Jennifer Koay, MD Assistant Professor Department of Radiology Advanced Imaging Jennifer Koay, MD Assistant Professor Department of Radiology

Objectives Discuss the use of advanced imaging in common clinical scenarios Define the American College of Radiology Appropriateness Criteria Apply these criteria to clinical scenarios Review basic imaging interpretation

Back pain and osteoarthritis are the second and third most common reasons for visits to U.S. healthcare providers 1 Evaluating and treating these conditions costs billions of dollars annually Part of the challenge for clinicians is to decide which patients should be imaged and what imaging studies to order

Advanced Imaging CT Bone detail Surgical hardware Preoperative planning Radiation to patient

Advanced Imaging MRI Soft tissue detail Bone marrow signal Spinal cord abnormalities No radiation to patient

How do we decide when to image and what imaging studies to order? American College of Radiology Appropriateness Criteria

ACR Appropriateness Criteria Widely accepted national quality standard developed by experts from multiple disciplines Evidence-based guidelines to assist referring providers in choosing the most appropriate imaging for a specific clinical condition

ACR Appropriateness Criteria No cost No logins or passwords www.acr.org/ac On the WVU CONNECT homepage under Physician Reference In Epic at point of radiology order entry

Red Flags MRI without and with contrast

Red Flags CT without contrast

Red Flags X-rays first, then CT

Red Flags MRI without contrast

35 year old female with back pain, right foot numbness, and weakness with dorsiflexion. She has tried physical therapy for 6 weeks with no improvement. Should we perform imaging? If so, what?

L1 L2 L3 L4 L5 S1

When is MRI contraindicated? Pacemakers Cochlear implants Extreme claustrophobia*

55 yo male presents with chronic neck pain, worse with extension, and right shoulder pain. What is the most appropriate initial imaging study? Cervical spine radiographs CT cervical spine MRI cervical spine

55 yo male presents with chronic neck pain, worse with extension, and right shoulder pain. What is the most appropriate initial imaging study? Cervical spine radiographs CT cervical spine MRI cervical spine

X-rays show mild degenerative changes X-rays show mild degenerative changes. What is the most appropriate next imaging study? CT cervical spine without IV contrast CT cervical spine with IV contrast MRI cervical spine without IV contrast MRI cervical spine with IV contrast

X-rays show mild degenerative changes X-rays show mild degenerative changes. What is the most appropriate next imaging study? CT cervical spine without IV contrast CT cervical spine with IV contrast MRI cervical spine without IV contrast MRI cervical spine with IV contrast

C2 C3 C4 C5 C6 C7

When is contrast-enhanced MRI helpful? Tumor Infection Recurrent back pain with prior surgery Vascular causes (e.g. AVM)

41 yo female with 2 weeks of low back pain, fever, and chills 41 yo female with 2 weeks of low back pain, fever, and chills. Elevated WBC. History of IV drug use. What is the most appropriate imaging study? CT lumbar spine with IV contrast MRI lumbar spine without and with IV contrast Bone scan

41 yo female with 2 weeks of low back pain, fever, and chills 41 yo female with 2 weeks of low back pain, fever, and chills. Elevated WBC. History of IV drug use. What is the most appropriate imaging study? CT lumbar spine with IV contrast MRI lumbar spine without and with IV contrast Bone scan

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When is gadolinium contrast contraindicated? Impaired renal function due to increased risk of Nephrogenic Systemic Fibrosis Our current policy: GFR > 40 – contrast given GFR < 40 – no contrast

Summary ACR Appropriateness Criteria help us select appropriate imaging for specific clinical conditions Patients with “red flags” need further workup with advanced imaging When MRI is contraindicated, CT is a good alternative Gadolinium contrast is helpful for evaluation of tumor, infection, recurrent back pain with prior surgery, and vascular abnormalities Gadolinium contrast is not administered to patients with GFR under 40

References Why Patients Visit Their Doctors: Assessing the Most Prevalent Conditions in a Defined American Population. St. Sauver, Jennifer L. et al. Mayo Clinic Proceedings , Volume 88 , Issue 1 , 56 – 67 "American College of Radiology." ACR Appropriateness Criteria® .Web. 30 Oct. 2016.