This document addresses the use of computed tomography (CT) and magnetic resonance imaging (MRI) for evaluation, diagnosis, and management of spine-related conditions in the outpatient setting.

Note: Please see the following related documents for additional information:

• CG-RAD-05 CT Myelogram
• RAD.00052 Positional MRI
• RAD.00055 MR Angiography (MRA) of the Spinal Canal

Computed Tomography Cervical Spine 

Medically Necessary
CT cervical spine is considered medically necessary for any of the following:

A. Trauma or Fracture

• Major trauma, at the time of the initial treatment; or
• Recent less severe trauma to the spine with abnormalities on neurologic exam or x-ray or persistent increasing localized neck, shoulder, or upper extremity pain.

B. Malignancy

• Clinical suspicion of cervical spine cancer with symptoms or signs suggesting involvement of the spine, spinal cord, meninges or positive bone scan; or
• Known diagnosis of cancer with suspicion of metastases to the cervical spine, meninges, or spinal cord.

C. Infectious Process

• Clinical suspicion of an infectious process such as abscess, osteomyelitis, or discitis involving the spine, spinal cord, or adjacent structures or spaces

D. Evaluation of Signs or Symptoms

• Neck or shoulder pain and signs or symptoms of spinal cord or nerve root compression, with or without surgery (e.g., focal neurologic deficit or abnormal findings on neurologic exam [e.g., abnormal EMG, motor weakness, dermatomal sensory loss or significant reflex abnormality]); or
• Pain or radiculopathy not improving despite 4 weeks of conservative therapy which may include appropriate pharmacologic interventions or physical therapy or exercises with the following exceptions:
  • Given the rarity of back pain in children, the 4 week requirement for treatment need not be applied to the pediatric patient; or
  • Individuals with rheumatoid arthritis are at increased risk for spinal misalignment and the requirement for 4 weeks of conservative treatment prior to imaging is not applicable to this group; or
• Signs or symptoms of cervical myelopathy or cervical nerve root compression with new onset of extremity weakness, ataxia, spasticity, spinal level sensory loss, etc.; or
• Signs or symptoms suggestive of spinal stenosis (e.g., weakness, spasticity, clonus, muscle wasting, generalized sensory loss, nerve root compression, hyperactive reflexes, suggestive x-ray findings); or
• Post myelogram CT.

E. Evaluation of Known Diseases or Conditions

• Further investigation of spinal abnormality of unknown or uncertain cause seen on plain film with recommended follow up; or
• Scoliosis (in pediatric patients, MRI preferred to minimize radiation exposure) in the following situations:
  • In patients with high risk for neural axis abnormalities, such as infantile and juvenile idiopathic scoliosis and congenital scoliosis; or
  • Adolescent idiopathic scoliosis and atypical findings, including:
    • Pain; or
    • Rapid progression; or
    • Development of neurologic signs or symptoms; or
  • Scoliosis related to other pathologic processes, such as neurofibromatosis; or
  • Pre-operative evaluation of severe scoliosis; or

• Suspected spinal cord infarct; or
• Suspicion of congenital or acquired abnormalities of spine or spinal cord following abnormal or undiagnostic cervical spine radiography, examples include:
  • Vertebral defects, such as segmentation and fusion abnormalities; or
  • Arnold Chiari malformation; or
  • Neural tube defect involving cervical spine, examples include:
    • Myelocele; or
    • Meningocele; or
    • Myelomeningocele; or
  • Syringohydromyelia (syrinx).

Not Medically Necessary
CT cervical spine is considered not medically necessary for either of the following:

• When the above criteria are not met; or
• For evaluation of demyelinating disease (i.e., multiple sclerosis) unless the patient cannot tolerate an MRI exam (e.g., due to claustrophobia).

Magnetic Resonance Imaging Cervical Spine 

Medically Necessary
MRI cervical spine is considered medically necessary for any of the following:

 A. Trauma or Fracture

• Major trauma, at the time of the initial treatment; or
• Recent less severe trauma to the spine with abnormalities on neurologic exam or x-ray or persistent increasing localized neck, shoulder, or upper extremity pain.

B. Malignancy

• Clinical suspicion of cervical spine cancer with symptoms or signs suggesting involvement of the spine, spinal cord, meninges or positive bone scan; or
• Known diagnosis of cancer with suspicion of metastases to the cervical spine, meninges, or spinal cord.

 C. Infectious Process

• Clinical suspicion of an infectious process such as abscess, osteomyelitis, or discitis involving the spine, spinal cord, or adjacent structures or spaces

D. Evaluation of Signs or Symptoms

• Neck or shoulder pain and signs or symptoms of spinal cord or nerve root compression, with or without surgery (e.g., focal neurologic deficit or abnormal findings on neurologic exam [e.g., abnormal EMG, motor weakness, dermatomal sensory loss or significant reflex abnormality]); or
• Pain or radiculopathy not improving despite 4 weeks of conservative therapy which may include appropriate pharmacologic interventions or physical therapy or exercises with the following exceptions:
  • Given the rarity of back pain in children the 4 week requirement for treatment need not be applied to the pediatric patient ; or
  • Individuals with rheumatoid arthritis are at increased risk for spinal misalignment and the requirement for 4 weeks of conservative treatment prior to imaging is not applicable to this group; or
• Signs or symptoms of cervical myelopathy or cervical nerve root compression with new onset of extremity weakness, ataxia, spasticity, spinal level sensory level loss, etc.; or
• Signs or symptoms suggestive of spinal stenosis (e.g., weakness, spasticity, clonus, muscle wasting, generalized sensory loss, nerve root compression, hyperactive reflexes, suggestive x-ray findings).

 E. Evaluation of Known Diseases or Conditions

• Demyelinating disorders, such as multiple sclerosis; or
• Further investigation of spinal abnormality of unknown or uncertain cause seen on plain film with recommended follow-up; or
• Scoliosis in the following situations:
  • In patients with high risk for neural axis abnormalities, such as infantile and juvenile idiopathic scoliosis and congenital scoliosis; or
  • Adolescent idiopathic scoliosis and atypical findings, including:
    • Pain; or
    • Rapid progression; or
    • Development of neurologic signs or symptoms; or
  • Scoliosis related to other pathologic processes, such as neurofibromatosis; or
  • Pre-operative evaluation of severe scoliosis; or

• Suspected spinal cord infarct; or
• Suspicion of congenital or acquired abnormalities of spine or spinal cord following abnormal or undiagnostic cervical spine radiography, examples include:
  • Arnold Chiari malformation; or
  • Neural tube defect involving cervical spine, examples include:
    • Myelocele; or
    • Meningocele; or
    • Myelomeningocele; or
  • Syringohydromyelia (syrinx).

Not Medically Necessary
MRI cervical spine is considered not medically necessary for the following:

• When the above criteria are not met

Computed Tomography Thoracic Spine

Medically Necessary
CT thoracic spine is considered medically necessary for any of the following:

A. Trauma or Fracture

• Major trauma, at the time of the initial treatment; or
• Recent less severe trauma to the spine with abnormalities on neurologic exam or x-ray or persistent increasing pain.

B. Malignancy

• Clinical suspicion of thoracic spine cancer with symptoms or signs suggesting involvement of the spine, spinal cord, meninges or positive bone scan; or
• Known diagnosis of cancer with suspicion of metastases to the thoracic spine, meninges, or spinal cord.

 C. Infectious Process

• Clinical suspicion of an infectious process such as abscess, osteomyelitis, or discitis involving the spine, spinal cord, or adjacent structures or spaces

D. Evaluation of Signs or Symptoms

• Signs or symptoms of spinal cord or nerve root compression, with or without surgery (e.g., focal neurologic deficit or abnormal findings on neurologic exam [e.g., motor weakness, dermatomal sensory loss or significant reflex abnormality]); or
• Pain or radiculopathy not improving despite 4 weeks of conservative therapy which may include appropriate pharmacologic interventions or physical therapy or exercises with the following exceptions:
  • Given the rarity of back pain in children the 4 week requirement for treatment need not be applied to the pediatric patient; or
  • Individuals with rheumatoid arthritis are at increased risk for spinal misalignment and the requirement for 4 weeks of conservative treatment prior to imaging is not applicable to this group; or
• Signs or symptoms of myelopathy or nerve root compression with new onset of extremity weakness, ataxia, spasticity, spinal level sensory loss, etc.; or
• Signs or symptoms suggestive of spinal stenosis (e.g., weakness, spasticity, clonus, muscle wasting, generalized sensory loss, nerve root compression, hyperactive reflexes, suggestive x-ray findings); or
• Post myelogram CT.

E. Evaluation of Known Diseases or Conditions

• Further investigation of spinal abnormality of unknown or uncertain cause seen on plain film with recommended follow up; or
• Scoliosis (in pediatric patients, MRI preferred to minimize radiation exposure) in the following situations:
  • In patients with high risk for neural axis abnormalities, such as infantile and juvenile idiopathic scoliosis and congenital scoliosis; or
  • Adolescent idiopathic scoliosis and atypical findings, including:
    • Pain; or
    • Rapid progression; or
    • Development of neurologic signs or symptoms; or
  • Scoliosis related to other pathologic processes, such as neurofibromatosis; or
  • Pre-operative evaluation of severe scoliosis; or

• Suspected spinal cord infarct; or
• Suspicion of congenital or acquired abnormalities of spine or spinal cord following abnormal or undiagnostic thoracic spine radiography, examples include:
  • Vertebral defects, such as segmentation and fusion abnormalities; or
  • Neural tube defect involving thoracic spine, examples include:
    • Myelocele; or
    • Meningocele; or
    • Myelomeningocele; or
  • Syringohydromyelia (syrinx).

Not Medically Necessary
CT thoracic spine is considered not medically necessary for either of the following:

• When the above criteria are not met; or
• For evaluation of demyelinating disease (i.e., multiple sclerosis) unless the patient cannot tolerate an MRI exam (e.g., due to claustrophobia)

Magnetic Resonance Imaging Thoracic Spine

Medically Necessary
MRI thoracic spine is considered medically necessary for any of the following:

A. Trauma or Fracture

• Major trauma, at the time of the initial treatment ; or
• Recent less severe trauma to the spine with abnormalities on neurologic exam or x-ray or persistent increasing pain.

B. Malignancy

• Clinical suspicion of thoracic spine cancer with symptoms or signs suggesting involvement of the spine, spinal cord, meninges or positive bone scan; or
• Known diagnosis of cancer with suspicion of metastases to the thoracic spine, meninges, or spinal cord.

C. Infectious Process

• Clinical suspicion of an infectious process such as abscess, osteomyelitis, or discitis involving the spine, spinal cord, or adjacent structures or spaces

D. Evaluation of Signs or Symptoms

• Signs or symptoms of spinal cord or nerve root compression, with or without surgery (e.g., focal neurologic deficit or abnormal findings on neurologic exam [e.g., motor weakness, dermatomal sensory loss or significant reflex abnormality]); or
• Pain or radiculopathy not improving despite 4 weeks of conservative therapy which may include appropriate pharmacologic interventions or physical therapy or exercises with the following exceptions:
  • Given the rarity of back pain in children the 4 week requirement for treatment need not be applied to the pediatric patient; or
  • Individuals with rheumatoid arthritis are at increased risk for spinal misalignment and the requirement for 4 weeks of conservative treatment prior to imaging is not applicable to this group; or
• Signs or symptoms of myelopathy or nerve root compression with new onset of extremity weakness, ataxia, spasticity, spinal level sensory loss, etc. ; or
• Signs or symptoms suggestive of spinal stenosis (e.g., weakness, spasticity, clonus, muscle wasting, generalized sensory loss, nerve root compression, hyperactive reflexes, suggestive x-ray findings).

E. Evaluation of Known Diseases or Conditions

• Demyelinating disorders, such as multiple sclerosis; or
• Further investigation of spinal abnormality of unknown or uncertain cause seen on plain film with recommended follow-up; or
• Scoliosis in the following situations:
  • In patients with high risk for neural axis abnormalities, such as infantile and juvenile idiopathic scoliosis and congenital scoliosis; or
  • Adolescent idiopathic scoliosis and atypical findings, including:
    • Pain; or
    • Rapid progression; or
    • Development of neurologic signs or symptoms; or
  • Scoliosis related to other pathologic processes, such as neurofibromatosis; or
  • Pre-operative evaluation of severe scoliosis; or

• Suspected spinal cord infarct; or
• Suspicion of congenital or acquired abnormalities of spine or spinal cord following abnormal or undiagnostic thoracic spine radiography, examples include:
  • Neural tube defect involving thoracic spine, examples include:
    • Myelocele; or
    • Meningocele; or
    • Myelomeningocele; or
  • Syringohydromyelia (syrinx). 

Not Medically Necessary
MRI thoracic spine is considered not medically necessary for the following:

• When the above criteria are not met

Computed Tomography Lumbar Spine

Medically Necessary
CT lumbar spine is considered medically necessary for any of the following:

A. Trauma or Fracture

• Major trauma, at the time of the initial treatment ; or
• Recent less severe trauma to the spine with abnormalities on neurologic exam or x-ray or persistent increasing pain.

B. Malignancy

• Clinical suspicion of lumbar spine cancer with symptoms or signs suggesting involvement of the spine, spinal cord, meninges or positive bone scan; or
• Known diagnosis of cancer with suspicion of metastases to the lumbar spine, meninges, or spinal cord.

C. Infectious Process

• Clinical suspicion of an infectious process such as abscess, arachnoiditis, osteomyelitis, or discitis involving the spine, spinal cord, or adjacent structures or spaces

D. Evaluation of Signs or Symptoms

• Signs or symptoms of spinal cord or nerve root compression, with or without surgery (e.g., focal neurologic deficit or abnormal findings on neurologic exam [e.g., motor weakness, dermatomal sensory loss or significant reflex abnormality]); or
• Pain or radiculopathy not improving despite 4 weeks of conservative therapy which may include appropriate pharmacologic interventions or physical therapy or exercises with the following exceptions:
  • Given the rarity of back pain in children the 4 week requirement for treatment need not be applied to the pediatric patient; or
  • Individuals with rheumatoid arthritis are at increased risk for spinal misalignment and the requirement for 4 weeks of conservative treatment prior to imaging is not applicable to this group; or
• Post lumbar spine surgery with persistent pain for evaluation of either of the following:
  • Differentiation of recurrent disc herniation from scarring; or
  • Evaluation of post surgical complications, such as epidural hematoma or abscess; or
• Signs or symptoms of lumbar myelopathy or nerve root compression with new onset of extremity weakness, bladder or bowel symptoms, ataxia, spasticity, spinal level sensory loss, etc.; or
• Signs or symptoms suggestive of spinal stenosis (e.g., weakness, spasticity, clonus, muscle wasting, generalized sensory loss, nerve root compression, hyperactive reflexes, suggestive x-ray findings); or
• CT following myelography, discography or other lumbar interventional procedure.

E. Evaluation of Known Diseases or Conditions

• Cauda equine syndrome with symptoms including, but not limited to:
  • Bilateral radiculopathy; or
  • Saddle anesthesia; or
  • Urinary retention or incontinence; or
  • Bowel dysfunction; or
• Following non diagnostic lumbar spine radiographs for either:
  • Further investigation of spinal abnormality of unknown or uncertain cause; or
  • Spondylosis and spondylolithesis; or
• Scoliosis (in pediatric patients, MRI preferred to minimize radiation exposure) in the following situations:
  • In patients with high risk for neural axis abnormalities, such as infantile and juvenile idiopathic scoliosis and congenital scoliosis; or
  • Adolescent idiopathic scoliosis and atypical findings, including:
    • Pain; or
    • Rapid progression; or
    • Development of neurologic signs or symptoms; or
  • Scoliosis related to other pathologic processes, such as neurofibromatosis; or
  • Pre-operative evaluation of severe scoliosis; or

• Suspected spinal cord infarct; or
• Suspicion of congenital or acquired abnormalities of spine or spinal cord following abnormal or undiagnostic lumbar spine radiography, examples include:
  • Neural tube defect, examples include:
    • Myelocele; or
    • Meningocele; or
    • Myelomeningocele; or
  • Vertebral defect, such as segmentation and fusion abnormalities; or
  • Syringohydromyelia (syrinx); or
  • Conus medullaris; or
  • Filum terminale.

Not Medically Necessary
CT lumbar spine is considered not medically necessary for either of the following:

• When the above criteria are not met; or
• For evaluation of demyelinating disease (i.e., multiple sclerosis) unless the patient cannot tolerate an MRI exam (e.g., due to claustrophobia).

Magnetic Resonance Imaging Lumbar Spine 

Medically Necessary
MRI lumbar spine is considered medically necessary for any of the following:

A. Trauma or Fracture

• Major trauma, at the time of the initial treatment; or
• Recent less severe trauma to the spine with abnormalities on neurologic exam or x-ray or persistent increasing pain.

B. Malignancy

• Clinical suspicion of lumbar spine cancer with symptoms or signs suggesting involvement of the spine, spinal cord, meninges or positive bone scan; or
• Known diagnosis of cancer with suspicion of metastases to the lumbar spine, meninges, or spinal cord.

C. Infectious Process

• Clinical suspicion of an infectious process such as abscess, arachnoiditis, osteomyelitis, or discitis involving the spine, spinal cord, or adjacent structures or spaces

D. Evaluation of Signs or Symptoms

• Signs or symptoms of spinal cord or nerve root compression, with or without surgery (e.g., focal neurologic deficit or abnormal findings on neurologic exam [e.g., motor weakness, dermatomal sensory loss or significant reflex abnormality]); or
• Pain or radiculopathy not improving despite 4 weeks of conservative therapy which may include appropriate pharmacologic interventions or physical therapy or exercises with the following exceptions:
  • Given the rarity of back pain in children the 4 week requirement for treatment need not be applied to the pediatric patient; or
  • Individuals with rheumatoid arthritis are at increased risk for spinal misalignment and the requirement for 4 weeks of conservative treatment prior to imaging is not applicable to this group; or
• Low back pain not meeting either of the above two criteria, but associated with "red flag" symptoms, such as unexplained weight loss, history of malignant disease, fever, abnormal serum electrophoresis suggestive of multiple myeloma, history of drug abuse or tuberculosis; or
• Post lumbar spine surgery with persistent pain for evaluation of either of the following:
  • Differentiation of recurrent disc herniation from scarring; or
  • Evaluation of post surgical complications, such as epidural hematoma or abscess; or
• Signs or symptoms of lumbar myelopathy or nerve root compression with new onset of extremity weakness, bladder or bowel symptoms, ataxia, spasticity, spinal level sensory loss, etc.; or
• Signs or symptoms suggestive of spinal stenosis (e.g., weakness, spasticity, clonus, muscle wasting, generalized sensory loss, nerve root compression, hyperactive reflexes, suggestive x-ray findings).

E. Evaluation of Known Diseases or Conditions

• Demyelinating disorders, such as multiple sclerosis; or
• Cauda equine syndrome with symptoms including, but not limited to:
  • Bilateral radiculopathy; or
  • Saddle anesthesia; or
  • Urinary retention or incontinence; or
  • Bowel dysfunction; or
• Following non diagnostic lumbar spine radiographs for either
  • Further investigation of spinal abnormality of unknown or uncertain cause; or
  • Spondylosis and spondylolithesis; or
• Scoliosis in the following situations:
  • In patients with high risk for neural axis abnormalities, such as infantile and juvenile idiopathic scoliosis and congenital scoliosis; or
  • Adolescent idiopathic scoliosis and atypical findings, including:
    • Pain; or
    • Rapid progression; or
    • Development of neurologic signs or symptoms; or
  • Scoliosis related to other pathologic processes, such as neurofibromatosis; or
  • Pre-operative evaluation of severe scoliosis; or

• Suspected spinal cord infarct; or
• Suspicion of congenital or acquired abnormalities of spine or spinal cord following abnormal or undiagnostic lumbar spine radiography, examples include:
  • Neural tube defects, examples include:
    • Myelocele; or
    • Meningocele; or
    • Myelomeningocele; or
  • Syringohydromyelia (syrinx); or
  • Conus medullaris; or
  • Filum terminale

Not Medically Necessary
MRI lumbar spine is considered not medically necessary for the following:

• When the above criteria are not met

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Computed tomography (CT), sometimes called CAT scan, is a diagnostic tool that uses special x-ray equipment to obtain image data from different angles around the body, then uses computer processing of the information to show a cross-section of body tissues and organs.

Magnetic resonance imaging (MRI) is a diagnostic technique that uses a cylindrical magnet and radio waves to produce high quality multiplanar images of organs and structures within the body without x-rays or radiation. The body's hydrogen atoms react to the magnetic field and pulses of radio waves. This reaction is changed to an image by a computer. CT and MRI are valuable imaging techniques most often used when preliminary diagnostics or symptoms suggest an abnormal condition requiring further analysis.

The ability of either MRI or CT scans to image the spinal area is well documented and the indications listed above summarize the most prevalent signs, symptoms and conditions. As noted in the Clinical Indications, there are many overlapping indications for CT and MRI. Imaging modality will depend on the specific indication and patient circumstances. The following situations describe indications where there is a relative preference of one imaging technique over another.

Imaging Preference Based on Indication

• CT scanning is preferred for studies to identify bony abnormalities, such as suspected fracture, follow-up of known fracture or congenital vertebral defects
• MRI is generally preferred for most other indications unless contraindicated or not tolerated by the patient (e.g., due to claustrophobia). In these situations, CT is considered an alternative

Imaging Preferences Based on Individual Patient Circumstances

The following are examples of specific patient characteristics that may dictate the preference of one imaging modality over another.

• The use of CT in children requires careful assessment of the risks, benefits and uses of the studies. Generally, children are more sensitive to radiation than adults and with their longer life expectancy there is a larger window of opportunity for incurring radiation damage
• Absolute and relative contraindications for scans requiring administration of intravascular contrast material may include:
  • Documented allergy from prior contrast administration or a history of atopy
  • Impaired renal function, when considering an enhanced CT with intravascular iodinated contrast agents
  • Multiple myeloma

• Contraindications for MRI may include situations where individuals:
  • Had placement of metal devices within the body. However, for those who have small amounts of implanted metal not located in the imaging area, an open MRI may be appropriate
  • Have intracranial surgical clips placed for an aneurysm that are not compatible with the use of MRI
  • Have conditions requiring external devices for care (e.g., portable oxygen tank)
  • Are claustrophobic; an open MRI may be appropriate

MRI is not appropriate as a screening tool (i.e., asymptomatic patients without a previous diagnosis of cervical nerve root compression).

Once a positive diagnosis of multiple sclerosis (MS) has been established, further diagnostic MRI scans of the cervical cord may prove useful in tracking the progress of the disease, establishing a prognosis or evaluating medication therapy. The frequency of repeat scans should be based on the patient's status. Changes in neurologic signs and symptoms may require repeat imaging. Early in the course of the disease, periodic scans may be warranted to assess for asymptomatic progression if this information would be used to make treatment determinations. Repeat imaging of the thoracic spine in MS patients should be based on changes in the patient's status.

Peer Reviewed Publications:

1. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009; 373(9662):463-472.
2. Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. J Trauma. 2005; 58(5):902-905.
3. Kendrick D, Fielding K, Bentley E, et al. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial BMJ, 2001; 322(7283):400-405.
4. Patel AT, Ogle AA. Diagnosis and management of acute low back pain. 2000; 61(6):1779-1786, 1789-1790.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American College of Radiology. ACR Appropriateness Criteria^®: Bone Tumors. 2005. Available at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria.aspx. Accessed on March 2, 2009.
2. American College of Radiology. ACR Appropriateness Criteria^®: Follow-up of Malignant or Aggressive Musculoskeletal Tumors. 2008. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria.aspx. Accessed on March 2, 2009.
3. American College of Radiology. ACR Appropriateness Criteria^®: Low Back Pain. 2008. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologic
   Imaging/LowBackPainDoc7.aspx Accessed on March 23, 2009.
4. American College of Radiology. ACR Appropriateness Criteria^®: Metastatic Bone Disease. 2005. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria.aspx. Accessed on March 2, 2009.
5. American College of Radiology. ACR Appropriateness Criteria^®: Stress/Insufficiency Fracture, Including Sacrum, Excluding Other Vertebrae. 2008. Available at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria.aspx. Accessed on March 2, 2009.
6. American College of Radiology. ACR Appropriateness Criteria^®: Suspected Spine Trauma. 2007. Available at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria.aspx. Accessed on March 2, 2009.
7. American College of Radiology. Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of Bone and Soft Tissue Tumors (2006). Available at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/musc.aspx. Accessed on March 2, 2009.
8. American College of Radiology. Practice Guideline for the Performance of Computed Tomography (CT) of the Spine (2006). Available at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/musc.aspx. Accessed on March 2, 2009.
9. American College of Radiology. Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Adult Spine (2006). Available at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/musc.aspx. Accessed on March 2, 2009.
10. Centers for Medicare and Medicaid Services. National Coverage Determination: Magnetic Resonance Imaging (MRI). NCD #220.2. Effective March 22, 1994. Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.2&ncd_version=1&basket=ncd%3A220%2E2%3A1%3AMagnetic+Resonance+Imaging+%28MRI%29. Accessed on March 2, 2009.
11. Centers for Medicare and Medicaid Services. National Coverage Determination: Computed Tomography. NCD #220.1. Effective March 12, 2008. Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=220.1&ncd_version=2&basket=ncd%3A220%2E1%3A2%3AComputed+Tomography. Accessed on March 20, 2009.
12. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147(7):478-491.
13. Diaz JJ Jr, Cullinane DC, Altman DT, et al. EAST Practice Management Guideline Committee. Practice management guidelines for the screening of thoracolumbar spine fracture. J Trauma. 2007; 63(3):709-718.

Back Pain
Cervical Spine
Computed Tomography (CT)
Lumbar Spine
Magnetic Resonance Imaging (MRI)
Multiple Sclerosis (MS)
Thoracic Spine