Red flags include suspected epidural abscess or hematoma presenting with acute pain, but no neurological symptoms (urgent imaging is required); suspected cancer; suspected infection; cauda equina syndrome; severe or progressive neurologic deficit; and suspected compression fracture. In patients with suspected uncomplicated herniated disc or spinal stenosis, imaging is only indicated after at least a six-week trial of conservative management and if symptoms are severe enough that surgery is being considered.
Choosing Wisely. American Academy of Family Physicians (AAFP): Fifteen things physicians and patients should question [Internet]. 2013 Sep 24 [cited 2015 May 5].
American College of Radiology. ACR appropriateness criteria® low back pain [Internet]. 2015 [cited 2017 May 5].
Bach SM, et al. Guideline update: What’s the best approach to acute low back pain? J Fam Pract. 2009 Dec;58(12):E1. PMID: 19961812. https://www.ncbi.nlm.nih.gov/pubmed/19961812
Chou R, et al. Imaging strategies for low-back pain: Systematic review and meta-analysis. Lancet. 2009 Feb 7;373(9662):463-72. PMID: 19200918.
Chou R, et al. Diagnostic imaging for low back pain: Advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011 Feb 1;154(3):181-9. PMID: 21282698.
Goertz M, et al. Adult acute and subacute low back pain [Internet]. 2012 Nov [cited 2017 May 5].
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National Collaborating Centre for Primary Care (UK). Low back pain: Early management of persistent non-specific low back pain. 2009 May. PMID: 20704057.
Toward Optimized Practice. Guideline for the evidence-informed primary care management of low back pain [Internet]. 2011 Nov [cited 2017 May 5].
University of Michigan Health System. Acute low back pain [Internet]. 2010 Jan [cited 2017 May 5].
van Rijn RM, et al. Computed tomography for the diagnosis of lumbar spinal pathology in adult patients with low back pain or sciatica: A diagnostic systematic review. Eur Spine J. 2012 Feb;21(2):228-39. PMID: 21915747.
Wassenaar M, et al. Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: A diagnostic systematic review. Eur Spine J. 2012 Feb;21(2):220-7. PMID: 21922287.
Patient Pamphlet: Imaging Tests for Lower Back Pain: When you need them and when you don’t
Red flags include Glasgow Coma Scale (GCS) less than 13; GCS less than 15 at 2 hours post-injury; a patient aged 65 years or older; obvious open skull fracture; suspected open or depressed skull fracture; any sign of basilar skull fracture (e.g., hemotympanum, raccoon eyes, Battle’s Sign, CSF otorhinorrhea); retrograde amnesia to the event lasting 30 minutes or longer after the event; “dangerous” mechanism (e.g., pedestrian struck by motor vehicle, occupant ejected from motor vehicle, or fall from higher than 3 feet or down more than 5 stairs); and coumadin-use or bleeding disorder.
Davis PC, et al. ACR appropriateness criteria® head trauma [Internet]. 2015 [cited 2017 May 5].
Holmes MW, et al. The cost-effectiveness of diagnostic management strategies for adults with minor head injury. Injury. 2012 Sep;43(9):1423-31. PMID: 21835403.
Jagoda AS, et al. Clinical policy: Neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2008 Dec;52(6):714-48. PMID: 19027497.
Management of Concussion/mTBI Working Group. VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury (mTBI)]. J Rehabil Res Dev. 2009;46(6):CP1-68. PMID: 20108447.
Marshall S, et al. Clinical practice guidelines for mild traumatic brain injury and persistent symptoms. Can Fam Physician. 2012 Mar;58(3):257,67, e128-40. PMID: 22518895.
Motor Accidents Authority NSW (MAA). Guidelines for mild traumatic brain injury following closed head injury: Acute/post-acute assessment and management [Internet]. 2008 [cited 2017 May 5].
Ontario Neurotrauma Foundation. Guidelines for mild traumatic brain injury and persistent symptoms [Internet]. 2011 [cited 2017 May 5].
Pandor A, et al. Diagnostic management strategies for adults and children with minor head injury: A systematic review and an economic evaluation. Health Technol Assess. 2011 Aug;15(27):1-202. PMID: 21806873.
Pandor A, et al. Diagnostic accuracy of clinical characteristics for identifying CT abnormality after minor brain injury: A systematic review and meta-analysis. J Neurotrauma. 2012 Mar 20;29(5):707-18. PMID: 21806474.
Reed D. Adult trauma clinical practice guidelines: Initial management of closed head injury in adults [Internet]. 2011 Nov [cited 2017 May 5].
Scottish Intercollegiate Guidelines Network (SIGN). Early management of patients with a head injury: A national clinical guideline [Internet]. 2009 May [cited 2017 May 5].
Smits M, et al. Minor head injury: CT-based strategies for management–a cost-effectiveness analysis. Radiology. 2010 Feb;254(2):532-40. PMID: 20093524.
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Work Loss Data Institute. Head (trauma, headaches, etc., not including stress & mental disorders) [Internet]. 2011 [cited 2017 May 5].
Red flags include recent onset, rapidly increasing frequency and severity of headache; headache causing the patient to wake from sleep; associated dizziness, lack of coordination, tingling or numbness, new neurologic deficit; and new onset of a headache in a patient with a history of cancer or immunodeficiency.
Beithon J, et al. Institute for clinical systems improvement. Diagnosis and treatment of headache [Internet]. 2013 Jan [cited 2017 May 5].
Choosing Wisely. American College of Radiology: Five things physicians and patients should question [Internet]. 2012 Apr 4 [cited 2017 May 5].
Edlow JA, et al. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2008 Oct;52(4):407-36. PMID: 18809105.
Hayes LL, et al. ACR appropriateness criteria®: Headache – child [Internet]. 2012 [cited 2014 Feb 23].
Health Quality Ontario. Neuroimaging for the evaluation of chronic headaches: An evidence-based analysis. Ont Health Technol Assess Ser. 2010;10(26):1-57. PMID: 23074404.
Jordan YJ, et al. Computed tomography imaging in the management of headache in the emergency department: Cost efficacy and policy implications. J Natl Med Assoc. 2009 Apr;101(4):331-5. PMID: 19397223.
National Institute for Health and Clinical Excellence (NICE). Headaches: Diagnosis and management of headaches in young people and adults [Internet]. 2012 Sep [2017 May 5].
Sandrini G, et al. Neurophysiological tests and neuroimaging procedures in non-acute headache (2nd edition). Eur J Neurol. 2011 Mar;18(3):373-81. PMID: 20868464.
Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of headache in adults: A national clinical guideline [Internet]. 2008 Nov [2017 May 5].
Toward Optimized Practice. Guideline for primary care management of headache in adults [Internet]. 2016 Sep [2017 May 5].
Patient Pamphlet: Imaging Tests for Headaches: When you need them and when you don’t
Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is nearly as good in experienced hands. Since ultrasound will reduce radiation exposure, ultrasound is the preferred initial imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94 percent.
Adibe OO, et al. An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed tomography in children. J Pediatr Surg. 2011 Jan;46(1):192-6. PMID: 21238665.
Bachur RG, et al. The effect of abdominal pain duration on the accuracy of diagnostic imaging for pediatric appendicitis. Ann Emerg Med. 2012 Nov;60(5):582,590.e3. PMID: 22841176.
Bachur RG, et al. Diagnostic imaging and negative appendectomy rates in children: Effects of age and gender. Pediatrics. 2012 May;129(5):877-84. PMID: 22508920.
Bachur RG, et al. Advanced radiologic imaging for pediatric appendicitis, 2005-2009: Trends and outcomes. J Pediatr. 2012 Jun;160(6):1034-8. PMID: 22192815.
Burr A, et al. Glowing in the dark: Time of day as a determinant of radiographic imaging in the evaluation of abdominal pain in children. J Pediatr Surg. 2011 Jan;46(1):188-91. PMID: 21238664.
Choosing Wisely. American College of Radiology: Five things physicians and patients should question [Internet]. 2013 [cited 2014 Mar 12].
Krishnamoorthi R, et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: Reducing radiation exposure in the age of ALARA. Radiology. 2011 Apr;259(1):231-9. PMID: 21324843.
Park JS, et al. Accuracies of diagnostic methods for acute appendicitis. Am Surg. 2013 Jan;79(1):101-6. PMID: 23317620.
Ramarajan N, et al. An interdisciplinary initiative to reduce radiation exposure: Evaluation of appendicitis in a pediatric emergency department with clinical assessment supported by a staged ultrasound and computed tomography pathway. Acad Emerg Med. 2009 Nov;16(11):1258-65. PMID: 20053244.
Santillanes G, et al. Prospective evaluation of a clinical practice guideline for diagnosis of appendicitis in children. Acad Emerg Med. 2012 Aug;19(8):886-93. PMID: 22849662.
Thirumoorthi AS, et al. Managing radiation exposure in children–reexamining the role of ultrasound in the diagnosis of appendicitis. J Pediatr Surg. 2012 Dec;47(12):2268-72. PMID: 23217887.
Wan MJ, et al. Acute appendicitis in young children: Cost-effectiveness of US versus CT in diagnosis–a Markov decision analytic model. Radiology. 2009 Feb;250(2):378-86. PMID: 19098225.
X-rays are only indicated if there is pain in the malleolar zone, bone tenderness at the posterior edge or tip of either malleolus, or inability to bear weight for four steps immediately after the trauma and in the emergency department.
Bennett DL, et al. ACR appropriateness criteria® acute trauma to the foot [Internet]. 2014 [cited 2017 May 5].
Blackham JE, et al. Can patients apply the ottawa ankle rules to themselves? Emerg Med J. 2008 Nov;25(11):750-1. PMID: 18955612.
Can U, et al. Safety and efficiency of the ottawa ankle rule in a swiss population with ankle sprains. Swiss Med Wkly. 2008 May 3;138(19-20):292-6. PMID: 18491243.
Dowling S, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. 2009 Apr;16(4):277-87. PMID: 19187397.
Gravel J, et al. Prospective validation and head-to-head comparison of 3 ankle rules in a pediatric population. Ann Emerg Med. 2009 Oct;54(4):534,540.e1. PMID: 19647341.
Jenkin M, et al. Clinical usefulness of the Ottawa ankle rules for detecting fractures of the ankle and midfoot. J Athl Train. 2010 Sep-Oct;45(5):480-2. PMID: 20831394.
Knudsen R, et al. Validation of the Ottawa ankle rules in a Danish emergency department. Dan Med Bull. 2010 May;57(5):A4142. PMID: 20441713.
Lin CW, et al. Economic evaluations of diagnostic tests, treatment and prevention for lateral ankle sprains: A systematic review. Br J Sports Med. 2013 Dec;47(18):1144-9. PMID: 22554849.
National Guideline Clearinghouse. Guideline summary: Ankle and foot disorders. 2013 Oct 28.
Petscavage J, et al. Overuse of concomitant foot radiographic series in patients sustaining minor ankle injuries. Emerg Radiol. 2010 Jul;17(4):261-5. PMID: 19834751.
Polzer H, et al. Diagnosis and treatment of acute ankle injuries: Development of an evidence-based algorithm. Orthop Rev (Pavia). 2012 Jan 2;4(1):e5. PMID: 22577506.
Seah R, et al. Managing ankle sprains in primary care: What is best practice? A systematic review of the last 10 years of evidence. Br Med Bull. 2011;97:105-35. PMID: 20710025.
Wang X, et al. Clinical value of the Ottawa ankle rules for diagnosis of fractures in acute ankle injuries. PLoS One. 2013 Apr 30;8(4):e63228. PMID: 23646202.
Work Loss Data Institute. Guideline summary: Ankle & foot (acute & chronic) 2013 Oct 28.
Common Tests, Treatments, and Procedures You May Think You Need
Let’s think again.
Imaging Tests for Headaches
When you need them and when you don’t.
Imaging Tests for Lower Back Pain
When you need them and when you don’t.