI cervical r thracic spine - CT cervical r thracic spine when MRI cntraindicated Signs and Symptms Cauda equina syndrme Advanced imaging f the spine is cnsidered medically necessary fr diagnsis and management when the results f imaging will impact treatment. Cpyright AIM Specialty Health. All Rights Reserved. 16

17 Imaging f the Spine Nte: Lw back pain r radicular pain in cnjunctin with any f the fllwing signs and symptms may suggest a diagnsis f cauda equina syndrme: severe bilateral sciatica; saddle r genital sensry disturbance; bladder, bwel, r sexual dysfunctin. Myelpathy - CT r MRI lumbar spine Advanced imaging f the spine is cnsidered medically necessary fr evaluatin when the results f imaging will impact treatment. - MRI all spinal levels - CT all spinal levels may be used as an alternative in pediatric patients, r when MRI is cntraindicated in adults Pain indicatins The fllwing pain indicatins shuld nt be utilized when there are underlying cnditins r clinical evidence f infectin, malignancy, r ther systemic pathlgy. Please refer t the indicatin/sectin fr imaging related t these cnditins. Fr pain related t acute trauma, see Trauma indicatins. Neck pain (cervical) ADULT Advanced imaging is cnsidered medically necessary when the patient is a ptential candidate fr spine interventin in EITHER f the fllwing scenaris: Lcalized r nn-radicular pain when persistent fllwing at least 6 weeks f cnservative management which includes at least 2 different frms f treatment and negative r nndiagnstic radigraphs Radicular pain in EITHER f the fllwing scenaris: PEDIATRIC Dcumented abnrmality n neurlgical exam in a dermatme/radicular distributin that has nt previusly been imaged r has prgressed since a prir imaging study has been perfrmed Lack f imprvement r wrsening during a 6-week curse f therapy with at least 2 different frms f treatment Advanced imaging is cnsidered medically necessary in EITHER f the fllwing scenaris: Lcalized r radicular pain nt explained by radigraph and nt respnsive t a curse f cnservative therapy Pain with evidence f nerve rt r crd cmpressin - CT r MRI cervical spine - CT myelgram Ratinale Neck pain is the furth leading cause f glbal disability and has an annual prevalence rate exceeding 30% A majrity (apprximately 70%) f patients with neck pain imprve with cnservative/medical management alne. 36 Cpyright AIM Specialty Health. All Rights Reserved. 17

18 Imaging f the Spine Agreement exists amng several high-quality guidelines that patients with prgressive neurlgical deficits shuld underg MRI, 37, 38 and that patients with majr neurlgic deficits at nset shuld als underg MRI. In the absence f neurlgic findings, the rle f imaging becmes less clear. Althugh plain radigraphs f the cervical spine are useful fr ruling ut instability, they are relatively nnspecific fr diagnsing cervical radiculpathy. Abut 65% f asymptmatic patients age 50 t 59 will have radigraphic evidence f significant cervical spine degeneratin, regardless f radiculpathy symptms. 39 Rutine use f CT and MRI in patients withut neurlgic insult r ther disease has nt been justified in view f the infrequency f abnrmalities detected, the lack f prgnstic value, inaccessibility, and the high cst f the prcedures. A majr limitatin is the lack f definite crrelatin between the patient s subjective symptms and abnrmal findings seen n imaging studies. As a result, debate cntinues as t whether persistent pain is attributable t structural pathlgy r t ther underlying causes. 40 A recent Cchrane review fund mderate evidence that neck/upper extremity strengthening exercises reduce neck pain in the near term; the average duratin f the exercise prgrams in this review was apprximately 12 weeks. 41 Several randmized cntrlled trials have shwn that a multimdal apprach t cnservative management is better than a unimdal ne: Exercise and educatin are better than educatin alne. 42 Multimdal exercises and cgnitive behaviral therapy result in less disability frm neck pain at 1 year when cmpared t general physitherapy. 42,43 Educatin and exercise are mre effective at reducing 4-mnth disability frm neck pain than manual therapy alne. 44 There is agreement amng multiple high-quality guidelines that further investigatin is required in patients with nnspecific neck pain wh have failed a curse f cnservative therapy, 37,45 and that imaging is indicated in this grup. In terms f the imaging mdality, there is n cnsensus fr rutine investigatin f patients with chrnic neck pain beynd plain radigraphs. Current evidence supprts referral at 4 t 8 weeks fr nn-prgressive radiculpathy. Advanced imaging can be cnsidered if there is n imprvement after 4 t 6 weeks. 39 Guidance n apprpriate neck imaging in pediatrics is mre limited. Degenerative changes n MRI d nt crrelate with either the frequency r intensity f headaches in adlescents. 46 The majrity f neck pain in children may be mechanical, althugh data is retrspective 47 and neck pain may be the presentatin f mre serius disease, including retrpharyngeal abscess r neplasm. 48 Mid-back pain (thracic) ADULT Advanced imaging is cnsidered medically necessary when the patient is a ptential candidate fr spine interventin, in EITHER f the fllwing scenaris: Pain with neurlgic findings suggesting thracic r lumbar nerve rt r crd cmpressin that has nt previusly been imaged r has prgressed since imaging was perfrmed Pain withut a neurlgic cmpnent that has nt respnded t at least 4 t 6 weeks f cnservative management supervised by the rdering physician PEDIATRIC Advanced imaging is cnsidered medically necessary in EITHER f the fllwing scenaris: Lcalized r radicular pain nt explained by radigraph and nt respnsive t a curse f cnservative therapy Pain with evidence f nerve rt r crd cmpressin - CT r MRI thracic spine - CT myelgram Lw back pain (lumbar) ADULT Advanced imaging is cnsidered medically necessary when the patient is a ptential candidate fr spine interventin, in EITHER f the fllwing scenaris: Cpyright AIM Specialty Health. All Rights Reserved. 18

19 Imaging f the Spine Pain with neurlgic findings suggesting thracic r lumbar nerve rt r crd cmpressin that has nt previusly been imaged r has prgressed since imaging was perfrmed Pain withut a neurlgic cmpnent that has nt respnded t at least 6 weeks f cnservative management supervised by the rdering physician PEDIATRIC Advanced imaging is cnsidered medically necessary in ANY f the fllwing scenaris: Persistent pain nt explained by radigraph and nt respnsive t a curse f cnservative therapy f at least 4 weeks duratin Pain in children yunger than age 5 Pain accmpanied by any red flag features (see Table 1) Table1: Red flag features f lw back pain Back pain characteristics Cnstitutinal signs Neurlgic signs and symptms Cnstant pain Disrupts sleep Recurrent pain Wrsening after initiatin f cnservative management Early mrning stiffness - CT r MRI lumbar spine - CT myelgram Ratinale Lw back pain (LBP) is currently the secnd mst cmmn cause f disability in the United States and is the mst cmmn cause f disability in thse under age ,50 It is the secnd mst cmmn reasn fr a physician visit and affects 80% t 85% f peple ver their lifetimes. 51 ACUTE LOW BACK PAIN The majrity f individuals with an episde f acute LBP imprve and return t wrk within the first 2 weeks. 52 The prbability f recurrence within the first year ranges frm 30% t 60%. 53 Mst f these recurrences will recver in much the same pattern as the initial event. In as many as 1/3 f the cases, the initial episde f LBP persists fr the next year. There is a gd prgnsis fr LBP. The majrity f patients experience significant imprvements in 2 t 4 weeks. 54 Mst patients wh seek attentin fr their back pain will imprve within 2 weeks, and mst experience significant imprvement within 4 weeks. 50 Practitiners shuld emphasize that acute LBP is nearly always benign and generally reslves within 1 t 6 weeks. 55 Mst patients presenting with uncmplicated acute LBP and/r radiculpathy d nt require imaging. 51 Rutine advanced imaging has nt been shwn t imprve patient utcmes and may in fact identify abnrmalities that are unrelated t the presenting symptms. 51 DISC HERNIATION A prspective study by Carragee et al. fund that 84% f patients with lumbar imaging abnrmalities befre the nset f LBP had unchanged r imprved findings after symptms develped. In additin, nnspecific lumbar disc abnrmalities are cmmn in asymptmatic patients. 51 Mst disc herniatins reslve in 8 weeks. 50 Patients typically see imprvement within 4 weeks f nninvasive management and there is little evidence t supprt rutine imaging. 56 In fact, a randmized cntrlled trial cmparing MRI and standard lumbar radigraphy fund that patients wh received MRI were mre than twice as likely t underg surgical interventins than patients in the lumbar radigraphy arm (risk difference,0.34; 95%CI, t 0.73). 57 Several randmized cntrlled trials suggest that early imaging fr LBP incurs csts in terms f increased health care resurce utilizatin but des nt imprve treatment r patient utcmes. In additin, early imaging may result in unnecessary treatment and the assciated negative impact n the patient s emtinal and psychlgical well-being. 58 SPINAL STENOSIS Bruising Lymphadenpathy Night sweats Unexplained fever Weight lss Rapid decline in patients with mild r mderately symptmatic degenerative lumbar stensis is rare and there is insufficient evidence t make a recmmendatin fr r against a crrelatin between clinical symptms r functin with the presence f anatmic narrwing f the spinal canal n MRI, CTM, r CT. 59 Altered gait Bwel r bladder dysfunctin Radicular pain Sensry symptms in a lumbar dermatme distributin Spasticity/abnrmal reflexes Weakness Cpyright AIM Specialty Health. All Rights Reserved. 19

20 Imaging f the Spine Clinicians shuld evaluate patients with persistent LBP and signs r symptms f radiculpathy r spinal stensis with MRI (preferred) r CT nly if they are ptential candidates fr surgery r epidural sterid injectin (fr suspected radiculpathy). 56 PEDIATRIC BACK PAIN LBP in children and adlescents is a cmmn prblem. The prevalence f LBP rises with age: 1% at age 7, 6% at age 10, and 18% at ages 14 t 16. By age 18, the lifetime prevalence f LBP appraches that dcumented in adults, with an estimated yearly prevalence f 20% and a lifetime prevalence f 75%. Mre than 7% f adlescents experiencing LBP will seek medical attentin. 60 The American Cllege f Radilgy states that fr a child with back pain and n clinical red flags (cnstant pain, night pain, radicular pain, pain lasting ver 4 weeks, and/r abnrmal neurlgic examinatin), imaging is nt recmmended. Fr a child with back pain and red flags, spine radigraphs are recmmended as the initial evaluatin. Fr a child with back pain, red flags and nrmal radigraphs, MRI spine withut cntrast is recmmended. MRI with cntrast is useful if there is cncern fr inflammatin, infectin, r neplasm. Fr a child with back pain and psitive radigraphs, MRI spine withut cntrast is recmmended. Fr a child with chrnic back pain frm veruse (mechanical), spine radigraphs are recmmended. MRI spine withut cntrast is recmmended t evaluate fr additinal site invlvement r when radigraphs d nt demnstrate an abnrmality, r t evaluate fr additinal sites f invlvement when radigraphs are abnrmal. 61 References 1. Šimundić A-M. Measures f Diagnstic Accuracy: Basic Definitins. EJIFCC. 2009;19(4): PMID: PMC Pereira EAC, Oxenham M, Lam KS. Intraspinal anmalies in early-nset idipathic sclisis. Bne Jint J. 2017;99- B(6): PMID: Callni SF, Huisman TA, Pretti A, et al. Back pain and sclisis in children: When t image, what t cnsider. The neurradilgy jurnal. 2017;30(5): Epub 2017/08/09. PMID: Wright N. Imaging in sclisis. Arch Dis Child. 2000;82(1): Epub 2000/01/12. PMID: Hrne JP, Flannery R, Usman S. Adlescent idipathic sclisis: diagnsis and management. Am Fam Physician. 2014;89(3): Epub 2014/02/11. PMID: Ameri E, Andalib A, Tari HV, et al. The Rle f Rutine Preperative Magnetic Resnance Imaging in Idipathic Sclisis: A Ten Years Review. Asian Spine Jurnal. 2015;9(4): PMID: Alvarad E, Leach J, Care M, et al. Pediatric Spinal Ultrasund: Nenatal and Intraperative Applicatins. Seminars in Ultrasund, CT and MRI. 2017;38(2): PMID: Ausili E, Maresca G, Massimi L, et al. Occult spinal dysraphisms in newbrns with skin markers: rle f ultrasngraphy and magnetic resnance imaging. Child's nervus system : ChNS : fficial jurnal f the Internatinal Sciety fr Pediatric Neursurgery. 2018;34(2): Epub 2017/10/28. PMID: O'Neill BR, Gallegs D, Herrn A, et al. Use f magnetic resnance imaging t detect ccult spinal dysraphism in infants. J Neursurg Pediatrics. 2017;19(2): PMID: van den Hndel D, Slts C, de Jng TH, et al. Screening and Treatment f Tethered Spinal Crd in Anrectal Malfrmatin Patients. Eurpean jurnal f pediatric surgery : fficial jurnal f Austrian Assciatin f Pediatric Surgery [et al] = Zeitschrift fur Kinderchirurgie. 2016;26(1):22-8. Epub 2015/09/24. PMID: Chauvin NA, Khwaja A. Imaging f Inflammatry Arthritis in Children: Status and Perspectives n the Use f Ultrasund, Radigraphs, and Magnetic Resnance Imaging. Rheum Dis Clin Nrth Am. 2016;42(4): Epub 2016/10/16. PMID: (RACGP) TRACGP. Clinical guideline fr the diagnsis and management f juvenile idipathic arthritis.: The Ryal Australian Cllege f General Practitiners (RACGP); 2009 [cited 2018 June 7, 2018]. Available frm: Clebatch-Burn AN, Edwards CJ, Cllad P, et al. EULAR-PReS pints t cnsider fr the use f imaging in the diagnsis and management f juvenile idipathic arthritis in clinical practice. Ann Rheum Dis. 2015;74(11): Epub 2015/08/08. PMID: Chauvin NA, Khwaja A. Imaging f Inflammatry Arthritis in Children: Status and Perspectives n the Use f Ultrasund, Radigraphs, and Magnetic Resnance Imaging. Rheum Dis Clin Nrth Am. 2016;42(4): PMID: Cpyright AIM Specialty Health. All Rights Reserved. 20