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

2. 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

3. 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

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

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

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

7. 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

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

23. Red Flags
MRI without and with contrast

24. Red Flags
CT without contrast

25. Red Flags
X-rays first,
then CT

26. Red Flags
MRI without contrast

27. 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?

29. L1 L2 L3 L4 L5 S1

31. When is MRI contraindicated?
Pacemakers
Cochlear implants
Extreme claustrophobia*

32. 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

33. 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

36. 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

37. 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

39. C2 C3 C4 C5 C6 C7

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

43. 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

44. 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

46. *

49. 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

50. 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

51. 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