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acrac_3094107_4

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

Conventional bone scintigraphy has low to moderate sensitivity and variable specificity for the diagnosis of axSpA [41,42,50]. If bone scintigraphy is used, SPECT should be performed during the examination because of the complexity of the sacroiliac joint anatomy [51]. Although bone scintigraphy is not typically performed during the evaluation of suspected axSpA because of its limited diagnostic utility, there is recent data that hybrid SPECT/CT has higher sensitivity than conventional bone scintigraphy in the detection of sacroiliitis [52,53]. However, there is not enough evidence currently to support its routine use for evaluation of the sacroiliac joints and spine. Bone Scan with SPECT or SPECT/CT Sacroiliac Joints and Spine Area of Interest Bone scintigraphy is not routinely suggested in the evaluation of patients with suspected axSpA [22]. Conventional bone scintigraphy has low to moderate sensitivity and variable specificity for the diagnosis of axSpA [41,42,50]. If bone scintigraphy is used, because of the complexity of the sacroiliac joint anatomy, the use of SPECT should be performed during the examination [51]. Although bone scintigraphy is not typically performed during the evaluation of suspected axSpA because of its limited diagnostic utility, there is recent data that hybrid SPECT/CT has higher sensitivity than conventional bone scintigraphy in the detection of sacroiliitis [52,53]. However, there is not enough evidence currently to support its routine use for evaluation of the sacroiliac joints and spine. CT Sacroiliac Joints CT demonstrates the structural changes of sacroiliitis in patients with axSpA that may not be apparent on radiographs [22]. These structural changes, including erosions, sclerosis, bone formation, and ankylosis, are best demonstrated on sacroiliac protocol examinations that include obliquely oriented reformatted images prescribed parallel and perpendicular to the long axis of the sacrum [54].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. Conventional bone scintigraphy has low to moderate sensitivity and variable specificity for the diagnosis of axSpA [41,42,50]. If bone scintigraphy is used, SPECT should be performed during the examination because of the complexity of the sacroiliac joint anatomy [51]. Although bone scintigraphy is not typically performed during the evaluation of suspected axSpA because of its limited diagnostic utility, there is recent data that hybrid SPECT/CT has higher sensitivity than conventional bone scintigraphy in the detection of sacroiliitis [52,53]. However, there is not enough evidence currently to support its routine use for evaluation of the sacroiliac joints and spine. Bone Scan with SPECT or SPECT/CT Sacroiliac Joints and Spine Area of Interest Bone scintigraphy is not routinely suggested in the evaluation of patients with suspected axSpA [22]. Conventional bone scintigraphy has low to moderate sensitivity and variable specificity for the diagnosis of axSpA [41,42,50]. If bone scintigraphy is used, because of the complexity of the sacroiliac joint anatomy, the use of SPECT should be performed during the examination [51]. Although bone scintigraphy is not typically performed during the evaluation of suspected axSpA because of its limited diagnostic utility, there is recent data that hybrid SPECT/CT has higher sensitivity than conventional bone scintigraphy in the detection of sacroiliitis [52,53]. However, there is not enough evidence currently to support its routine use for evaluation of the sacroiliac joints and spine. CT Sacroiliac Joints CT demonstrates the structural changes of sacroiliitis in patients with axSpA that may not be apparent on radiographs [22]. These structural changes, including erosions, sclerosis, bone formation, and ankylosis, are best demonstrated on sacroiliac protocol examinations that include obliquely oriented reformatted images prescribed parallel and perpendicular to the long axis of the sacrum [54].

3094107

acrac_3094107_5

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

Several studies have shown CT to have higher sensitivity for detection of sacroiliitis than radiography [43,44,47,55]. Low-dose CT is increasingly being performed and can demonstrate the fine structural changes of axSpA better than radiography [45]. Additionally, the interreader reliability has shown to be excellent for grading sacroiliitis on CT, higher than for radiography, because of the increased level of structural detail demonstrated by CT [47]. Although conventional CT has the ability to demonstrate the chronic structural changes of sacroiliitis, it cannot demonstrate active inflammation, and therefore MRI remains the technique of choice for the diagnosis of axSpA [1,3,19,22]. There is evolving literature on the use of dual-energy CT (DECT) in the evaluation of sacroiliitis in axSpA, with early studies showing the ability of DECT to demonstrate bone marrow edema in patients with axSpA in addition to the inherent ability of CT to demonstrate the chronic structural changes of sacroiliitis [56,57]. One study shows that DECT has a sensitivity of 87% to 93% and specificity of 91% to 94% for detection of bone marrow edema using MRI as the reference standard, but more data are needed to support the diagnostic utility of DECT in the evaluation of axSpA [56]. There is no role for intravenous (IV) contrast in CT evaluation of axSpA. CT Sacroiliac Joints and Spine Area of Interest CT demonstrates structural changes in the sacroiliac joints and spine in patients with axSpA that may not be apparent on radiographs [22]. These structural changes include erosions, sclerosis, bone formation, syndesmophytes, and ankylosis [49,54]. In addition to its diagnostic utility in assessment of the sacroiliac joints, CT of the spine has the ability to demonstrate syndesmophytes with higher sensitivity than radiographs, and low-dose protocols can be utilized [58].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. Several studies have shown CT to have higher sensitivity for detection of sacroiliitis than radiography [43,44,47,55]. Low-dose CT is increasingly being performed and can demonstrate the fine structural changes of axSpA better than radiography [45]. Additionally, the interreader reliability has shown to be excellent for grading sacroiliitis on CT, higher than for radiography, because of the increased level of structural detail demonstrated by CT [47]. Although conventional CT has the ability to demonstrate the chronic structural changes of sacroiliitis, it cannot demonstrate active inflammation, and therefore MRI remains the technique of choice for the diagnosis of axSpA [1,3,19,22]. There is evolving literature on the use of dual-energy CT (DECT) in the evaluation of sacroiliitis in axSpA, with early studies showing the ability of DECT to demonstrate bone marrow edema in patients with axSpA in addition to the inherent ability of CT to demonstrate the chronic structural changes of sacroiliitis [56,57]. One study shows that DECT has a sensitivity of 87% to 93% and specificity of 91% to 94% for detection of bone marrow edema using MRI as the reference standard, but more data are needed to support the diagnostic utility of DECT in the evaluation of axSpA [56]. There is no role for intravenous (IV) contrast in CT evaluation of axSpA. CT Sacroiliac Joints and Spine Area of Interest CT demonstrates structural changes in the sacroiliac joints and spine in patients with axSpA that may not be apparent on radiographs [22]. These structural changes include erosions, sclerosis, bone formation, syndesmophytes, and ankylosis [49,54]. In addition to its diagnostic utility in assessment of the sacroiliac joints, CT of the spine has the ability to demonstrate syndesmophytes with higher sensitivity than radiographs, and low-dose protocols can be utilized [58].

3094107

acrac_3094107_6

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

CT is especially helpful for evaluation of the thoracic spine and facet joints, which can be challenging to evaluate on radiography [49]. There is not a consistently established convention to guide the clinician on whether to image only the sacroiliac joints or both the sacroiliac joints and spine in patients with suspected axSpA. However, spinal involvement is common, and numerous studies have shown that axSpA involvement can be isolated to the spine, isolated to the sacroiliac joints, or can involve both the sacroiliac joints and spine [19,59-63]. Therefore, if CT is performed, imaging the spine in addition to the sacroiliac joints is beneficial in the setting of symptoms referable to the spine. There is no role for IV contrast in the CT evaluation of axSpA. Fluoride PET/CT Skull Base to Mid-Thigh There is not enough data to support the routine use of F-18-fluoride PET/CT in the evaluation of patients with suspected axSpA. F-18-fluoride has been shown to be a potentially useful tracer in identifying sites of osteoblastic activity in axSpA patients [64], with uptake corresponding to sites of active bone formation on histology [65]. Uptake on PET/CT has also been shown to correlate with clinical disease activity in patients with axSpA [66,67]; however, there is conflicting evidence regarding the extent to which tracer uptake correlates with specific Inflammatory Back Pain inflammatory and structural lesions seen on CT and MRI resulting in uncertainty about its diagnostic utility [64,67- 72]. In one study, the interreader reliability of diagnosing sacroiliitis on PET/CT was poor and substantially lower than that for MRI or CT [67]. In a small study using radiographs as the reference standard, F-18-fluoride PET/CT had a sensitivity of 80% and specificity of 77% for the detection of sacroiliitis in AS, although there are inherent limitations in the use of radiographs as the reference standard for diagnosing axSpA [73].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. CT is especially helpful for evaluation of the thoracic spine and facet joints, which can be challenging to evaluate on radiography [49]. There is not a consistently established convention to guide the clinician on whether to image only the sacroiliac joints or both the sacroiliac joints and spine in patients with suspected axSpA. However, spinal involvement is common, and numerous studies have shown that axSpA involvement can be isolated to the spine, isolated to the sacroiliac joints, or can involve both the sacroiliac joints and spine [19,59-63]. Therefore, if CT is performed, imaging the spine in addition to the sacroiliac joints is beneficial in the setting of symptoms referable to the spine. There is no role for IV contrast in the CT evaluation of axSpA. Fluoride PET/CT Skull Base to Mid-Thigh There is not enough data to support the routine use of F-18-fluoride PET/CT in the evaluation of patients with suspected axSpA. F-18-fluoride has been shown to be a potentially useful tracer in identifying sites of osteoblastic activity in axSpA patients [64], with uptake corresponding to sites of active bone formation on histology [65]. Uptake on PET/CT has also been shown to correlate with clinical disease activity in patients with axSpA [66,67]; however, there is conflicting evidence regarding the extent to which tracer uptake correlates with specific Inflammatory Back Pain inflammatory and structural lesions seen on CT and MRI resulting in uncertainty about its diagnostic utility [64,67- 72]. In one study, the interreader reliability of diagnosing sacroiliitis on PET/CT was poor and substantially lower than that for MRI or CT [67]. In a small study using radiographs as the reference standard, F-18-fluoride PET/CT had a sensitivity of 80% and specificity of 77% for the detection of sacroiliitis in AS, although there are inherent limitations in the use of radiographs as the reference standard for diagnosing axSpA [73].

3094107

acrac_3094107_7

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

Given the available data, the utility of PET/CT in the diagnosis of axSpA is uncertain at this time. MRI Sacroiliac Joints After radiography is performed, MRI of the sacroiliac joints is the next imaging technique of choice in the evaluation of patients with suspected axSpA [1,3,19,22]. MRI of the sacroiliac joints is widely recognized as an important tool in the evaluation of patients with suspected axSpA, resulting in improved diagnostic confidence and yielding findings that stimulate changes in both diagnosis and treatment plans for patients [1,3,19,22,74]. Additionally, MRI findings have been shown to be predictive of both subsequent radiographic disease progression and the likelihood of response to therapy [36,63,75,76]. MRI, utilizing short tau inversion recovery (STIR) and T1-weighted images, can identify both active inflammatory lesions of the sacroiliac joints (bone marrow edema, capsulitis, synovitis, and enthesitis) and chronic structural lesions (sclerosis, erosions, fat deposition, and ankylosis) that are typical for sacroiliitis [38,77]. MRI demonstrates active sacroiliitis with higher sensitivity and earlier than radiography because of its ability to detect inflammatory lesions of axSpA [13,36,37,78]. The inflammatory changes of sacroiliitis on MRI have been shown to precede structural radiographic findings by three to seven years [36,37]. MRI can also detect the chronic structural lesions of the sacroiliac joints with higher accuracy than radiographs [45]. It is important to recognize that the sensitivity and specificity of MRI for axSpA depends on the imaging criteria used, patient population, and reference standard for diagnosis. Early literature showed 95% sensitivity and 100% specificity of MRI for sacroiliitis, substantially higher than radiographs or bone scintigraphy, although that study included a small number of patients, and most subsequent studies demonstrate smaller yields [41].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. Given the available data, the utility of PET/CT in the diagnosis of axSpA is uncertain at this time. MRI Sacroiliac Joints After radiography is performed, MRI of the sacroiliac joints is the next imaging technique of choice in the evaluation of patients with suspected axSpA [1,3,19,22]. MRI of the sacroiliac joints is widely recognized as an important tool in the evaluation of patients with suspected axSpA, resulting in improved diagnostic confidence and yielding findings that stimulate changes in both diagnosis and treatment plans for patients [1,3,19,22,74]. Additionally, MRI findings have been shown to be predictive of both subsequent radiographic disease progression and the likelihood of response to therapy [36,63,75,76]. MRI, utilizing short tau inversion recovery (STIR) and T1-weighted images, can identify both active inflammatory lesions of the sacroiliac joints (bone marrow edema, capsulitis, synovitis, and enthesitis) and chronic structural lesions (sclerosis, erosions, fat deposition, and ankylosis) that are typical for sacroiliitis [38,77]. MRI demonstrates active sacroiliitis with higher sensitivity and earlier than radiography because of its ability to detect inflammatory lesions of axSpA [13,36,37,78]. The inflammatory changes of sacroiliitis on MRI have been shown to precede structural radiographic findings by three to seven years [36,37]. MRI can also detect the chronic structural lesions of the sacroiliac joints with higher accuracy than radiographs [45]. It is important to recognize that the sensitivity and specificity of MRI for axSpA depends on the imaging criteria used, patient population, and reference standard for diagnosis. Early literature showed 95% sensitivity and 100% specificity of MRI for sacroiliitis, substantially higher than radiographs or bone scintigraphy, although that study included a small number of patients, and most subsequent studies demonstrate smaller yields [41].

3094107

acrac_3094107_8

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

The ASAS criteria developed in 2009 utilize the presence of bone marrow edema to define a positive MRI of the sacroiliac joints in axSpA [79]. Using solely the imaging arm of the ASAS algorithm (which includes positive radiographs or positive MRI with one clinical axSpA feature), the ASAS criteria were initially shown to have a sensitivity of 66.2% and specificity of 97.3%, although by combining both imaging and clinical arms of the algorithm the sensitivity was 82.9% and specificity was 84.4% for axSpA [19]. Subsequently, in an inception cohort followed for 8 years, the ASAS definition of a positive MRI demonstrated a sensitivity of 79% and a specificity of 89% for the diagnosis of axSpA [80]. Although the presence of bone marrow edema provides a sensitive evaluation for inflammatory changes in axSpA, bone marrow edema can also be seen in noninflammatory conditions such as in age-related degenerative changes, postpartum patients, patients with chronic back pain, athletes, and in up to 30% of healthy controls [81-85]. As a result, the ASAS MRI criteria have been criticized for decreased specificity of bone marrow edema as the sole MRI diagnostic criterion [82]. Importantly, although bone marrow edema may be nonspecific in some cases, one study found that the presence of a deep bone marrow edema lesion which extends at least 1 cm deep to the articular surface is more specific and found almost exclusively in axSpA [86]. Structural changes of axSpA including erosions, sclerosis, fatty deposition, and ankylosis are not accounted for in the ASAS definition of a positive MRI, although they are important findings in axSpA and should be identified in clinical practice [38].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. The ASAS criteria developed in 2009 utilize the presence of bone marrow edema to define a positive MRI of the sacroiliac joints in axSpA [79]. Using solely the imaging arm of the ASAS algorithm (which includes positive radiographs or positive MRI with one clinical axSpA feature), the ASAS criteria were initially shown to have a sensitivity of 66.2% and specificity of 97.3%, although by combining both imaging and clinical arms of the algorithm the sensitivity was 82.9% and specificity was 84.4% for axSpA [19]. Subsequently, in an inception cohort followed for 8 years, the ASAS definition of a positive MRI demonstrated a sensitivity of 79% and a specificity of 89% for the diagnosis of axSpA [80]. Although the presence of bone marrow edema provides a sensitive evaluation for inflammatory changes in axSpA, bone marrow edema can also be seen in noninflammatory conditions such as in age-related degenerative changes, postpartum patients, patients with chronic back pain, athletes, and in up to 30% of healthy controls [81-85]. As a result, the ASAS MRI criteria have been criticized for decreased specificity of bone marrow edema as the sole MRI diagnostic criterion [82]. Importantly, although bone marrow edema may be nonspecific in some cases, one study found that the presence of a deep bone marrow edema lesion which extends at least 1 cm deep to the articular surface is more specific and found almost exclusively in axSpA [86]. Structural changes of axSpA including erosions, sclerosis, fatty deposition, and ankylosis are not accounted for in the ASAS definition of a positive MRI, although they are important findings in axSpA and should be identified in clinical practice [38].

3094107

acrac_3094107_9

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

Two related studies on a group of 187 patients demonstrated high sensitivity of 90% to 92% and specificity of 94% to 97% for the diagnosis of AS by using global assessment of both inflammatory and structural lesions [83,87], and subsequently this group of authors showed that identifying erosions and/or bone marrow edema increases sensitivity for axSpA compared with bone marrow edema alone, without decreasing specificity [85]. They also showed that identifying erosions and/or bone marrow edema on MRI increased both sensitivity and specificity for axSpA compared with the diagnostic criterion of solely bone marrow edema [88]. Subchondral fatty deposition, another chronic finding of structural marrow remodeling, is an additional helpful and highly specific finding in axSpA with reported specificities up to 95% to 98% [89,90]. Finally, intra-articular signal changes including increased T1 signal, T2 hyperintense joint fluid, and ankylosis are highly specific findings for axSpA, and when found together with bone marrow edema can increase the positive predictive value for a diagnosis of axSpA compared with bone marrow edema alone [91,92]. Overall, it is clear that interrogation of sacroiliac joint MRI using both STIR and T1-weighted images is critical to identify both the inflammatory and structural changes of axSpA in clinical practice. MRI has long been considered inferior to CT in demonstrating the structural changes of axSpA, although evolving literature demonstrates that a specific MRI sequence, volumetric interpolated breath-hold examination (VIBE), can Inflammatory Back Pain demonstrate erosions with higher sensitivity and similar specificity compared to conventional T1-weighted imaging, and may be comparable to CT [93,94], making it a promising technique for identifying structural lesions of axSpA on MRI.

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. Two related studies on a group of 187 patients demonstrated high sensitivity of 90% to 92% and specificity of 94% to 97% for the diagnosis of AS by using global assessment of both inflammatory and structural lesions [83,87], and subsequently this group of authors showed that identifying erosions and/or bone marrow edema increases sensitivity for axSpA compared with bone marrow edema alone, without decreasing specificity [85]. They also showed that identifying erosions and/or bone marrow edema on MRI increased both sensitivity and specificity for axSpA compared with the diagnostic criterion of solely bone marrow edema [88]. Subchondral fatty deposition, another chronic finding of structural marrow remodeling, is an additional helpful and highly specific finding in axSpA with reported specificities up to 95% to 98% [89,90]. Finally, intra-articular signal changes including increased T1 signal, T2 hyperintense joint fluid, and ankylosis are highly specific findings for axSpA, and when found together with bone marrow edema can increase the positive predictive value for a diagnosis of axSpA compared with bone marrow edema alone [91,92]. Overall, it is clear that interrogation of sacroiliac joint MRI using both STIR and T1-weighted images is critical to identify both the inflammatory and structural changes of axSpA in clinical practice. MRI has long been considered inferior to CT in demonstrating the structural changes of axSpA, although evolving literature demonstrates that a specific MRI sequence, volumetric interpolated breath-hold examination (VIBE), can Inflammatory Back Pain demonstrate erosions with higher sensitivity and similar specificity compared to conventional T1-weighted imaging, and may be comparable to CT [93,94], making it a promising technique for identifying structural lesions of axSpA on MRI.

3094107

acrac_3094107_10

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

Multiple studies have examined diffusion-weighted imaging and dynamic contrast-enhanced MRI to determine their diagnostic utility and performance as imaging biomarkers of inflammation. Although these studies show correlation between diffusion-weighted imaging, dynamic contrast-enhanced, and conventional sequences, there is no evidence that these MRI techniques provide additional diagnostic utility compared with conventional MRI sequences [95- 106]. Contrast-enhanced MRI can demonstrate active inflammatory changes of the sacroiliac joints in axSpA, although multiple studies show that noncontrast and contrast-enhanced MRI have overall similar diagnostic utility for axSpA [107-111]. Contrast-enhanced MRI has been reported to increase the diagnostic confidence of MRI interpretation in 1 study [107]. MRI Sacroiliac Joints and Spine Area of Interest After radiography is performed, MRI is the next imaging technique of choice in the evaluation of suspected axSpA [1,3,19,22]. MRI of the sacroiliac joints and spine is associated with improved diagnostic confidence in axSpA and yields findings that stimulate changes in both diagnosis and treatment plans for patients [74]. Although there is agreement in the literature and among experts that MRI should include the sacroiliac joints, there is not a consistently established convention to guide the clinician on whether to image only the sacroiliac joints or both the sacroiliac joints and the spine in patients with suspected axSpA [1,3,19,22]. Not unexpectedly, there is heterogeneity in clinical practice regarding the use of MRI to evaluate the sacroiliac joints and/or spine in these patients [112]. One study has shown that the majority of patients can be diagnosed with axSpA by obtaining MRI of the sacroiliac joints only [60]. Another study shows that the addition of spine MRI to sacroiliac joint MRI adds little incremental value in the diagnosis of nonradiographic axSpA [113].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. Multiple studies have examined diffusion-weighted imaging and dynamic contrast-enhanced MRI to determine their diagnostic utility and performance as imaging biomarkers of inflammation. Although these studies show correlation between diffusion-weighted imaging, dynamic contrast-enhanced, and conventional sequences, there is no evidence that these MRI techniques provide additional diagnostic utility compared with conventional MRI sequences [95- 106]. Contrast-enhanced MRI can demonstrate active inflammatory changes of the sacroiliac joints in axSpA, although multiple studies show that noncontrast and contrast-enhanced MRI have overall similar diagnostic utility for axSpA [107-111]. Contrast-enhanced MRI has been reported to increase the diagnostic confidence of MRI interpretation in 1 study [107]. MRI Sacroiliac Joints and Spine Area of Interest After radiography is performed, MRI is the next imaging technique of choice in the evaluation of suspected axSpA [1,3,19,22]. MRI of the sacroiliac joints and spine is associated with improved diagnostic confidence in axSpA and yields findings that stimulate changes in both diagnosis and treatment plans for patients [74]. Although there is agreement in the literature and among experts that MRI should include the sacroiliac joints, there is not a consistently established convention to guide the clinician on whether to image only the sacroiliac joints or both the sacroiliac joints and the spine in patients with suspected axSpA [1,3,19,22]. Not unexpectedly, there is heterogeneity in clinical practice regarding the use of MRI to evaluate the sacroiliac joints and/or spine in these patients [112]. One study has shown that the majority of patients can be diagnosed with axSpA by obtaining MRI of the sacroiliac joints only [60]. Another study shows that the addition of spine MRI to sacroiliac joint MRI adds little incremental value in the diagnosis of nonradiographic axSpA [113].

3094107

acrac_3094107_11

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

However, axSpA often involves the axial skeleton proximal to the sacroiliac joints and may exhibit findings isolated to the spine. For example, in a study of whole-body MRI in active axSpA, 99% of patients were found to have active inflammatory lesions in the axial skeleton, with inflammatory changes isolated to the sacroiliac joints in 52% of patients, inflammatory changes isolated to the spine in 5% of patients, and with inflammatory changes at both the sacroiliac joints and spine in 41% of patients [59]. Other studies have shown widely varying degrees of isolated spinal involvement on MRI ranging from 1% to 49% [19,60-63,114,115]. In early axSpA, it has been shown that inflammation involving both the sacroiliac joints and spine can be seen in 28.3% of patients [116]. Therefore, it can be useful in some cases to image both the sacroiliac joints and the spine to help ensure MRI yields the highest diagnostic utility and establishes the extent of disease burden. The decision on whether to image the spine as well as the sacroiliac joints could be based on the site of symptoms. Although there is some disagreement about the extent to which inflammatory changes in the axial skeleton correspond with symptoms, imaging the spine in the clinical region of interest is beneficial in the setting of referable symptoms [62,117-119]. Multiple authors utilize whole-spine or whole-body MRI to identify the burden of disease throughout the spine rather than imaging specific segments because findings may potentially be found in any portion of the spine [10,59,63,89,114,120-122]. The spine MRI findings of axSpA include the active inflammatory changes of spondylitis and spondylodiscitis, inflammatory changes of the costovertebral joints, costotransverse joints, and facet joints, and areas of enthesitis along other vertebral ligamentous attachments [123].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. However, axSpA often involves the axial skeleton proximal to the sacroiliac joints and may exhibit findings isolated to the spine. For example, in a study of whole-body MRI in active axSpA, 99% of patients were found to have active inflammatory lesions in the axial skeleton, with inflammatory changes isolated to the sacroiliac joints in 52% of patients, inflammatory changes isolated to the spine in 5% of patients, and with inflammatory changes at both the sacroiliac joints and spine in 41% of patients [59]. Other studies have shown widely varying degrees of isolated spinal involvement on MRI ranging from 1% to 49% [19,60-63,114,115]. In early axSpA, it has been shown that inflammation involving both the sacroiliac joints and spine can be seen in 28.3% of patients [116]. Therefore, it can be useful in some cases to image both the sacroiliac joints and the spine to help ensure MRI yields the highest diagnostic utility and establishes the extent of disease burden. The decision on whether to image the spine as well as the sacroiliac joints could be based on the site of symptoms. Although there is some disagreement about the extent to which inflammatory changes in the axial skeleton correspond with symptoms, imaging the spine in the clinical region of interest is beneficial in the setting of referable symptoms [62,117-119]. Multiple authors utilize whole-spine or whole-body MRI to identify the burden of disease throughout the spine rather than imaging specific segments because findings may potentially be found in any portion of the spine [10,59,63,89,114,120-122]. The spine MRI findings of axSpA include the active inflammatory changes of spondylitis and spondylodiscitis, inflammatory changes of the costovertebral joints, costotransverse joints, and facet joints, and areas of enthesitis along other vertebral ligamentous attachments [123].

3094107

acrac_3094107_12

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

The chronic structural changes of fatty deposition, erosions, and syndesmophytes are also characteristic findings [123]. One study showed that the presence of two or more corner inflammatory lesions had a sensitivity of 69% and specificity of 94% for AS and that lateral vertebral inflammatory lesions had high specificity of 97% [120]. The presence of multiple lesions in the spine has shown to be useful; specifically the presence of at least 5 inflammatory lesions or 5 fatty lesions in the spine has been shown to have a specificity of 95% for axSpA [89]. One study shows that the corner sign in the lumbar spine on T1- weighted or T2-weighted images without fat saturation has a sensitivity of 62% and specificity of 96% for AS [12]. Furthermore, it has been shown that the presence of multiple fatty corner lesions in the spine has a high specificity of 98% and can be useful in the absence of active inflammatory lesions [11]. The ASAS considers a spine MRI positive for axSpA if there are three or more sites of inflammatory spondylitis and considers fatty corner deposition at several sites suggestive of axSpA especially in younger adults [123]. A subsequent study confirmed that the presence of multiple corner lesions has high specificity for axSpA, although it showed a low diagnostic utility because of low sensitivity [121]. Importantly, the findings on spine MRI should be interpreted alongside sacroiliac joint MRI to ensure the highest diagnostic utility. Additionally, MRI findings should be interpreted with specific Inflammatory Back Pain attention to identify associated morphologic findings such as disc degeneration or osteophytes that favor degenerative changes rather than axSpA, because both inflammatory and fatty lesions can occur in degenerative changes [124].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. The chronic structural changes of fatty deposition, erosions, and syndesmophytes are also characteristic findings [123]. One study showed that the presence of two or more corner inflammatory lesions had a sensitivity of 69% and specificity of 94% for AS and that lateral vertebral inflammatory lesions had high specificity of 97% [120]. The presence of multiple lesions in the spine has shown to be useful; specifically the presence of at least 5 inflammatory lesions or 5 fatty lesions in the spine has been shown to have a specificity of 95% for axSpA [89]. One study shows that the corner sign in the lumbar spine on T1- weighted or T2-weighted images without fat saturation has a sensitivity of 62% and specificity of 96% for AS [12]. Furthermore, it has been shown that the presence of multiple fatty corner lesions in the spine has a high specificity of 98% and can be useful in the absence of active inflammatory lesions [11]. The ASAS considers a spine MRI positive for axSpA if there are three or more sites of inflammatory spondylitis and considers fatty corner deposition at several sites suggestive of axSpA especially in younger adults [123]. A subsequent study confirmed that the presence of multiple corner lesions has high specificity for axSpA, although it showed a low diagnostic utility because of low sensitivity [121]. Importantly, the findings on spine MRI should be interpreted alongside sacroiliac joint MRI to ensure the highest diagnostic utility. Additionally, MRI findings should be interpreted with specific Inflammatory Back Pain attention to identify associated morphologic findings such as disc degeneration or osteophytes that favor degenerative changes rather than axSpA, because both inflammatory and fatty lesions can occur in degenerative changes [124].

3094107

acrac_3094107_13

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

Contrast-enhanced MRI can demonstrate active inflammatory changes of the sacroiliac joints and spine in axSpA, although multiple studies show that noncontrast and contrast-enhanced MRI have overall similar diagnostic utility for axSpA [9,107-111,125-129]. Contrast-enhanced MRI has been reported to increase the diagnostic confidence and reliability of MRI interpretation in 2 studies [9,107]. US Sacroiliac Joints US is not suggested as a routine diagnostic modality for the evaluation of sacroiliitis in patients with suspected axSpA because of its lack of established diagnostic utility [22]. Importantly, US provides evaluation limited to the superficial posterior margins of the sacroiliac joints, and therefore many structural details are not demonstrated. Many of the available studies examine the utility of Doppler evaluation. It has been shown that patients with active sacroiliitis because of axSpA have lower Doppler US resistive indices than healthy controls or patients with osteoarthritis at the sacroiliac joints [130-132]. Using MRI as the reference standard in a study of 51 patients with AS, a pulsatile monophasic waveform was shown to have a sensitivity of 82% and specificity of 92% for active disease, although 18.5% of active AS patients, 70.8% of inactive AS patients, and 63.3% of normal patients had no Doppler flow identified, and the sensitivity for detection of AS patients overall was only 43% [133]. One study reported higher sensitivity of contrast-enhanced US compared with conventional US [134,135]. A recent systematic review of US of the sacroiliac joints in spondyloarthritis reported a median sensitivity of 90% and specificity of 89% in seven of those studies, although with variation in the method of evaluation and reference standard. The authors concluded that there is not enough evidence to support the use of US for the diagnosis of axSpA [136].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. Contrast-enhanced MRI can demonstrate active inflammatory changes of the sacroiliac joints and spine in axSpA, although multiple studies show that noncontrast and contrast-enhanced MRI have overall similar diagnostic utility for axSpA [9,107-111,125-129]. Contrast-enhanced MRI has been reported to increase the diagnostic confidence and reliability of MRI interpretation in 2 studies [9,107]. US Sacroiliac Joints US is not suggested as a routine diagnostic modality for the evaluation of sacroiliitis in patients with suspected axSpA because of its lack of established diagnostic utility [22]. Importantly, US provides evaluation limited to the superficial posterior margins of the sacroiliac joints, and therefore many structural details are not demonstrated. Many of the available studies examine the utility of Doppler evaluation. It has been shown that patients with active sacroiliitis because of axSpA have lower Doppler US resistive indices than healthy controls or patients with osteoarthritis at the sacroiliac joints [130-132]. Using MRI as the reference standard in a study of 51 patients with AS, a pulsatile monophasic waveform was shown to have a sensitivity of 82% and specificity of 92% for active disease, although 18.5% of active AS patients, 70.8% of inactive AS patients, and 63.3% of normal patients had no Doppler flow identified, and the sensitivity for detection of AS patients overall was only 43% [133]. One study reported higher sensitivity of contrast-enhanced US compared with conventional US [134,135]. A recent systematic review of US of the sacroiliac joints in spondyloarthritis reported a median sensitivity of 90% and specificity of 89% in seven of those studies, although with variation in the method of evaluation and reference standard. The authors concluded that there is not enough evidence to support the use of US for the diagnosis of axSpA [136].

3094107

acrac_3094107_14

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

US Sacroiliac Joints and Spine Area of Interest US is not suggested as a routine diagnostic modality for the evaluation of sacroiliitis in patients with suspected axSpA because of its lack of established diagnostic utility [22]. Importantly, US provides evaluation limited to the superficial posterior margins of the sacroiliac joints and spine, and therefore many structural details are not demonstrated. Many of the available studies examine the utility of Doppler evaluation. In addition to data showing decreased resistive indices at the sacroiliac joints in patients with active sacroiliitis joints [130-132], there is evidence that resistive indices of the thoracolumbar paraspinal areas are also decreased in patients with AS [132]. However, there is not enough evidence to support the use of US for the diagnosis of axSpA. Variant 3: Inflammatory back pain. Suspected axial spondyloarthritis. Negative radiographs and negative MRI of the sacroiliac joints. Next imaging study. The body regions covered in this clinical scenario are the sacroiliac joints, cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information. Bone Scan with SPECT or SPECT/CT Spine Area of Interest Bone scintigraphy is not routinely suggested in the evaluation of patients with suspected axSpA because of its lack of established diagnostic utility [22]. Conventional bone scintigraphy has low to moderate sensitivity and variable specificity for the diagnosis of axSpA [41,42,50]. If bone scintigraphy is used, because of the complexity of the spine anatomy, the use of SPECT should be performed during the examination [51].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. US Sacroiliac Joints and Spine Area of Interest US is not suggested as a routine diagnostic modality for the evaluation of sacroiliitis in patients with suspected axSpA because of its lack of established diagnostic utility [22]. Importantly, US provides evaluation limited to the superficial posterior margins of the sacroiliac joints and spine, and therefore many structural details are not demonstrated. Many of the available studies examine the utility of Doppler evaluation. In addition to data showing decreased resistive indices at the sacroiliac joints in patients with active sacroiliitis joints [130-132], there is evidence that resistive indices of the thoracolumbar paraspinal areas are also decreased in patients with AS [132]. However, there is not enough evidence to support the use of US for the diagnosis of axSpA. Variant 3: Inflammatory back pain. Suspected axial spondyloarthritis. Negative radiographs and negative MRI of the sacroiliac joints. Next imaging study. The body regions covered in this clinical scenario are the sacroiliac joints, cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information. Bone Scan with SPECT or SPECT/CT Spine Area of Interest Bone scintigraphy is not routinely suggested in the evaluation of patients with suspected axSpA because of its lack of established diagnostic utility [22]. Conventional bone scintigraphy has low to moderate sensitivity and variable specificity for the diagnosis of axSpA [41,42,50]. If bone scintigraphy is used, because of the complexity of the spine anatomy, the use of SPECT should be performed during the examination [51].

3094107

acrac_3094107_15

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

Although bone scintigraphy is not typically performed during the evaluation of suspected axSpA because of its limited diagnostic utility, there is recent data that hybrid SPECT/CT has higher sensitivity than conventional bone scintigraphy in the detection of sacroiliitis [52,53], although there is not enough evidence at this time to support its routine use for evaluating the sacroiliac joints or spine. CT Spine Area of Interest CT demonstrates structural changes in the spine that may not be apparent on radiographs [22], including structural changes such as erosions, sclerosis, bone formation, syndesmophytes, and ankyloses [49,54]. CT has been shown to demonstrate syndesmophytes with higher sensitivity than radiographs and low-dose protocols can be utilized [58]. CT is especially helpful for evaluation of the thoracic spine and facet joints, which can be challenging to evaluate on radiography [49]. Although MRI remains the technique of choice for the diagnosis of axSpA [1,3,19,22], CT can be useful in patients in the setting of prior negative radiographic and negative CT evaluation of Inflammatory Back Pain the sacroiliac joints in order to identify patients with axSpA who have disease isolated to the spine, which has been shown to occur in a variable percentage of patients based on data from MRI studies [19,59-63]. There is no role for contrast-enhanced CT in the evaluation of axSpA. Fluoride PET/CT Skull Base to Mid-Thigh There is not enough data to support the routine use of PET/CT in the evaluation of patients with suspected axSpA. F-18-fluoride has been shown to be a potentially useful tracer in identifying sites of osteoblastic activity in axSpA patients [64,65].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. Although bone scintigraphy is not typically performed during the evaluation of suspected axSpA because of its limited diagnostic utility, there is recent data that hybrid SPECT/CT has higher sensitivity than conventional bone scintigraphy in the detection of sacroiliitis [52,53], although there is not enough evidence at this time to support its routine use for evaluating the sacroiliac joints or spine. CT Spine Area of Interest CT demonstrates structural changes in the spine that may not be apparent on radiographs [22], including structural changes such as erosions, sclerosis, bone formation, syndesmophytes, and ankyloses [49,54]. CT has been shown to demonstrate syndesmophytes with higher sensitivity than radiographs and low-dose protocols can be utilized [58]. CT is especially helpful for evaluation of the thoracic spine and facet joints, which can be challenging to evaluate on radiography [49]. Although MRI remains the technique of choice for the diagnosis of axSpA [1,3,19,22], CT can be useful in patients in the setting of prior negative radiographic and negative CT evaluation of Inflammatory Back Pain the sacroiliac joints in order to identify patients with axSpA who have disease isolated to the spine, which has been shown to occur in a variable percentage of patients based on data from MRI studies [19,59-63]. There is no role for contrast-enhanced CT in the evaluation of axSpA. Fluoride PET/CT Skull Base to Mid-Thigh There is not enough data to support the routine use of PET/CT in the evaluation of patients with suspected axSpA. F-18-fluoride has been shown to be a potentially useful tracer in identifying sites of osteoblastic activity in axSpA patients [64,65].

3094107

acrac_3094107_16

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

Uptake on PET/CT has also been shown to correlate with clinical disease activity in patients with axSpA [66,67]; however, there is conflicting evidence regarding the extent to which tracer uptake correlates with specific inflammatory and structural lesions seen on CT and MRI resulting in uncertainty about its diagnostic utility [64,67-72]. In one study, the interreader reliability of diagnosing sacroiliitis on PET/CT was poor and substantially lower than that for MRI or CT [67]. In a small study using radiographs as the reference standard, F-18-fluoride PET/CT had a sensitivity of 80% and specificity of 77% for the detection of sacroiliitis in AS, although there are inherent limitations in the use of radiographs as the reference standard for diagnosing axSpA [73]. Given the available data, the utility of PET/CT in the diagnosis of axSpA, including its utility in assessment of the spine, is uncertain at this time. MRI Spine Area of Interest Although MRI of the sacroiliac joints has high utility for the diagnosis of axSpA, some patients will not demonstrate imaging features of axSpA in the sacroiliac joints on MRI as indicated by sensitivities of all studies to varying degrees below 100% [22], and therefore some patients may need further imaging evaluation with MRI given that it is the imaging modality of choice for the diagnosis of axSpA [1,3,19,22]. Studies have shown widely varying degrees of isolated spinal involvement on MRI in axSpA ranging from 1% to 49% [19,59-63,114,115]. Therefore, imaging of the spine is beneficial for patients in whom there is suspicion for axSpA but imaging of the sacroiliac joints has been negative. Some authors have shown the utility of using whole-spine or whole-body MRI to identify the burden of disease rather than selecting specific areas of the spine to image because findings may be potentially isolated to any portion of the spine [10,59,63,89,114,120-122].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. Uptake on PET/CT has also been shown to correlate with clinical disease activity in patients with axSpA [66,67]; however, there is conflicting evidence regarding the extent to which tracer uptake correlates with specific inflammatory and structural lesions seen on CT and MRI resulting in uncertainty about its diagnostic utility [64,67-72]. In one study, the interreader reliability of diagnosing sacroiliitis on PET/CT was poor and substantially lower than that for MRI or CT [67]. In a small study using radiographs as the reference standard, F-18-fluoride PET/CT had a sensitivity of 80% and specificity of 77% for the detection of sacroiliitis in AS, although there are inherent limitations in the use of radiographs as the reference standard for diagnosing axSpA [73]. Given the available data, the utility of PET/CT in the diagnosis of axSpA, including its utility in assessment of the spine, is uncertain at this time. MRI Spine Area of Interest Although MRI of the sacroiliac joints has high utility for the diagnosis of axSpA, some patients will not demonstrate imaging features of axSpA in the sacroiliac joints on MRI as indicated by sensitivities of all studies to varying degrees below 100% [22], and therefore some patients may need further imaging evaluation with MRI given that it is the imaging modality of choice for the diagnosis of axSpA [1,3,19,22]. Studies have shown widely varying degrees of isolated spinal involvement on MRI in axSpA ranging from 1% to 49% [19,59-63,114,115]. Therefore, imaging of the spine is beneficial for patients in whom there is suspicion for axSpA but imaging of the sacroiliac joints has been negative. Some authors have shown the utility of using whole-spine or whole-body MRI to identify the burden of disease rather than selecting specific areas of the spine to image because findings may be potentially isolated to any portion of the spine [10,59,63,89,114,120-122].

3094107

acrac_3094107_17

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

The spine MRI findings of axSpA include the active inflammatory changes of spondylitis and spondylodiscitis, the inflammatory changes of the costovertebral joints, costotransverse joints, and facet joints and areas of enthesitis along other vertebral ligamentous attachments [123]. The chronic structural changes of fatty deposition, erosions, and syndesmophytes are also characteristic findings [123]. One study showed that the presence of two or more corner inflammatory lesions had a sensitivity of 69% and specificity of 94% for AS and that lateral vertebral inflammatory lesions had high specificity of 97% [120]. The presence of multiple lesions in the spine has shown to be useful; specifically the presence of at least five inflammatory lesions or five fatty lesions in the spine has been shown to have a specificity of 95% for axSpA [89]. One study shows that the corner sign in the lumbar spine on T1-weighted or T2-weighted images without fat saturation has a sensitivity of 62% and specificity of 96% for AS [12]. Furthermore, it has been shown that the presence of multiple fatty corner lesions in the spine has a high specificity of 98% and can be useful in the absence of active inflammatory lesions [11]. The ASAS considers a spine MRI positive for axSpA if there are three or more sites of inflammatory spondylitis and considers fatty corner deposition at several sites suggestive of axSpA especially in younger adults [123]. A subsequent study confirmed that the presence of multiple corner lesions has a high specificity for axSpA, although it showed a low diagnostic utility because of low sensitivity [121]. Importantly, the findings on spine MRI should be interpreted alongside sacroiliac joint MRI to ensure the highest diagnostic utility.

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. The spine MRI findings of axSpA include the active inflammatory changes of spondylitis and spondylodiscitis, the inflammatory changes of the costovertebral joints, costotransverse joints, and facet joints and areas of enthesitis along other vertebral ligamentous attachments [123]. The chronic structural changes of fatty deposition, erosions, and syndesmophytes are also characteristic findings [123]. One study showed that the presence of two or more corner inflammatory lesions had a sensitivity of 69% and specificity of 94% for AS and that lateral vertebral inflammatory lesions had high specificity of 97% [120]. The presence of multiple lesions in the spine has shown to be useful; specifically the presence of at least five inflammatory lesions or five fatty lesions in the spine has been shown to have a specificity of 95% for axSpA [89]. One study shows that the corner sign in the lumbar spine on T1-weighted or T2-weighted images without fat saturation has a sensitivity of 62% and specificity of 96% for AS [12]. Furthermore, it has been shown that the presence of multiple fatty corner lesions in the spine has a high specificity of 98% and can be useful in the absence of active inflammatory lesions [11]. The ASAS considers a spine MRI positive for axSpA if there are three or more sites of inflammatory spondylitis and considers fatty corner deposition at several sites suggestive of axSpA especially in younger adults [123]. A subsequent study confirmed that the presence of multiple corner lesions has a high specificity for axSpA, although it showed a low diagnostic utility because of low sensitivity [121]. Importantly, the findings on spine MRI should be interpreted alongside sacroiliac joint MRI to ensure the highest diagnostic utility.

3094107

acrac_3094107_18

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

Additionally, MRI findings should be interpreted with specific attention to identify associated morphologic findings such as disc degeneration or osteophytes that favor degenerative changes rather than axSpA, because both inflammatory and fatty lesions can occur in degenerative changes [124]. Contrast-enhanced MRI can demonstrate active inflammatory changes of the spine in axSpA, although multiple studies show that noncontrast and contrast-enhanced MRI have overall similar diagnostic utility for axSpA [9,125- 129]. Contrast-enhanced MRI has been reported to increase reliability of MRI interpretation in 1 study [9]. Radiography Spine Area of Interest If radiographs and MRI of the sacroiliac joints have been negative, radiographic evaluation of the spine can be obtained to evaluate for the structural imaging findings of axSpA, including syndesmophytes, erosions, shiny corners, vertebral body squaring, and ankylosis [38]. Although radiographs show structural changes, they will not demonstrate the inflammatory changes or fatty infiltration that can be demonstrated on MRI. Inflammatory Back Pain US Spine Area of Interest US is not beneficial as a diagnostic tool for the evaluation of sacroiliitis in patients with suspected axSpA because of its lack of established diagnostic utility [22]. Importantly, US provides limited evaluation of the superficial posterior margins of the spine, and therefore many structural details are not demonstrated. There is a paucity of evidence literature evaluating US in the spine in patients with axSpA. One study demonstrates that resistive indices of the thoracolumbar paraspinal areas are also decreased in patients with AS, similar to findings reported at the sacroiliac joints [132]. Variant 4: Known axial spondyloarthritis. Follow-up for treatment response or disease progression. The body regions covered in this clinical scenario are the sacroiliac joints, cervical, thoracic, and lumbar spine.

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. Additionally, MRI findings should be interpreted with specific attention to identify associated morphologic findings such as disc degeneration or osteophytes that favor degenerative changes rather than axSpA, because both inflammatory and fatty lesions can occur in degenerative changes [124]. Contrast-enhanced MRI can demonstrate active inflammatory changes of the spine in axSpA, although multiple studies show that noncontrast and contrast-enhanced MRI have overall similar diagnostic utility for axSpA [9,125- 129]. Contrast-enhanced MRI has been reported to increase reliability of MRI interpretation in 1 study [9]. Radiography Spine Area of Interest If radiographs and MRI of the sacroiliac joints have been negative, radiographic evaluation of the spine can be obtained to evaluate for the structural imaging findings of axSpA, including syndesmophytes, erosions, shiny corners, vertebral body squaring, and ankylosis [38]. Although radiographs show structural changes, they will not demonstrate the inflammatory changes or fatty infiltration that can be demonstrated on MRI. Inflammatory Back Pain US Spine Area of Interest US is not beneficial as a diagnostic tool for the evaluation of sacroiliitis in patients with suspected axSpA because of its lack of established diagnostic utility [22]. Importantly, US provides limited evaluation of the superficial posterior margins of the spine, and therefore many structural details are not demonstrated. There is a paucity of evidence literature evaluating US in the spine in patients with axSpA. One study demonstrates that resistive indices of the thoracolumbar paraspinal areas are also decreased in patients with AS, similar to findings reported at the sacroiliac joints [132]. Variant 4: Known axial spondyloarthritis. Follow-up for treatment response or disease progression. The body regions covered in this clinical scenario are the sacroiliac joints, cervical, thoracic, and lumbar spine.

3094107

acrac_3094107_19

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information. Bone Scan with SPECT or SPECT/CT Sacroiliac Joints Bone scintigraphy is not routinely obtained to evaluate for treatment response or disease progression in axSpA patients, and there is no relevant literature supporting its use in this setting. Bone Scan with SPECT or SPECT/CT Sacroiliac Joints and Spine Area of Interest Bone scintigraphy is not routinely obtained to evaluate for treatment response or disease progression in axSpA patients, and there is no relevant literature supporting its use in this setting. CT Sacroiliac Joints CT demonstrates structural changes of the sacroiliac joints in axSpA that may not be apparent on radiographs [22]; however, it is not routinely used for follow-up or assessing disease progression. CT Sacroiliac Joints and Spine Area of Interest CT demonstrates structural changes of the sacroiliac joints in axSpA that may not be apparent on radiographs [22] and can better demonstrate spinal syndesmophyte growth than radiographs using low-dose techniques [49,58]. However, it is not routinely used for follow-up or assessing disease progression. Fluoride PET/CT Skull Base to Mid-Thigh F-18-fluoride PET/CT is not routinely obtained to evaluate for treatment response or disease progression in axSpA patients, and there is no relevant literature supporting its use in this setting. MRI Sacroiliac Joints There is no standard method of following patients with MRI to evaluate for treatment response or disease progression [22,30]. Although multiple studies demonstrate decreasing inflammation on MRI following treatment with TNF-inhibitors, including some long-term studies showing sustained reduction in inflammation, the degree to which MRI findings correlate with disease activity is variable [30].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information. Bone Scan with SPECT or SPECT/CT Sacroiliac Joints Bone scintigraphy is not routinely obtained to evaluate for treatment response or disease progression in axSpA patients, and there is no relevant literature supporting its use in this setting. Bone Scan with SPECT or SPECT/CT Sacroiliac Joints and Spine Area of Interest Bone scintigraphy is not routinely obtained to evaluate for treatment response or disease progression in axSpA patients, and there is no relevant literature supporting its use in this setting. CT Sacroiliac Joints CT demonstrates structural changes of the sacroiliac joints in axSpA that may not be apparent on radiographs [22]; however, it is not routinely used for follow-up or assessing disease progression. CT Sacroiliac Joints and Spine Area of Interest CT demonstrates structural changes of the sacroiliac joints in axSpA that may not be apparent on radiographs [22] and can better demonstrate spinal syndesmophyte growth than radiographs using low-dose techniques [49,58]. However, it is not routinely used for follow-up or assessing disease progression. Fluoride PET/CT Skull Base to Mid-Thigh F-18-fluoride PET/CT is not routinely obtained to evaluate for treatment response or disease progression in axSpA patients, and there is no relevant literature supporting its use in this setting. MRI Sacroiliac Joints There is no standard method of following patients with MRI to evaluate for treatment response or disease progression [22,30]. Although multiple studies demonstrate decreasing inflammation on MRI following treatment with TNF-inhibitors, including some long-term studies showing sustained reduction in inflammation, the degree to which MRI findings correlate with disease activity is variable [30].

3094107

acrac_3094107_20

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

The American College of Rheumatology and European League Against Rheumatism agree that the decision to repeat MRI to assess disease activity or monitor for disease response depends on the clinical circumstances [22,30]. Specifically, MRI of the sacroiliac joints may be helpful for cases in which the disease activity is unclear, available clinical or laboratory data are conflicting, or knowledge of MRI findings is expected to alter treatment [30]. MRI can also detect chronic structural changes on axSpA in the sacroiliac joints, although the clinical utility of follow-up for that purpose is not established [137]. Noncontrast and contrast-enhanced MRI have overall similar diagnostic utility for evaluation of the sacroiliac joints in axSpA [107-111]. The Spondyloarthritis Research Consortium of Canada method has been utilized as a scoring system for quantification and follow-up of lesions at the sacroiliac joints on MRI [138]. MRI Sacroiliac Joints and Spine Area of Interest There is no standard method of following patients with MRI to evaluate for treatment response or disease progression [22,30]. Although multiple studies demonstrate decreasing inflammation on MRI following treatment with TNF-inhibitors, including some long-term studies showing sustained reduction in inflammation, the degree to which MRI findings correlate with disease activity is variable [30]. The American College of Rheumatology and European League Against Rheumatism agree that the decision to repeat MRI to assess disease activity or monitor for disease response depends on the clinical circumstances [22,30]. Specifically, MRI of the sacroiliac joints and spine may be helpful for cases in which the disease activity is unclear, available clinical or laboratory data are conflicting, or knowledge of MRI findings is expected to alter treatment [30].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. The American College of Rheumatology and European League Against Rheumatism agree that the decision to repeat MRI to assess disease activity or monitor for disease response depends on the clinical circumstances [22,30]. Specifically, MRI of the sacroiliac joints may be helpful for cases in which the disease activity is unclear, available clinical or laboratory data are conflicting, or knowledge of MRI findings is expected to alter treatment [30]. MRI can also detect chronic structural changes on axSpA in the sacroiliac joints, although the clinical utility of follow-up for that purpose is not established [137]. Noncontrast and contrast-enhanced MRI have overall similar diagnostic utility for evaluation of the sacroiliac joints in axSpA [107-111]. The Spondyloarthritis Research Consortium of Canada method has been utilized as a scoring system for quantification and follow-up of lesions at the sacroiliac joints on MRI [138]. MRI Sacroiliac Joints and Spine Area of Interest There is no standard method of following patients with MRI to evaluate for treatment response or disease progression [22,30]. Although multiple studies demonstrate decreasing inflammation on MRI following treatment with TNF-inhibitors, including some long-term studies showing sustained reduction in inflammation, the degree to which MRI findings correlate with disease activity is variable [30]. The American College of Rheumatology and European League Against Rheumatism agree that the decision to repeat MRI to assess disease activity or monitor for disease response depends on the clinical circumstances [22,30]. Specifically, MRI of the sacroiliac joints and spine may be helpful for cases in which the disease activity is unclear, available clinical or laboratory data are conflicting, or knowledge of MRI findings is expected to alter treatment [30].

3094107

acrac_3094107_21

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

MRI can also detect chronic structural changes on axSpA in the sacroiliac joints and spine, although the clinical utility of follow-up for that purpose is not Inflammatory Back Pain established [110,137]. Noncontrast and contrast-enhanced MRI have overall similar diagnostic utility for evaluation of the sacroiliac joints and spine in axSpA [9,107-111,125-129]. The Spondyloarthritis Research Consortium of Canada and Berlin methods have been used as scoring systems for quantification and follow-up of lesions in the sacroiliac joints and spine on MRI [138-140]. Radiography Sacroiliac Joints There is no standard method of following patients with radiographs to evaluate for progression of structural changes [22], and the American College of Rheumatology recommends against routine radiographic follow-up given the lack of proven benefit [30]. Repeat radiographs can be obtained as necessary for counseling patients on the status and prognosis of their disease, although radiographs are more typically performed to evaluate the spine rather than the sacroiliac joints [30]. This is because of the low utility of sacroiliac joint radiographs for detecting disease progression based on the relatively poor intra- and interreader reliability of interpretation [141]. Radiographs can demonstrate evolving structural changes or bone formation, although these changes occur slowly over time at the sacroiliac joints, often requiring years to detect a change and prompting many authors to suggest a radiographic imaging interval of axSpA patients of no less than 2 years for assessment of disease progression [141-146]. There is evidence that patients on TNF-inhibitors may have slower progression of structural damage at the sacroiliac joints [147,148], although there is some disagreement in the literature [149].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. MRI can also detect chronic structural changes on axSpA in the sacroiliac joints and spine, although the clinical utility of follow-up for that purpose is not Inflammatory Back Pain established [110,137]. Noncontrast and contrast-enhanced MRI have overall similar diagnostic utility for evaluation of the sacroiliac joints and spine in axSpA [9,107-111,125-129]. The Spondyloarthritis Research Consortium of Canada and Berlin methods have been used as scoring systems for quantification and follow-up of lesions in the sacroiliac joints and spine on MRI [138-140]. Radiography Sacroiliac Joints There is no standard method of following patients with radiographs to evaluate for progression of structural changes [22], and the American College of Rheumatology recommends against routine radiographic follow-up given the lack of proven benefit [30]. Repeat radiographs can be obtained as necessary for counseling patients on the status and prognosis of their disease, although radiographs are more typically performed to evaluate the spine rather than the sacroiliac joints [30]. This is because of the low utility of sacroiliac joint radiographs for detecting disease progression based on the relatively poor intra- and interreader reliability of interpretation [141]. Radiographs can demonstrate evolving structural changes or bone formation, although these changes occur slowly over time at the sacroiliac joints, often requiring years to detect a change and prompting many authors to suggest a radiographic imaging interval of axSpA patients of no less than 2 years for assessment of disease progression [141-146]. There is evidence that patients on TNF-inhibitors may have slower progression of structural damage at the sacroiliac joints [147,148], although there is some disagreement in the literature [149].

3094107

acrac_3094107_22

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

Radiographic scoring systems, such as the Bath Ankylosing Spondylitis Radiology Index for the sacroiliac joints, have been utilized for quantification and follow-up of radiographic progression in patients over time [29,150]. Radiography Sacroiliac Joints and Spine Area of Interest There is no standard method of following patients with radiographs to evaluate for progression of structural changes [22], and the American College of Rheumatology recommends against routine follow-up given the lack of proven benefit [30]. Repeat radiographs can be obtained for counseling patients on the status and prognosis of their disease, although radiographs are more typically performed to evaluate the spine rather than the sacroiliac joints [30]. This is because of the low utility of sacroiliac joint radiographs for detecting disease progression based on the relatively poor intra- and interreader reliability of interpretation [141]. Radiographic follow-up can demonstrate evolving structural changes or bone formation, although these changes occur slowly over time at the sacroiliac joints and spine, often requiring years to detect a change and prompting some authors to suggest a radiographic imaging interval of axSpA patients of no less than 2 years for assessment of disease progression [141,143-145,151-153]. There is evidence that patients on TNF-inhibitors may have slower progression of structural damage at the sacroiliac joints and spine [148,154-156], although there is some disagreement in the literature [149]. Radiographic scoring systems, such as the Bath Ankylosing Spondylitis Radiology Index for the sacroiliac joints and the modified Stoke Ankylosing Spondylitis Spine Score for the spine, have been utilized for quantification and follow-up of radiographic progression over time [29,150,157]. US Sacroiliac Joints US of the sacroiliac joints is not utilized as a routine diagnostic tool in the assessment of treatment response or disease progression.

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. Radiographic scoring systems, such as the Bath Ankylosing Spondylitis Radiology Index for the sacroiliac joints, have been utilized for quantification and follow-up of radiographic progression in patients over time [29,150]. Radiography Sacroiliac Joints and Spine Area of Interest There is no standard method of following patients with radiographs to evaluate for progression of structural changes [22], and the American College of Rheumatology recommends against routine follow-up given the lack of proven benefit [30]. Repeat radiographs can be obtained for counseling patients on the status and prognosis of their disease, although radiographs are more typically performed to evaluate the spine rather than the sacroiliac joints [30]. This is because of the low utility of sacroiliac joint radiographs for detecting disease progression based on the relatively poor intra- and interreader reliability of interpretation [141]. Radiographic follow-up can demonstrate evolving structural changes or bone formation, although these changes occur slowly over time at the sacroiliac joints and spine, often requiring years to detect a change and prompting some authors to suggest a radiographic imaging interval of axSpA patients of no less than 2 years for assessment of disease progression [141,143-145,151-153]. There is evidence that patients on TNF-inhibitors may have slower progression of structural damage at the sacroiliac joints and spine [148,154-156], although there is some disagreement in the literature [149]. Radiographic scoring systems, such as the Bath Ankylosing Spondylitis Radiology Index for the sacroiliac joints and the modified Stoke Ankylosing Spondylitis Spine Score for the spine, have been utilized for quantification and follow-up of radiographic progression over time [29,150,157]. US Sacroiliac Joints US of the sacroiliac joints is not utilized as a routine diagnostic tool in the assessment of treatment response or disease progression.

3094107

acrac_3094107_23

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

Importantly, a US evaluation is limited to the superficial posterior margins of the sacroiliac joints and spine, and therefore many structural details are not demonstrated. Many of the available studies examine the utility of Doppler evaluation. There is evidence in small studies that Doppler resistive indices at the sacroiliac joints increase following treatment with TNF-inhibitors [132,158,159], although more data are necessary to justify the routine use of US in this setting. US Sacroiliac Joints and Spine Area of Interest US of the sacroiliac joints is not utilized as a routine diagnostic tool in the assessment of treatment response or disease progression. Importantly, an US evaluation is limited to the superficial posterior margins of the sacroiliac joints and spine, and therefore many structural details are not demonstrated. Many of the available studies examine the utility of Doppler evaluation. There is evidence in small studies that Doppler-resistive indices at the sacroiliac joints increase following treatment with TNF-inhibitors [132,158,159], and there is limited data showing potentially similar findings in thoracolumbar paraspinal spondylitis [132], although more data are necessary to justify routine use of US in this setting. Variant 5: Axial spondyloarthritis with spine ankylosis. Suspected fracture. Initial imaging. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information. Inflammatory Back Pain Bone Scan with SPECT or SPECT/CT Spine Area of Interest Bone scintigraphy is not routinely obtained to evaluate for suspected fracture in axSpA patients with spine ankylosis, and there is no relevant literature supporting its use in this setting.

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. Importantly, a US evaluation is limited to the superficial posterior margins of the sacroiliac joints and spine, and therefore many structural details are not demonstrated. Many of the available studies examine the utility of Doppler evaluation. There is evidence in small studies that Doppler resistive indices at the sacroiliac joints increase following treatment with TNF-inhibitors [132,158,159], although more data are necessary to justify the routine use of US in this setting. US Sacroiliac Joints and Spine Area of Interest US of the sacroiliac joints is not utilized as a routine diagnostic tool in the assessment of treatment response or disease progression. Importantly, an US evaluation is limited to the superficial posterior margins of the sacroiliac joints and spine, and therefore many structural details are not demonstrated. Many of the available studies examine the utility of Doppler evaluation. There is evidence in small studies that Doppler-resistive indices at the sacroiliac joints increase following treatment with TNF-inhibitors [132,158,159], and there is limited data showing potentially similar findings in thoracolumbar paraspinal spondylitis [132], although more data are necessary to justify routine use of US in this setting. Variant 5: Axial spondyloarthritis with spine ankylosis. Suspected fracture. Initial imaging. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination as guided by physical examination findings, patient history, and other available information. Inflammatory Back Pain Bone Scan with SPECT or SPECT/CT Spine Area of Interest Bone scintigraphy is not routinely obtained to evaluate for suspected fracture in axSpA patients with spine ankylosis, and there is no relevant literature supporting its use in this setting.

3094107

acrac_3094107_24

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

CT Spine Area of Interest CT and MRI are the imaging techniques of choice for definitive evaluation of the patient with ankylosis and suspected fracture [22,32]. CT can be performed rapidly in trauma patients and excellently depicts the complex structures of each vertebral column that can injured in this setting [31] and therefore is typically the preferred modality [22]. The sensitivities of CT and MRI for fracture detection are similar in the available small case series, notably with some fractures better detected on CT and some better detected on MRI, suggesting these modalities have a degree of complementary diagnostic utility [34,160,161]. CT, similar to MRI, has higher sensitivity for detection of fracture in the setting of ankylosis than radiographs [31,32,34,161]. The cervical spine is most frequently involved in a fracture [32,33,35]. The presence of two or more fractures is common [160], and therefore, the entire spine should be imaged to both ensure detection of the potential fracture(s) and to detect multilevel involvement [32]. Fluoride PET/CT Skull Base to Mid-Thigh F-18-fluoride PET/CT is not routinely obtained to evaluate for suspected fracture in axSpA patients with spine ankylosis, and there is no relevant literature supporting its use in this setting. MRI Spine Area of Interest CT and MRI are the imaging techniques of choice for definitive evaluation of the patient with ankylosis and suspected fracture [22,32]. Technical difficulties can be encountered during an MRI of some patients with spine ankylosis in the acute posttraumatic setting, including inability of patients to remain immobile during the examination, difficulty with coil selection, and motion artifact. These factors combined with varying degrees of spinal deformity and occasional lack of associated bone marrow edema at fracture sites can result in challenging interpretation [160]. Therefore, CT is typically the preferred modality in this setting [22].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. CT Spine Area of Interest CT and MRI are the imaging techniques of choice for definitive evaluation of the patient with ankylosis and suspected fracture [22,32]. CT can be performed rapidly in trauma patients and excellently depicts the complex structures of each vertebral column that can injured in this setting [31] and therefore is typically the preferred modality [22]. The sensitivities of CT and MRI for fracture detection are similar in the available small case series, notably with some fractures better detected on CT and some better detected on MRI, suggesting these modalities have a degree of complementary diagnostic utility [34,160,161]. CT, similar to MRI, has higher sensitivity for detection of fracture in the setting of ankylosis than radiographs [31,32,34,161]. The cervical spine is most frequently involved in a fracture [32,33,35]. The presence of two or more fractures is common [160], and therefore, the entire spine should be imaged to both ensure detection of the potential fracture(s) and to detect multilevel involvement [32]. Fluoride PET/CT Skull Base to Mid-Thigh F-18-fluoride PET/CT is not routinely obtained to evaluate for suspected fracture in axSpA patients with spine ankylosis, and there is no relevant literature supporting its use in this setting. MRI Spine Area of Interest CT and MRI are the imaging techniques of choice for definitive evaluation of the patient with ankylosis and suspected fracture [22,32]. Technical difficulties can be encountered during an MRI of some patients with spine ankylosis in the acute posttraumatic setting, including inability of patients to remain immobile during the examination, difficulty with coil selection, and motion artifact. These factors combined with varying degrees of spinal deformity and occasional lack of associated bone marrow edema at fracture sites can result in challenging interpretation [160]. Therefore, CT is typically the preferred modality in this setting [22].

3094107

acrac_3094107_25

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs

The sensitivities of CT and MRI for fracture detection are similar in the available small case series, notably with some fractures better detected on CT and some better detected on MRI, suggesting these modalities have a degree of complementary diagnostic utility [34,160,161]. MRI, similar to CT, has higher sensitivity for detection of fracture in the setting of ankylosis than radiographs [32,34,161]. MRI can detect both osseous fractures as well as soft tissue injuries such as ligamentous disruption or spinal cord injury [31,34,160]. In the setting of neurologic deficit, MRI should be performed, either as the sole cross-sectional imaging modality or in addition to CT [22,162]. The cervical spine is most frequently involved by fracture [32,33,35]. The presence of two or more fractures is common [160], and therefore the entire spine should be imaged to both ensure detection of the potential fracture(s) and to detect multilevel involvement [32]. Radiography Spine Area of Interest Radiography of the spine can be considered as an initial imaging modality in patients with axSpA and suspected fracture [22], although fractures can be difficult to detect on radiographs in axSpA patients, especially in the setting of structural abnormalities and osteopenia, contributing further to an already inherent lower sensitivity of radiography for fracture detection compared with CT or MRI [31,32,34,160,161]. Negative radiographs in these patients should be followed by cross-sectional imaging. If obtained, radiographs should cover the entire spine in patients with ankylosis and suspected fracture because of the potential for multilevel fractures [32,160].

Inflammatory Back Pain Known or Suspected Axial Spondyloarthropathy PCAs. The sensitivities of CT and MRI for fracture detection are similar in the available small case series, notably with some fractures better detected on CT and some better detected on MRI, suggesting these modalities have a degree of complementary diagnostic utility [34,160,161]. MRI, similar to CT, has higher sensitivity for detection of fracture in the setting of ankylosis than radiographs [32,34,161]. MRI can detect both osseous fractures as well as soft tissue injuries such as ligamentous disruption or spinal cord injury [31,34,160]. In the setting of neurologic deficit, MRI should be performed, either as the sole cross-sectional imaging modality or in addition to CT [22,162]. The cervical spine is most frequently involved by fracture [32,33,35]. The presence of two or more fractures is common [160], and therefore the entire spine should be imaged to both ensure detection of the potential fracture(s) and to detect multilevel involvement [32]. Radiography Spine Area of Interest Radiography of the spine can be considered as an initial imaging modality in patients with axSpA and suspected fracture [22], although fractures can be difficult to detect on radiographs in axSpA patients, especially in the setting of structural abnormalities and osteopenia, contributing further to an already inherent lower sensitivity of radiography for fracture detection compared with CT or MRI [31,32,34,160,161]. Negative radiographs in these patients should be followed by cross-sectional imaging. If obtained, radiographs should cover the entire spine in patients with ankylosis and suspected fracture because of the potential for multilevel fractures [32,160].

3094107

acrac_3102388_0

Antenatal Hydronephrosis Infant

Introduction/Background Antenatal hydronephrosis is the most frequent urinary tract anomaly detected on prenatal screening by ultrasonography (US). Antenatal hydronephrosis occurs approximately twice as often in males as in females [1-4]. With an estimated 4 million births per year in the United States, up to 80,000 fetal studies may detect antenatal hydronephrosis. Most antenatal hydronephrosis is transient with little long-term significance [5-8]. Few children with antenatal hydronephrosis, including some with ureteropelvic junction obstruction (UPJO), vesicoureteral reflux (VUR), and primary megaureter will have significant obstruction, develop symptoms or complications, which requires surgical intervention. Some male children will be diagnosed with more serious conditions, such as posterior urethral valves (PUV), which may require intervention. Early detection and treatment of obstructive uropathy is necessary to mitigate the potential morbidity from loss of renal function. During prenatal evaluation, most antenatal hydronephrosis is mild, and the cause cannot always be determined with certainty. As a result, postnatal evaluation of these children is frequently performed. In an effort to standardize grading of antenatal hydronephrosis, the Society for Fetal Urology (SFU) introduced a five point grading system in 1988, based on degree of pelvic and calyceal dilation and the thickness of the parenchyma overlying the calices [9]. Since its introduction, the SFU grading system has become the most widely used method to grade pediatric hydronephrosis [10]. Subsequently, several alternative classification schemes have also been devised [3,4,11,12].

Antenatal Hydronephrosis Infant. Introduction/Background Antenatal hydronephrosis is the most frequent urinary tract anomaly detected on prenatal screening by ultrasonography (US). Antenatal hydronephrosis occurs approximately twice as often in males as in females [1-4]. With an estimated 4 million births per year in the United States, up to 80,000 fetal studies may detect antenatal hydronephrosis. Most antenatal hydronephrosis is transient with little long-term significance [5-8]. Few children with antenatal hydronephrosis, including some with ureteropelvic junction obstruction (UPJO), vesicoureteral reflux (VUR), and primary megaureter will have significant obstruction, develop symptoms or complications, which requires surgical intervention. Some male children will be diagnosed with more serious conditions, such as posterior urethral valves (PUV), which may require intervention. Early detection and treatment of obstructive uropathy is necessary to mitigate the potential morbidity from loss of renal function. During prenatal evaluation, most antenatal hydronephrosis is mild, and the cause cannot always be determined with certainty. As a result, postnatal evaluation of these children is frequently performed. In an effort to standardize grading of antenatal hydronephrosis, the Society for Fetal Urology (SFU) introduced a five point grading system in 1988, based on degree of pelvic and calyceal dilation and the thickness of the parenchyma overlying the calices [9]. Since its introduction, the SFU grading system has become the most widely used method to grade pediatric hydronephrosis [10]. Subsequently, several alternative classification schemes have also been devised [3,4,11,12].

3102388

acrac_3102388_1

Antenatal Hydronephrosis Infant

Adherence to standardized reporting models is not well adopted according to a recent survey of pediatric radiologists [13,14], In order to increase standardization of reporting and care, a consensus group from many separate organizations recommended adoption of the urinary tract dilation (UTD) classification system which incorporates prenatal and postnatal imaging findings based on: 1) anterior-posterior renal pelvic diameter (APRPD); 2) calyceal dilation with distinction between central and peripheral calyceal dilation postnatally; 3) renal parenchymal thickness; 4) renal parenchymal appearance; 5) bladder abnormalities; and 6) ureteral abnormalities. For antenatal studies, the seventh US finding to report is the quantity of amniotic fluid [3]. This recently proposed grading classification system, as with any system, will require extensive evaluation to assess and confirm its usefulness in predicting clinical outcomes [3]. For the purposes of the current evaluation, degree of hydronephrosis is based on the SFU grading. The SFU system has been in use for a longer period of time and has good inter-rater reliability [3,15,16]. There are studies that have shown increased accuracy of hydronephrosis grading system if APRPD is measured [17,18]. We therefore have included an APRPD of >15 mm on postnatal imaging as a sign of severe hydronephrosis. Over time, the UTD classification system may predominate, but at present, familiarity with the SFU system is more widespread. Inclusion of the APRPD >15 mm conforms to the intermediate- to high-risk urinary tract dilation stratification [3]. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected]

Antenatal Hydronephrosis Infant. Adherence to standardized reporting models is not well adopted according to a recent survey of pediatric radiologists [13,14], In order to increase standardization of reporting and care, a consensus group from many separate organizations recommended adoption of the urinary tract dilation (UTD) classification system which incorporates prenatal and postnatal imaging findings based on: 1) anterior-posterior renal pelvic diameter (APRPD); 2) calyceal dilation with distinction between central and peripheral calyceal dilation postnatally; 3) renal parenchymal thickness; 4) renal parenchymal appearance; 5) bladder abnormalities; and 6) ureteral abnormalities. For antenatal studies, the seventh US finding to report is the quantity of amniotic fluid [3]. This recently proposed grading classification system, as with any system, will require extensive evaluation to assess and confirm its usefulness in predicting clinical outcomes [3]. For the purposes of the current evaluation, degree of hydronephrosis is based on the SFU grading. The SFU system has been in use for a longer period of time and has good inter-rater reliability [3,15,16]. There are studies that have shown increased accuracy of hydronephrosis grading system if APRPD is measured [17,18]. We therefore have included an APRPD of >15 mm on postnatal imaging as a sign of severe hydronephrosis. Over time, the UTD classification system may predominate, but at present, familiarity with the SFU system is more widespread. Inclusion of the APRPD >15 mm conforms to the intermediate- to high-risk urinary tract dilation stratification [3]. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected]

3102388

acrac_3102388_2

Antenatal Hydronephrosis Infant

OR Discussion of Procedures by Variant Variant 1: Antenatal diagnosis of hydronephrosis. Initial neonatal imaging. US Kidneys and Bladder Retroperitoneal US in the immediate postnatal period evaluates for the presence and severity of underlying urologic abnormalities and therefore has a role in guiding management [3,6,12,19-25]. Because of the relative low urine production in newborns, initial imaging should be delayed at least 48 to 72 hours after birth [3,26-29]. Exceptions include newborns with severe, bilateral hydronephrosis and bladder abnormalities, oligohydramnios, or situations in which follow-up studies may be difficult to obtain. In these infants, earlier imaging is indicated [20,27,29,30]. Fluoroscopic Voiding Cystourethrography There is controversy regarding whether all children with antenatal hydronephrosis should undergo voiding cystourethrography (VCUG). A meta-analysis by the American Urology Association found that, on average, approximately 16% of neonates and infants with antenatal hydronephrosis will have VUR. The incidence of VUR was independent of degree of antenatal hydronephrosis, and a quarter of these were found to have no hydronephrosis on postnatal US [31]. There is disagreement over whether this VUR is clinically significant and therefore over the need for diagnosis. Some authors advocate VCUG for all infants with antenatal hydronephrosis, to guide treatment with prophylactic antibiotics [20,27,32,33]. However, currently, most authors (including the 2010 SFU consensus statement) recommend against routine VCUG for antenatal hydronephrosis [2,12,29,34,35]. This is largely because the benefit of prophylactic antibiotics in children with urinary tract infection (UTI) has not been clearly demonstrated and remains controversial. Some studies have suggested that prophylactic antibiotics may be beneficial in patients with VUR [36-38].

Antenatal Hydronephrosis Infant. OR Discussion of Procedures by Variant Variant 1: Antenatal diagnosis of hydronephrosis. Initial neonatal imaging. US Kidneys and Bladder Retroperitoneal US in the immediate postnatal period evaluates for the presence and severity of underlying urologic abnormalities and therefore has a role in guiding management [3,6,12,19-25]. Because of the relative low urine production in newborns, initial imaging should be delayed at least 48 to 72 hours after birth [3,26-29]. Exceptions include newborns with severe, bilateral hydronephrosis and bladder abnormalities, oligohydramnios, or situations in which follow-up studies may be difficult to obtain. In these infants, earlier imaging is indicated [20,27,29,30]. Fluoroscopic Voiding Cystourethrography There is controversy regarding whether all children with antenatal hydronephrosis should undergo voiding cystourethrography (VCUG). A meta-analysis by the American Urology Association found that, on average, approximately 16% of neonates and infants with antenatal hydronephrosis will have VUR. The incidence of VUR was independent of degree of antenatal hydronephrosis, and a quarter of these were found to have no hydronephrosis on postnatal US [31]. There is disagreement over whether this VUR is clinically significant and therefore over the need for diagnosis. Some authors advocate VCUG for all infants with antenatal hydronephrosis, to guide treatment with prophylactic antibiotics [20,27,32,33]. However, currently, most authors (including the 2010 SFU consensus statement) recommend against routine VCUG for antenatal hydronephrosis [2,12,29,34,35]. This is largely because the benefit of prophylactic antibiotics in children with urinary tract infection (UTI) has not been clearly demonstrated and remains controversial. Some studies have suggested that prophylactic antibiotics may be beneficial in patients with VUR [36-38].

3102388

acrac_3102388_3

Antenatal Hydronephrosis Infant

The efficacy of prophylactic antibiotics in preventing UTIs or renal damage in patients with antenatal hydronephrosis, with or without VUR, is difficult to determine because of variability in methods and results [39]. In addition, most of the VUR spontaneously resolves [40]. One of the potential risks of VCUG is iatrogenic UTI. This was reported in about 2% of VCUG studies performed for evaluation of antenatal hydronephrosis [39]. Voiding Urosonography Multiple recent investigations evaluating real-time contrast-enhanced US techniques have demonstrated a high degree of diagnostic accuracy, and some demonstrated increased sensitivity as compared to fluoroscopic VCUG in the detection of VUR [41-45]. The main potential disadvantage of voiding urosonography is a lower anatomical detail of the bladder and urethra, and therefore it should not be used as the first study for male patients. Therefore, arguments for and against using voiding urosonography are similar to that of VCUG with the exception of male patients. Nuclear Medicine Cystography Some studies have suggested equal sensitivity for Tc-99m pertechnetate radionuclide cystography and VCUG [46], whereas others have indicated that radionuclide cystography has improved sensitivity for VUR in infants up to 1 year of age [47]. The main disadvantage of radionuclide cystography is that it does not provide anatomical details of the bladder and urethra and therefore should not be used as the first study for male patients. Therefore, arguments for and against using radionuclide cystography are similar to that of VCUG with the exception of male patients. DTPA Renal Scan There is no relevant literature to support the routine use of Tc-99m diethylenetriamine pentaacetic acid (DTPA) renal scan in the initial postnatal evaluation of antenatal hydronephrosis.

Antenatal Hydronephrosis Infant. The efficacy of prophylactic antibiotics in preventing UTIs or renal damage in patients with antenatal hydronephrosis, with or without VUR, is difficult to determine because of variability in methods and results [39]. In addition, most of the VUR spontaneously resolves [40]. One of the potential risks of VCUG is iatrogenic UTI. This was reported in about 2% of VCUG studies performed for evaluation of antenatal hydronephrosis [39]. Voiding Urosonography Multiple recent investigations evaluating real-time contrast-enhanced US techniques have demonstrated a high degree of diagnostic accuracy, and some demonstrated increased sensitivity as compared to fluoroscopic VCUG in the detection of VUR [41-45]. The main potential disadvantage of voiding urosonography is a lower anatomical detail of the bladder and urethra, and therefore it should not be used as the first study for male patients. Therefore, arguments for and against using voiding urosonography are similar to that of VCUG with the exception of male patients. Nuclear Medicine Cystography Some studies have suggested equal sensitivity for Tc-99m pertechnetate radionuclide cystography and VCUG [46], whereas others have indicated that radionuclide cystography has improved sensitivity for VUR in infants up to 1 year of age [47]. The main disadvantage of radionuclide cystography is that it does not provide anatomical details of the bladder and urethra and therefore should not be used as the first study for male patients. Therefore, arguments for and against using radionuclide cystography are similar to that of VCUG with the exception of male patients. DTPA Renal Scan There is no relevant literature to support the routine use of Tc-99m diethylenetriamine pentaacetic acid (DTPA) renal scan in the initial postnatal evaluation of antenatal hydronephrosis.

3102388

acrac_3102388_4

Antenatal Hydronephrosis Infant

MAG3 Renal Scan There is no relevant literature to support the routine use of Tc-99m mercaptoacetyltriglycine (MAG3) diuretic renal scan in the initial postnatal evaluation of antenatal hydronephrosis. MRI Abdomen and Pelvis There is no relevant literature to support the routine use of MR urography (MRU) in the initial postnatal evaluation of antenatal hydronephrosis. Fluoroscopic Voiding Cystourethrography There is controversy regarding whether all children with antenatal hydronephrosis should undergo VCUG. A meta- analysis by the American Urology Association found that on average, approximately 16% of neonates and infants with antenatal hydronephrosis will have VUR. The incidence of VUR was independent of degree of antenatal hydronephrosis, and a quarter of these were found to have no hydronephrosis on postnatal US [31]. There is disagreement over whether this VUR is clinically significant and therefore over the need for diagnosis. Some authors advocate VCUG for all infants with antenatal hydronephrosis, to guide treatment with prophylactic antibiotics [20,27,32,33]. However, currently, most authors (including the 2010 SFU consensus statement) recommend against routine VCUG for antenatal hydronephrosis [2,12,29,34,35]. This is largely because the benefit of prophylactic antibiotic in children with UTI has not been clearly demonstrated [36]. The efficacy of prophylactic antibiotics in preventing UTIs or renal damage in patients with antenatal hydronephrosis, with or without VUR, is difficult to determine because of variability in methods and results [39]. In addition, most of the VUR spontaneously resolves [40]. One of the potential risks of VCUG is iatrogenic UTI. This was reported in about 2% of VCUG studies performed for evaluation of antenatal hydronephrosis [39].

Antenatal Hydronephrosis Infant. MAG3 Renal Scan There is no relevant literature to support the routine use of Tc-99m mercaptoacetyltriglycine (MAG3) diuretic renal scan in the initial postnatal evaluation of antenatal hydronephrosis. MRI Abdomen and Pelvis There is no relevant literature to support the routine use of MR urography (MRU) in the initial postnatal evaluation of antenatal hydronephrosis. Fluoroscopic Voiding Cystourethrography There is controversy regarding whether all children with antenatal hydronephrosis should undergo VCUG. A meta- analysis by the American Urology Association found that on average, approximately 16% of neonates and infants with antenatal hydronephrosis will have VUR. The incidence of VUR was independent of degree of antenatal hydronephrosis, and a quarter of these were found to have no hydronephrosis on postnatal US [31]. There is disagreement over whether this VUR is clinically significant and therefore over the need for diagnosis. Some authors advocate VCUG for all infants with antenatal hydronephrosis, to guide treatment with prophylactic antibiotics [20,27,32,33]. However, currently, most authors (including the 2010 SFU consensus statement) recommend against routine VCUG for antenatal hydronephrosis [2,12,29,34,35]. This is largely because the benefit of prophylactic antibiotic in children with UTI has not been clearly demonstrated [36]. The efficacy of prophylactic antibiotics in preventing UTIs or renal damage in patients with antenatal hydronephrosis, with or without VUR, is difficult to determine because of variability in methods and results [39]. In addition, most of the VUR spontaneously resolves [40]. One of the potential risks of VCUG is iatrogenic UTI. This was reported in about 2% of VCUG studies performed for evaluation of antenatal hydronephrosis [39].

3102388

acrac_3102388_5

Antenatal Hydronephrosis Infant

Voiding Urosonography Multiple recent investigations evaluating real-time contrast-enhanced US techniques have demonstrated a high degree of diagnostic accuracy, and some demonstrated increased sensitivity as compared to fluoroscopic VCUG in the detection of VUR [41-45]. The main potential disadvantage of voiding urosonography is a lower anatomical detail of the bladder and urethra, and therefore it should not be used as the first study for male patients. Therefore, arguments for and against using voiding urosonography are similar to that of VCUG with the exception of male patients. Nuclear Medicine Cystography Some studies have suggested equal sensitivity for Tc-99m pertechnetate radionuclide cystography and VCUG [46], whereas others have indicated that radionuclide cystography has improved sensitivity for VUR in infants up to 1 year of age [47]. The main disadvantage of radionuclide cystography is that it does not provide anatomical details of the bladder and urethra and therefore should not be used as the first study for male patients. Therefore, arguments for and against using radionuclide cystography are similar to that of VCUG with the exception of male patients. DTPA Renal Scan There is no relevant literature to support the routine use of Tc-99m DTPA renal scan in the setting of a normal neonatal US. MAG3 Renal Scan There is no relevant literature to support the routine use of Tc-99m MAG3 diuretic renal scan in the setting of a normal neonatal US. MRI Abdomen and Pelvis There is no relevant literature to support the routine use of MRU in the in the setting of a normal neonatal US. Fluoroscopic Voiding Cystourethrography There is controversy regarding whether all children with antenatal hydronephrosis should undergo VCUG. A meta- analysis by the American Urology Association found that, on average, approximately 16% of neonates and infants with antenatal hydronephrosis will have VUR.

Antenatal Hydronephrosis Infant. Voiding Urosonography Multiple recent investigations evaluating real-time contrast-enhanced US techniques have demonstrated a high degree of diagnostic accuracy, and some demonstrated increased sensitivity as compared to fluoroscopic VCUG in the detection of VUR [41-45]. The main potential disadvantage of voiding urosonography is a lower anatomical detail of the bladder and urethra, and therefore it should not be used as the first study for male patients. Therefore, arguments for and against using voiding urosonography are similar to that of VCUG with the exception of male patients. Nuclear Medicine Cystography Some studies have suggested equal sensitivity for Tc-99m pertechnetate radionuclide cystography and VCUG [46], whereas others have indicated that radionuclide cystography has improved sensitivity for VUR in infants up to 1 year of age [47]. The main disadvantage of radionuclide cystography is that it does not provide anatomical details of the bladder and urethra and therefore should not be used as the first study for male patients. Therefore, arguments for and against using radionuclide cystography are similar to that of VCUG with the exception of male patients. DTPA Renal Scan There is no relevant literature to support the routine use of Tc-99m DTPA renal scan in the setting of a normal neonatal US. MAG3 Renal Scan There is no relevant literature to support the routine use of Tc-99m MAG3 diuretic renal scan in the setting of a normal neonatal US. MRI Abdomen and Pelvis There is no relevant literature to support the routine use of MRU in the in the setting of a normal neonatal US. Fluoroscopic Voiding Cystourethrography There is controversy regarding whether all children with antenatal hydronephrosis should undergo VCUG. A meta- analysis by the American Urology Association found that, on average, approximately 16% of neonates and infants with antenatal hydronephrosis will have VUR.

3102388

acrac_3102388_6

Antenatal Hydronephrosis Infant

The incidence of VUR was independent of degree of antenatal hydronephrosis, and a quarter of these were found to have no hydronephrosis on postnatal US [31]. There is disagreement over whether this VUR is clinically significant and therefore over the need for diagnosis. Some authors advocate VCUG for all infants with antenatal hydronephrosis, to guide treatment with prophylactic antibiotics [20,27,32,33]. However, currently, most authors (including the 2010 SFU consensus statement) recommend against routine VCUG for antenatal hydronephrosis [2,12,29,34,35]. This is largely because the benefit of prophylactic antibiotic in children with UTI has not been clearly demonstrated [36]. The efficacy of prophylactic antibiotics in preventing UTIs or renal damage in patients with antenatal hydronephrosis, with or without VUR, is difficult to determine because of variability in methods and results [39]. In addition, most of the VUR spontaneously resolves [40]. One of the potential risks of VCUG is iatrogenic UTI. This was reported in about 2% of VCUG studies performed for evaluation of antenatal hydronephrosis [39]. Voiding Urosonography Multiple recent investigations evaluating real-time contrast-enhanced US techniques have demonstrated a high degree of diagnostic accuracy, and some demonstrated increased sensitivity as compared to fluoroscopic VCUG in the detection of VUR [41-45]. The main potential disadvantage of voiding urosonography is a lower anatomical detail of the bladder and urethra, and therefore it should not be used as the first study for male patients. Therefore, arguments for and against using voiding urosonography are similar to that of VCUG with the exception of male patients. Nuclear Medicine Cystography Some studies have suggested equal sensitivity for Tc-99m pertechnetate radionuclide cystography and VCUG [46], whereas others have indicated that radionuclide cystography has improved sensitivity for VUR in infants up to 1 year of age [47].

Antenatal Hydronephrosis Infant. The incidence of VUR was independent of degree of antenatal hydronephrosis, and a quarter of these were found to have no hydronephrosis on postnatal US [31]. There is disagreement over whether this VUR is clinically significant and therefore over the need for diagnosis. Some authors advocate VCUG for all infants with antenatal hydronephrosis, to guide treatment with prophylactic antibiotics [20,27,32,33]. However, currently, most authors (including the 2010 SFU consensus statement) recommend against routine VCUG for antenatal hydronephrosis [2,12,29,34,35]. This is largely because the benefit of prophylactic antibiotic in children with UTI has not been clearly demonstrated [36]. The efficacy of prophylactic antibiotics in preventing UTIs or renal damage in patients with antenatal hydronephrosis, with or without VUR, is difficult to determine because of variability in methods and results [39]. In addition, most of the VUR spontaneously resolves [40]. One of the potential risks of VCUG is iatrogenic UTI. This was reported in about 2% of VCUG studies performed for evaluation of antenatal hydronephrosis [39]. Voiding Urosonography Multiple recent investigations evaluating real-time contrast-enhanced US techniques have demonstrated a high degree of diagnostic accuracy, and some demonstrated increased sensitivity as compared to fluoroscopic VCUG in the detection of VUR [41-45]. The main potential disadvantage of voiding urosonography is a lower anatomical detail of the bladder and urethra, and therefore it should not be used as the first study for male patients. Therefore, arguments for and against using voiding urosonography are similar to that of VCUG with the exception of male patients. Nuclear Medicine Cystography Some studies have suggested equal sensitivity for Tc-99m pertechnetate radionuclide cystography and VCUG [46], whereas others have indicated that radionuclide cystography has improved sensitivity for VUR in infants up to 1 year of age [47].

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Antenatal Hydronephrosis Infant

The main disadvantage of radionuclide cystography is that it does not provide anatomical details of the bladder and urethra and therefore should not be used as the first study for male patients. Therefore, arguments for and against using radionuclide cystography are similar to that of VCUG with the exception of male patients. DTPA Renal Scan There is no relevant literature to support the routine use of Tc-99m DTPA renal scan as the first imaging in the evaluation of mild antenatal hydronephrosis, because there is low risk of underlying anatomic abnormality such as UPJO in the setting of mild hydronephrosis. MAG3 Renal Scan There is no relevant literature to support the routine use of Tc-99m MAG3 diuretic renal scan as the first imaging in the evaluation of mild antenatal hydronephrosis, because there is low risk of underlying anatomic abnormality such as UPJO in the setting of mild hydronephrosis. MRI abdomen and pelvis There is no relevant literature to support the routine use of MRU in the initial evaluation of mild antenatal hydronephrosis. VUR can be either primary or secondary to other urologic abnormalities. In male patients with moderate or severe hydronephrosis found on neonatal US, VCUG has a role in the evaluation of urologic abnormalities that may need immediate care, and bladder outlet obstruction from PUV must be excluded [12,20,28,29,50,57]. The catheter placed for initial bladder decompression can be used for this study. There is no need to remove the bladder catheter to assess for PUV [58]. Frequently, the study will show VUR in addition to bladder wall thickening and the dilated posterior urethra. When the diagnosis of PUV is made, immediate referral to urology is needed. Furthermore, it can reveal other anomalies such as a duplex collecting system, which helps to determine whether the reflux is primary or secondary. Other infants with severe or bilateral moderate antenatal hydronephrosis may have VUR in isolation.

Antenatal Hydronephrosis Infant. The main disadvantage of radionuclide cystography is that it does not provide anatomical details of the bladder and urethra and therefore should not be used as the first study for male patients. Therefore, arguments for and against using radionuclide cystography are similar to that of VCUG with the exception of male patients. DTPA Renal Scan There is no relevant literature to support the routine use of Tc-99m DTPA renal scan as the first imaging in the evaluation of mild antenatal hydronephrosis, because there is low risk of underlying anatomic abnormality such as UPJO in the setting of mild hydronephrosis. MAG3 Renal Scan There is no relevant literature to support the routine use of Tc-99m MAG3 diuretic renal scan as the first imaging in the evaluation of mild antenatal hydronephrosis, because there is low risk of underlying anatomic abnormality such as UPJO in the setting of mild hydronephrosis. MRI abdomen and pelvis There is no relevant literature to support the routine use of MRU in the initial evaluation of mild antenatal hydronephrosis. VUR can be either primary or secondary to other urologic abnormalities. In male patients with moderate or severe hydronephrosis found on neonatal US, VCUG has a role in the evaluation of urologic abnormalities that may need immediate care, and bladder outlet obstruction from PUV must be excluded [12,20,28,29,50,57]. The catheter placed for initial bladder decompression can be used for this study. There is no need to remove the bladder catheter to assess for PUV [58]. Frequently, the study will show VUR in addition to bladder wall thickening and the dilated posterior urethra. When the diagnosis of PUV is made, immediate referral to urology is needed. Furthermore, it can reveal other anomalies such as a duplex collecting system, which helps to determine whether the reflux is primary or secondary. Other infants with severe or bilateral moderate antenatal hydronephrosis may have VUR in isolation.

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acrac_3102388_8

Antenatal Hydronephrosis Infant

There is higher risk for UTI in children with VUR [59]. Although the benefit of prophylactic antibiotics in this population is unknown, some authors recommend beginning antibiotics on these patients [26,60]. Voiding Urosonography Multiple recent investigations evaluating real-time contrast-enhanced US techniques have demonstrated a high degree of diagnostic accuracy, and some demonstrated increased sensitivity compared to fluoroscopic VCUG in the detection of VUR [41-45]. However, given the significant disadvantage of voiding urosonography in providing lower anatomical detail of the bladder and urethra, it should not be used as the first study for male patients. Nuclear Medicine Cystography Although some studies have suggested equal sensitivity for Tc-99m pertechnetate radionuclide cystography and VCUG [46], it does not provide sufficient anatomical detail of the bladder and urethra and therefore should not be used as the first study for male patients. DTPA Renal Scan Tc-99m DTPA is excreted primarily by glomerular filtration. Its extraction fraction is approximately 20% accounting for greater background, versus renal, activity compared to MAG3 [61]. Tc-99m DTPA renal scan provides information on renal function and urinary tract drainage based on split renal function and renal washout curves and can be useful for the evaluation of severe grade 3 and 4 hydronephrosis in concert with VCUG [20,29,53,62,63]. Given the lower glomerular filtration rate in newborns, these examinations are frequently delayed until at least 2 months of age [29,63-65]. However, because of its rapid renal clearance and primary excretion by the tubules on which furosemide acts, Tc-99m MAG3 is preferred over Tc-99m DTPA in patients with suspected obstruction or impaired renal function [61]. MAG3 Renal Scan Tc-99m MAG3 is primarily excreted through active renal tubular transport, and its extraction fraction is 40% to 50% [61].

Antenatal Hydronephrosis Infant. There is higher risk for UTI in children with VUR [59]. Although the benefit of prophylactic antibiotics in this population is unknown, some authors recommend beginning antibiotics on these patients [26,60]. Voiding Urosonography Multiple recent investigations evaluating real-time contrast-enhanced US techniques have demonstrated a high degree of diagnostic accuracy, and some demonstrated increased sensitivity compared to fluoroscopic VCUG in the detection of VUR [41-45]. However, given the significant disadvantage of voiding urosonography in providing lower anatomical detail of the bladder and urethra, it should not be used as the first study for male patients. Nuclear Medicine Cystography Although some studies have suggested equal sensitivity for Tc-99m pertechnetate radionuclide cystography and VCUG [46], it does not provide sufficient anatomical detail of the bladder and urethra and therefore should not be used as the first study for male patients. DTPA Renal Scan Tc-99m DTPA is excreted primarily by glomerular filtration. Its extraction fraction is approximately 20% accounting for greater background, versus renal, activity compared to MAG3 [61]. Tc-99m DTPA renal scan provides information on renal function and urinary tract drainage based on split renal function and renal washout curves and can be useful for the evaluation of severe grade 3 and 4 hydronephrosis in concert with VCUG [20,29,53,62,63]. Given the lower glomerular filtration rate in newborns, these examinations are frequently delayed until at least 2 months of age [29,63-65]. However, because of its rapid renal clearance and primary excretion by the tubules on which furosemide acts, Tc-99m MAG3 is preferred over Tc-99m DTPA in patients with suspected obstruction or impaired renal function [61]. MAG3 Renal Scan Tc-99m MAG3 is primarily excreted through active renal tubular transport, and its extraction fraction is 40% to 50% [61].

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acrac_3102388_9

Antenatal Hydronephrosis Infant

This greater extraction fraction, versus DTPA, accounts for less background, versus renal, activity compared to DTPA. Because of its rapid renal clearance and primary excretion by the tubules on which furosemide acts, Tc-99m MAG3 is preferred over Tc-99m DTPA in patients with suspected obstruction or impaired renal function [61]. Tc-99m MAG3 renal scan is useful for the evaluation of severe grade 3 and 4 hydronephrosis and may be performed in concert with a VCUG study [20,29,53,62,63]. Tc-99m MAG3 renal scan provides information on renal function and urinary tract drainage based on split renal function [61]. Diuretic renal scan is used for diagnosis of multiple causes of obstruction, including primary obstructing megaureter [52,66-68]. Approximately 5% to 10% of antenatal hydronephrosis is attributable to primary megaureter [4,69] diagnosed by persistent ureteral dilation (>7 mm). Primary megaureter is classified according to the presence or absence of reflux and obstruction. Most will resolve spontaneously [20,70-72]. Surgical intervention is decided based on evidence of obstruction and depends upon T1/2 of time activity curve (T1/2 >20 minutes), decreased renal function (<40% differential renal function), deteriorating function (>5% change on consecutive renal scans), or worsening drainage on serial imaging. Tc-99m MAG3 renal scan can be used to monitor function over time, with a decrease in differential renal function on the affected side often serving as an indicator of a need for intervention [55,73]. MRI Abdomen and Pelvis There is no consensus on the role of MRU, performed without and with intravenous (IV) contrast, in patients with moderate to severe postnatal hydronephrosis especially before VCUG is performed.

Antenatal Hydronephrosis Infant. This greater extraction fraction, versus DTPA, accounts for less background, versus renal, activity compared to DTPA. Because of its rapid renal clearance and primary excretion by the tubules on which furosemide acts, Tc-99m MAG3 is preferred over Tc-99m DTPA in patients with suspected obstruction or impaired renal function [61]. Tc-99m MAG3 renal scan is useful for the evaluation of severe grade 3 and 4 hydronephrosis and may be performed in concert with a VCUG study [20,29,53,62,63]. Tc-99m MAG3 renal scan provides information on renal function and urinary tract drainage based on split renal function [61]. Diuretic renal scan is used for diagnosis of multiple causes of obstruction, including primary obstructing megaureter [52,66-68]. Approximately 5% to 10% of antenatal hydronephrosis is attributable to primary megaureter [4,69] diagnosed by persistent ureteral dilation (>7 mm). Primary megaureter is classified according to the presence or absence of reflux and obstruction. Most will resolve spontaneously [20,70-72]. Surgical intervention is decided based on evidence of obstruction and depends upon T1/2 of time activity curve (T1/2 >20 minutes), decreased renal function (<40% differential renal function), deteriorating function (>5% change on consecutive renal scans), or worsening drainage on serial imaging. Tc-99m MAG3 renal scan can be used to monitor function over time, with a decrease in differential renal function on the affected side often serving as an indicator of a need for intervention [55,73]. MRI Abdomen and Pelvis There is no consensus on the role of MRU, performed without and with intravenous (IV) contrast, in patients with moderate to severe postnatal hydronephrosis especially before VCUG is performed.

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acrac_3102388_10

Antenatal Hydronephrosis Infant

Although MRU is not routinely recommended in the initial workup of antenatal hydronephrosis, some authors have argued that it can add value through improved anatomical imaging, for example, in the evaluation of hydronephrosis in the setting of atypical urinary tract anatomy, such as certain duplicated collecting systems or renal dysgenesis [74]. MRU can also adequately assess degree of obstruction [75]. One potential limitation of MRU is that there are systematic differences in estimation of split renal function compared with the gold standard MAG-3 renal scan in kidneys with severely diminished renal function [75] and kidneys with severe hydronephrosis [76]. VUR can be either primary or secondary to other urologic abnormalities. In patients with moderate or severe hydronephrosis found on neonatal US, VCUG has a role in the evaluation of urologic abnormalities that may need immediate care [12,20,28,29,50,57]. Furthermore, it can reveal other anomalies, such as a duplex collecting system, which help to determine whether the reflux is primary or secondary. Other infants with severe or bilateral moderate antenatal hydronephrosis may have VUR in isolation. There is higher risk for UTI in children with VUR [59]. Although the benefit of prophylactic antibiotics in this population is unknown, some authors recommend beginning antibiotics on these patients [26,60]. Nuclear Medicine Cystography Some studies have suggested equal sensitivity for Tc-99m pertechnetate radionuclide cystography and VCUG [46], whereas others have indicated that radionuclide cystography has improved sensitivity for VUR in infants up to 1 year of age [47]. Arguments for and against using radionuclide cystography are similar to that of VCUG for the female patient. DTPA Renal Scan Tc-99m DTPA is excreted primarily by glomerular filtration. Its extraction fraction is approximately 20% accounting for greater background, versus renal, activity compared to MAG3 [61].

Antenatal Hydronephrosis Infant. Although MRU is not routinely recommended in the initial workup of antenatal hydronephrosis, some authors have argued that it can add value through improved anatomical imaging, for example, in the evaluation of hydronephrosis in the setting of atypical urinary tract anatomy, such as certain duplicated collecting systems or renal dysgenesis [74]. MRU can also adequately assess degree of obstruction [75]. One potential limitation of MRU is that there are systematic differences in estimation of split renal function compared with the gold standard MAG-3 renal scan in kidneys with severely diminished renal function [75] and kidneys with severe hydronephrosis [76]. VUR can be either primary or secondary to other urologic abnormalities. In patients with moderate or severe hydronephrosis found on neonatal US, VCUG has a role in the evaluation of urologic abnormalities that may need immediate care [12,20,28,29,50,57]. Furthermore, it can reveal other anomalies, such as a duplex collecting system, which help to determine whether the reflux is primary or secondary. Other infants with severe or bilateral moderate antenatal hydronephrosis may have VUR in isolation. There is higher risk for UTI in children with VUR [59]. Although the benefit of prophylactic antibiotics in this population is unknown, some authors recommend beginning antibiotics on these patients [26,60]. Nuclear Medicine Cystography Some studies have suggested equal sensitivity for Tc-99m pertechnetate radionuclide cystography and VCUG [46], whereas others have indicated that radionuclide cystography has improved sensitivity for VUR in infants up to 1 year of age [47]. Arguments for and against using radionuclide cystography are similar to that of VCUG for the female patient. DTPA Renal Scan Tc-99m DTPA is excreted primarily by glomerular filtration. Its extraction fraction is approximately 20% accounting for greater background, versus renal, activity compared to MAG3 [61].

3102388

acrac_3102388_11

Antenatal Hydronephrosis Infant

Tc-99m DTPA renal scan provides information on renal function and urinary tract drainage based on split renal function and renal washout curves and can be useful for the evaluation of severe grade 3 and 4 hydronephrosis in concert with VCUG [20,29,53,62,63]. Given the lower glomerular filtration rate in newborns, these examinations are frequently delayed until at least 2 months of age [29,63-65]. However, because of its rapid renal clearance and primary excretion by the tubules on which furosemide acts, Tc-99m MAG3 is preferred over Tc-99m DTPA in patients with suspected obstruction or impaired renal function [61]. MAG3 Renal Scan Tc-99m MAG3 is primarily excreted through active renal tubular transport, and its extraction fraction is 40% to 50% [61]. This greater extraction fraction, versus DTPA, accounts for less background, versus renal, activity compared to DTPA. Because of its rapid renal clearance and primary excretion by the tubules on which furosemide acts, Tc-99m MAG3 is preferred over Tc-99m DTPA in patients with suspected obstruction or impaired renal function [61]. Tc-99m MAG3 renal scan is useful for the evaluation of severe grade 3 and 4 hydronephrosis and may be performed in concert with a VCUG study [20,29,53,62,63]. Tc-99m MAG3 renal scan provides information on renal function and urinary tract drainage based on split renal function [61]. Diuretic renal scan is used for diagnosis of multiple causes of obstruction, including primary obstructing megaureter [52,66-68]. Approximately 5% to 10% of antenatal hydronephrosis is attributable to primary megaureter [4,69] diagnosed by persistent ureteral dilation (>7 mm). Primary megaureter is classified according to the presence or absence of reflux and obstruction. Most will resolve spontaneously [20,70-72].

Antenatal Hydronephrosis Infant. Tc-99m DTPA renal scan provides information on renal function and urinary tract drainage based on split renal function and renal washout curves and can be useful for the evaluation of severe grade 3 and 4 hydronephrosis in concert with VCUG [20,29,53,62,63]. Given the lower glomerular filtration rate in newborns, these examinations are frequently delayed until at least 2 months of age [29,63-65]. However, because of its rapid renal clearance and primary excretion by the tubules on which furosemide acts, Tc-99m MAG3 is preferred over Tc-99m DTPA in patients with suspected obstruction or impaired renal function [61]. MAG3 Renal Scan Tc-99m MAG3 is primarily excreted through active renal tubular transport, and its extraction fraction is 40% to 50% [61]. This greater extraction fraction, versus DTPA, accounts for less background, versus renal, activity compared to DTPA. Because of its rapid renal clearance and primary excretion by the tubules on which furosemide acts, Tc-99m MAG3 is preferred over Tc-99m DTPA in patients with suspected obstruction or impaired renal function [61]. Tc-99m MAG3 renal scan is useful for the evaluation of severe grade 3 and 4 hydronephrosis and may be performed in concert with a VCUG study [20,29,53,62,63]. Tc-99m MAG3 renal scan provides information on renal function and urinary tract drainage based on split renal function [61]. Diuretic renal scan is used for diagnosis of multiple causes of obstruction, including primary obstructing megaureter [52,66-68]. Approximately 5% to 10% of antenatal hydronephrosis is attributable to primary megaureter [4,69] diagnosed by persistent ureteral dilation (>7 mm). Primary megaureter is classified according to the presence or absence of reflux and obstruction. Most will resolve spontaneously [20,70-72].

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acrac_3102388_12

Antenatal Hydronephrosis Infant

Surgical intervention is decided based on evidence of obstruction and depends upon T1/2 of time activity curve (T1/2 >20 minutes), decreased renal function (<40% differential renal function), deteriorating function (>5% change on consecutive renal scans), or worsening drainage on serial imaging. Tc-99m MAG3 renal scan can be used to monitor function over time, with a decrease in differential renal function on the affected side often serving as an indicator of a need for intervention [55,73]. MRI Abdomen and Pelvis There is no consensus on the role of MRU, performed without and with IV contrast, in patients with moderate to severe postnatal hydronephrosis especially before VCUG is performed. Although MRU is not routinely recommended in the initial workup of antenatal hydronephrosis, some authors have argued that it can add value through improved anatomical imaging, for example, in the evaluation of hydronephrosis in the setting of atypical urinary tract anatomy, such as certain duplicated collecting systems or renal dysgenesis [74]. MRU can also adequately assess degree of obstruction [75]. One potential limitation of MRU is inaccurate estimation of split renal function compared with renal scan in kidneys with severely diminished renal function [75] and kidneys with severe hydronephrosis [76]. should be considered [6,29,53,77]. Of the causes of hydronephrosis, UPJO accounts for approximately 10% to 65% of cases and in 90% of cases the obstruction is unilateral [2,4,22,48]. As the severity of hydronephrosis increases, the risk of UPJO also increases, and as much as 35% of significant hydronephrosis (>10 mm APRPD postnatally) was attributable to UPJO in one study. Lee et al [51] showed a 54% risk of UPJO in severe (>15 mm APRPD postnatally) urinary tract dilation. Even in the setting of abnormal findings on initial neonatal US, further follow- up US between 1 and 6 months may be useful to re-evaluate a dilated urinary tract after bladder catheterization [1,21,23,53-55].

Antenatal Hydronephrosis Infant. Surgical intervention is decided based on evidence of obstruction and depends upon T1/2 of time activity curve (T1/2 >20 minutes), decreased renal function (<40% differential renal function), deteriorating function (>5% change on consecutive renal scans), or worsening drainage on serial imaging. Tc-99m MAG3 renal scan can be used to monitor function over time, with a decrease in differential renal function on the affected side often serving as an indicator of a need for intervention [55,73]. MRI Abdomen and Pelvis There is no consensus on the role of MRU, performed without and with IV contrast, in patients with moderate to severe postnatal hydronephrosis especially before VCUG is performed. Although MRU is not routinely recommended in the initial workup of antenatal hydronephrosis, some authors have argued that it can add value through improved anatomical imaging, for example, in the evaluation of hydronephrosis in the setting of atypical urinary tract anatomy, such as certain duplicated collecting systems or renal dysgenesis [74]. MRU can also adequately assess degree of obstruction [75]. One potential limitation of MRU is inaccurate estimation of split renal function compared with renal scan in kidneys with severely diminished renal function [75] and kidneys with severe hydronephrosis [76]. should be considered [6,29,53,77]. Of the causes of hydronephrosis, UPJO accounts for approximately 10% to 65% of cases and in 90% of cases the obstruction is unilateral [2,4,22,48]. As the severity of hydronephrosis increases, the risk of UPJO also increases, and as much as 35% of significant hydronephrosis (>10 mm APRPD postnatally) was attributable to UPJO in one study. Lee et al [51] showed a 54% risk of UPJO in severe (>15 mm APRPD postnatally) urinary tract dilation. Even in the setting of abnormal findings on initial neonatal US, further follow- up US between 1 and 6 months may be useful to re-evaluate a dilated urinary tract after bladder catheterization [1,21,23,53-55].

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acrac_3102388_13

Antenatal Hydronephrosis Infant

DTPA Renal Scan Tc-99m DTPA is excreted primarily by glomerular filtration. Its extraction fraction is approximately 20% accounting for greater background, versus renal, activity compared to MAG3 [61]. Tc-99m DTPA renal scan provides information on renal function and urinary tract drainage based on split renal function and renal washout curves and can be useful for the evaluation of severe grade 3 and 4 hydronephrosis [20,29,53,62,63]. Given the lower glomerular filtration rate in newborns, these examinations are frequently delayed until at least 2 months of age [29,63-65]. However, because of its rapid renal clearance and primary excretion by the tubules on which furosemide acts, Tc-99m MAG3 is preferred over Tc-99m DTPA in patients with suspected obstruction or impaired renal function [61]. MAG3 Renal Scan Tc-99m MAG3 is primarily excreted through active renal tubular transport, and its extraction fraction is 40% to 50%. This greater extraction fraction, versus DTPA, accounts for less background, versus renal, activity compared to DTPA. Because of its rapid renal clearance and primary excretion by the tubules on which furosemide acts, Tc- 99m MAG3 is preferred over Tc-99m DTPA in patient with suspected obstruction or impaired renal function [61]. Tc-99m MAG3 renal scan provides information on split renal function and urinary tract drainage based on renal washout curve [3,22,27,28]. Diuretic renal scan is used for diagnosis of multiple causes of obstruction, including primary obstructing megaureter [52,66-68]. Approximately 5% to 10% of antenatal hydronephrosis is attributable to primary megaureter [4,69] diagnosed by persistent ureteral dilation (>7 mm). Primary megaureter is classified according to the presence or absence of reflux and obstruction. Most will resolve spontaneously [20,70-72].

Antenatal Hydronephrosis Infant. DTPA Renal Scan Tc-99m DTPA is excreted primarily by glomerular filtration. Its extraction fraction is approximately 20% accounting for greater background, versus renal, activity compared to MAG3 [61]. Tc-99m DTPA renal scan provides information on renal function and urinary tract drainage based on split renal function and renal washout curves and can be useful for the evaluation of severe grade 3 and 4 hydronephrosis [20,29,53,62,63]. Given the lower glomerular filtration rate in newborns, these examinations are frequently delayed until at least 2 months of age [29,63-65]. However, because of its rapid renal clearance and primary excretion by the tubules on which furosemide acts, Tc-99m MAG3 is preferred over Tc-99m DTPA in patients with suspected obstruction or impaired renal function [61]. MAG3 Renal Scan Tc-99m MAG3 is primarily excreted through active renal tubular transport, and its extraction fraction is 40% to 50%. This greater extraction fraction, versus DTPA, accounts for less background, versus renal, activity compared to DTPA. Because of its rapid renal clearance and primary excretion by the tubules on which furosemide acts, Tc- 99m MAG3 is preferred over Tc-99m DTPA in patient with suspected obstruction or impaired renal function [61]. Tc-99m MAG3 renal scan provides information on split renal function and urinary tract drainage based on renal washout curve [3,22,27,28]. Diuretic renal scan is used for diagnosis of multiple causes of obstruction, including primary obstructing megaureter [52,66-68]. Approximately 5% to 10% of antenatal hydronephrosis is attributable to primary megaureter [4,69] diagnosed by persistent ureteral dilation (>7 mm). Primary megaureter is classified according to the presence or absence of reflux and obstruction. Most will resolve spontaneously [20,70-72].

3102388

acrac_3102388_14

Antenatal Hydronephrosis Infant

Surgical intervention is decided based on evidence of obstruction based on T1/2 of time activity curve (T1/2 >20 minutes), decreased renal function (<40% differential renal function), deteriorating function (>5% change on consecutive renal scans), or worsening drainage on serial imaging [55,73]. Tc-99m MAG3 renal scan can be used to monitor function over time, with a decrease in differential renal function on the affected side often serving as an indicator of a need for intervention [55,73]. MRI Abdomen and Pelvis There is no consensus on the role of MRU, performed without and with IV contrast, in patients with moderate to severe postnatal hydronephrosis. Although MRU is not routinely recommended in the initial workup of antenatal hydronephrosis, some authors have argued that it can add value through improved anatomical imaging, for example, in the evaluation of hydronephrosis in the setting of atypical urinary tract anatomy, such as certain duplicated collecting systems or renal dysgenesis [74]. MRU can also adequately assess degree of obstruction [75]. One potential limitation of MRU is that there are systematic differences in estimation of split renal function compared with renal scan in kidneys with severely diminished renal function and kidneys with severe hydronephrosis [76]. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www. acr.org/ac. Appropriateness Category Names and Definitions Relative Radiation Level Information Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure.

Antenatal Hydronephrosis Infant. Surgical intervention is decided based on evidence of obstruction based on T1/2 of time activity curve (T1/2 >20 minutes), decreased renal function (<40% differential renal function), deteriorating function (>5% change on consecutive renal scans), or worsening drainage on serial imaging [55,73]. Tc-99m MAG3 renal scan can be used to monitor function over time, with a decrease in differential renal function on the affected side often serving as an indicator of a need for intervention [55,73]. MRI Abdomen and Pelvis There is no consensus on the role of MRU, performed without and with IV contrast, in patients with moderate to severe postnatal hydronephrosis. Although MRU is not routinely recommended in the initial workup of antenatal hydronephrosis, some authors have argued that it can add value through improved anatomical imaging, for example, in the evaluation of hydronephrosis in the setting of atypical urinary tract anatomy, such as certain duplicated collecting systems or renal dysgenesis [74]. MRU can also adequately assess degree of obstruction [75]. One potential limitation of MRU is that there are systematic differences in estimation of split renal function compared with renal scan in kidneys with severely diminished renal function and kidneys with severe hydronephrosis [76]. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www. acr.org/ac. Appropriateness Category Names and Definitions Relative Radiation Level Information Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure.

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acrac_3099312_0

Evaluation of Nipple Discharge

Special Imaging Considerations In 2018, Schulz-Wendtland et al [25] first described a technique combining digital breast tomosynthesis (DBT) and ductography and evaluated 5 women with pathologic nipple discharge. They found that DBT-ductography performed comparably to high-resolution ultrasound (US) in identifying suspicious imaging lesions. In 2020 Moschetta et al [26] used this nascent technique on 49 consecutive patients with spontaneous, unilateral, single- pore discharge and inconclusive conventional digital mammography and US. In this series, they compared DBT- Reprint requests to: [email protected] Evaluation of Nipple Discharge ductography with conventional full-field galactography and found improved sensitivity (95% versus 77%) and accuracy (96% versus 80%) with identical specificity (80%). OR Discussion of Procedures by Variant Variant 1: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Physiologic nipple discharge. Initial imaging. Physiologic nipple discharge is defined as bilateral, originating from multiple ducts, white/green/yellow in color, or milky in appearance [27]. It tends to occur only when provoked [8]. Many studies have shown physiologic nipple discharge to be benign, with no association within situ or invasive carcinoma [9,28,29]. Mammography Diagnostic If patient history and physical examination demonstrate physiologic nipple discharge and routine screening mammography is up to date, no further radiologic investigation is needed [28,29]. Digital Breast Tomosynthesis Diagnostic If patient history and physical examination demonstrate physiologic nipple discharge and routine screening mammography is up to date, no further radiologic investigation is needed [28,29]. US Breast If patient history and physical examination demonstrate physiologic nipple discharge and routine screening mammography is up to date, no further radiologic investigation is needed [28,29].

Evaluation of Nipple Discharge. Special Imaging Considerations In 2018, Schulz-Wendtland et al [25] first described a technique combining digital breast tomosynthesis (DBT) and ductography and evaluated 5 women with pathologic nipple discharge. They found that DBT-ductography performed comparably to high-resolution ultrasound (US) in identifying suspicious imaging lesions. In 2020 Moschetta et al [26] used this nascent technique on 49 consecutive patients with spontaneous, unilateral, single- pore discharge and inconclusive conventional digital mammography and US. In this series, they compared DBT- Reprint requests to: [email protected] Evaluation of Nipple Discharge ductography with conventional full-field galactography and found improved sensitivity (95% versus 77%) and accuracy (96% versus 80%) with identical specificity (80%). OR Discussion of Procedures by Variant Variant 1: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Physiologic nipple discharge. Initial imaging. Physiologic nipple discharge is defined as bilateral, originating from multiple ducts, white/green/yellow in color, or milky in appearance [27]. It tends to occur only when provoked [8]. Many studies have shown physiologic nipple discharge to be benign, with no association within situ or invasive carcinoma [9,28,29]. Mammography Diagnostic If patient history and physical examination demonstrate physiologic nipple discharge and routine screening mammography is up to date, no further radiologic investigation is needed [28,29]. Digital Breast Tomosynthesis Diagnostic If patient history and physical examination demonstrate physiologic nipple discharge and routine screening mammography is up to date, no further radiologic investigation is needed [28,29]. US Breast If patient history and physical examination demonstrate physiologic nipple discharge and routine screening mammography is up to date, no further radiologic investigation is needed [28,29].

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Ductography If patient history and physical examination demonstrate physiologic nipple discharge and routine screening mammography is up to date, no further radiologic investigation is needed [28,29]. MRI Breast If patient history and physical examination demonstrate physiologic nipple discharge and routine screening mammography is up to date, no further radiologic investigation is needed [28,29]. FDG-PET Breast Dedicated If patient history and physical examination demonstrate physiologic nipple discharge and routine screening mammography is up to date, no further radiologic investigation is needed [28,29]. Image-guided Core Biopsy Breast Image-guided core biopsy is not required for the evaluation of physiologic nipple discharge in the female patient. Image-Guided Fine Needle Aspiration Breast Image-guided fine-needle aspiration (FNA) is not required for the evaluation of physiologic nipple discharge in the female patient. Sestamibi MBI If patient history and physical examination demonstrate physiologic nipple discharge and routine screening mammography is up to date, no further radiologic investigation is needed [28,29]. Evaluation of Nipple Discharge Variant 2: Adult male or female 40 years of age or older. Pathologic nipple discharge. Initial imaging. Mammography Diagnostic Mammography is the first-line imaging modality for evaluation of pathologic nipple discharge in male and female patients in this age group [30]. Although 3% to 29% of pathologic nipple discharge is due to an underlying breast cancer, full-field mammography often does not demonstrate these lesions because they may be very small, contain no calcifications, or are completely intraductal [1-3]. To better evaluate the subareolar breast in patients with an asymmetry/focal asymmetry or suspicious microcalcifications, additional mammographic views with spot compression and magnification may be needed [31]. Most cases of pathologic nipple discharge are due to a benign intraductal papilloma [32].

Evaluation of Nipple Discharge. Ductography If patient history and physical examination demonstrate physiologic nipple discharge and routine screening mammography is up to date, no further radiologic investigation is needed [28,29]. MRI Breast If patient history and physical examination demonstrate physiologic nipple discharge and routine screening mammography is up to date, no further radiologic investigation is needed [28,29]. FDG-PET Breast Dedicated If patient history and physical examination demonstrate physiologic nipple discharge and routine screening mammography is up to date, no further radiologic investigation is needed [28,29]. Image-guided Core Biopsy Breast Image-guided core biopsy is not required for the evaluation of physiologic nipple discharge in the female patient. Image-Guided Fine Needle Aspiration Breast Image-guided fine-needle aspiration (FNA) is not required for the evaluation of physiologic nipple discharge in the female patient. Sestamibi MBI If patient history and physical examination demonstrate physiologic nipple discharge and routine screening mammography is up to date, no further radiologic investigation is needed [28,29]. Evaluation of Nipple Discharge Variant 2: Adult male or female 40 years of age or older. Pathologic nipple discharge. Initial imaging. Mammography Diagnostic Mammography is the first-line imaging modality for evaluation of pathologic nipple discharge in male and female patients in this age group [30]. Although 3% to 29% of pathologic nipple discharge is due to an underlying breast cancer, full-field mammography often does not demonstrate these lesions because they may be very small, contain no calcifications, or are completely intraductal [1-3]. To better evaluate the subareolar breast in patients with an asymmetry/focal asymmetry or suspicious microcalcifications, additional mammographic views with spot compression and magnification may be needed [31]. Most cases of pathologic nipple discharge are due to a benign intraductal papilloma [32].

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When visible on mammography, imaging findings of papilloma include asymmetrically dilated ducts, a circumscribed benign- appearing subareolar mass, or grouped microcalcifications [1]. Up to 12% of patients with ductal carcinoma in situ (DCIS) present with nipple discharge [33]. DCIS is usually detected mammographically as fine, linear, discontinuous, and branching microcalcifications in linear, ductal, or segmental distribution and less often as a mass, asymmetry/focal asymmetry, or architectural distortion on mammography [11]. The mammographic features of invasive carcinomas are well known, including a mass of various margin characteristics with or without microcalcifications or an asymmetry, focal asymmetry, or architectural distortion [34]. For detection of malignancy (DCIS and invasive cancer), the reported sensitivity of mammography varies widely between 15% and 68%, with a specificity between 38% and 98% [3,9,23,28]. In one study, the positive predictive value (PPV) was 42%, and the negative predictive value (NPV) was 90% [23]. Malignant and high-risk lesions are identified by mammography with a reported sensitivity of 10% to 26%, specificity of 94% to 95%, PPV of 18%, and NPV of 88% [3,16]. The possible causes of the wide variation in reported sensitivity include differences in imaging technology (digital versus film-screen mammography) and varied breast density among different cohorts of patients. In a study of 106 patients >30 years of age with pathologic nipple discharge, Gray et al [28] showed the risk of carcinoma to be 3% with a negative mammogram and 0% when both mammogram and subareolar US were negative. Although low in sensitivity and PPV, mammography remains useful in the evaluation of pathologic nipple discharge because of its high specificity and high NPV.

Evaluation of Nipple Discharge. When visible on mammography, imaging findings of papilloma include asymmetrically dilated ducts, a circumscribed benign- appearing subareolar mass, or grouped microcalcifications [1]. Up to 12% of patients with ductal carcinoma in situ (DCIS) present with nipple discharge [33]. DCIS is usually detected mammographically as fine, linear, discontinuous, and branching microcalcifications in linear, ductal, or segmental distribution and less often as a mass, asymmetry/focal asymmetry, or architectural distortion on mammography [11]. The mammographic features of invasive carcinomas are well known, including a mass of various margin characteristics with or without microcalcifications or an asymmetry, focal asymmetry, or architectural distortion [34]. For detection of malignancy (DCIS and invasive cancer), the reported sensitivity of mammography varies widely between 15% and 68%, with a specificity between 38% and 98% [3,9,23,28]. In one study, the positive predictive value (PPV) was 42%, and the negative predictive value (NPV) was 90% [23]. Malignant and high-risk lesions are identified by mammography with a reported sensitivity of 10% to 26%, specificity of 94% to 95%, PPV of 18%, and NPV of 88% [3,16]. The possible causes of the wide variation in reported sensitivity include differences in imaging technology (digital versus film-screen mammography) and varied breast density among different cohorts of patients. In a study of 106 patients >30 years of age with pathologic nipple discharge, Gray et al [28] showed the risk of carcinoma to be 3% with a negative mammogram and 0% when both mammogram and subareolar US were negative. Although low in sensitivity and PPV, mammography remains useful in the evaluation of pathologic nipple discharge because of its high specificity and high NPV.

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Digital Breast Tomosynthesis Diagnostic Although there is no relevant literature to support the use of DBT alone in assessing nipple discharge, mammography is useful for evaluating pathologic nipple discharge in male and female patients in this age group [30]. Early studies with DBT demonstrate promise is assessing the symptomatic breast [35,36]. US Breast US is useful in identifying invasive cancer and assessing extent of disease but has a diminished sensitivity for detecting DCIS [9,12,37,38]. In patients with pathologic nipple discharge, US identifies lesions not visible on mammography 63% to 69% of the time [30,39]. US adds specificity for some lesions when compared with mammography if it identifies the mammographic finding as a simple cyst or duct ectasia. US expands on ductography in its ability to visualize and detect abnormalities in multiple rather than single ducts [24]. Although more sensitive than mammography, US suffers from lower specificity in differentiating benign versus malignant lesions [9]. False-positive US results may be due to volume averaging with the ductal wall in a tortuous duct, intraductal and periductal fibrosis, adherent blood clots, or inspissated debris [31]. Previous studies have also reported mammography and US to be unreliable in predicting histology in patients with pathologic nipple discharge, which underscores the necessity of histological diagnosis [17,23]. In male and female patients, US is useful in identifying and assessing lesions and for biopsy guidance [40]. Ductography Ductography may demonstrate small lesions and localize the duct responsible for the nipple discharge. Ductography is minimally invasive, may be uncomfortable, and can be time-consuming. The procedure is technically challenging with 10% to 15% of cases resulting in inadequate or incomplete results [41,42]. The discharge must be present on Evaluation of Nipple Discharge the day of ductography so that a cannula can be placed in the appropriate duct.

Evaluation of Nipple Discharge. Digital Breast Tomosynthesis Diagnostic Although there is no relevant literature to support the use of DBT alone in assessing nipple discharge, mammography is useful for evaluating pathologic nipple discharge in male and female patients in this age group [30]. Early studies with DBT demonstrate promise is assessing the symptomatic breast [35,36]. US Breast US is useful in identifying invasive cancer and assessing extent of disease but has a diminished sensitivity for detecting DCIS [9,12,37,38]. In patients with pathologic nipple discharge, US identifies lesions not visible on mammography 63% to 69% of the time [30,39]. US adds specificity for some lesions when compared with mammography if it identifies the mammographic finding as a simple cyst or duct ectasia. US expands on ductography in its ability to visualize and detect abnormalities in multiple rather than single ducts [24]. Although more sensitive than mammography, US suffers from lower specificity in differentiating benign versus malignant lesions [9]. False-positive US results may be due to volume averaging with the ductal wall in a tortuous duct, intraductal and periductal fibrosis, adherent blood clots, or inspissated debris [31]. Previous studies have also reported mammography and US to be unreliable in predicting histology in patients with pathologic nipple discharge, which underscores the necessity of histological diagnosis [17,23]. In male and female patients, US is useful in identifying and assessing lesions and for biopsy guidance [40]. Ductography Ductography may demonstrate small lesions and localize the duct responsible for the nipple discharge. Ductography is minimally invasive, may be uncomfortable, and can be time-consuming. The procedure is technically challenging with 10% to 15% of cases resulting in inadequate or incomplete results [41,42]. The discharge must be present on Evaluation of Nipple Discharge the day of ductography so that a cannula can be placed in the appropriate duct.

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Failure to cannulate the discharging duct may lead to a false negative [43]. Ductography is not recommended in lactating women or patients with active mastitis. Known hypersensitivity to iodinated contrast agents is a relative contraindication. Findings on ductography suggestive of malignant or papillary lesions include intraductal filling defect, partial or complete obstruction of a duct, duct expansion or distortion, and duct wall irregularity [1]. In patients with pathologic nipple discharge and a negative mammogram and US, Morrogh et al [44] reported the PPV and NPV of ductography for detection of cancer and high-risk lesions to be 19% and 63%, respectively. In the setting of negative standard evaluations, ductography localized 76% of otherwise occult malignant/high-risk lesions and 91% of benign lesions [39]. When the standard evaluation is positive, ductography facilitated preoperative localization of the causative lesion in 78% of cases [39]. For detection of cancer in patients with pathologic nipple discharge, 2 studies showed the sensitivity, specificity, PPV, and NPV of ductography to be 75% to 100%, 6% to 49%, 16% to 18%, and 93% to 100%, respectively [16,23]. For detection of high-risk lesions, Adepoju et al [16] reported the sensitivity, specificity, PPV, and NPV of ductography to be 75%, 53%, 22%, and 92%, respectively. Ductography is more sensitive than mammography and US but has lower specificity than both modalities. A negative ductogram does not reliably exclude an underlying cancer or high-risk lesion, with the false-negative rate reported to be as high as 20% to 30% [44]. As such, the primary value of ductography is to localize intraductal lesions and assist in surgery [45]. A study found that patients who underwent ductography-guided operations or any other surgical procedure with image guidance of the lesion were significantly more likely to have a specific underlying lesion identified than patients who underwent central duct excision alone [23,42].

Evaluation of Nipple Discharge. Failure to cannulate the discharging duct may lead to a false negative [43]. Ductography is not recommended in lactating women or patients with active mastitis. Known hypersensitivity to iodinated contrast agents is a relative contraindication. Findings on ductography suggestive of malignant or papillary lesions include intraductal filling defect, partial or complete obstruction of a duct, duct expansion or distortion, and duct wall irregularity [1]. In patients with pathologic nipple discharge and a negative mammogram and US, Morrogh et al [44] reported the PPV and NPV of ductography for detection of cancer and high-risk lesions to be 19% and 63%, respectively. In the setting of negative standard evaluations, ductography localized 76% of otherwise occult malignant/high-risk lesions and 91% of benign lesions [39]. When the standard evaluation is positive, ductography facilitated preoperative localization of the causative lesion in 78% of cases [39]. For detection of cancer in patients with pathologic nipple discharge, 2 studies showed the sensitivity, specificity, PPV, and NPV of ductography to be 75% to 100%, 6% to 49%, 16% to 18%, and 93% to 100%, respectively [16,23]. For detection of high-risk lesions, Adepoju et al [16] reported the sensitivity, specificity, PPV, and NPV of ductography to be 75%, 53%, 22%, and 92%, respectively. Ductography is more sensitive than mammography and US but has lower specificity than both modalities. A negative ductogram does not reliably exclude an underlying cancer or high-risk lesion, with the false-negative rate reported to be as high as 20% to 30% [44]. As such, the primary value of ductography is to localize intraductal lesions and assist in surgery [45]. A study found that patients who underwent ductography-guided operations or any other surgical procedure with image guidance of the lesion were significantly more likely to have a specific underlying lesion identified than patients who underwent central duct excision alone [23,42].

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Contrast-enhanced breast MRI has high sensitivity for detecting benign papillary lesions as well as in situ and invasive carcinoma [3]. Furthermore, MRI allows identification of index lesions in peripheral ducts that are beyond the area normally encompassed by terminal duct excision, ductography, or targeted US [44]. Index or synchronous lesions found on MRI alone can be percutaneously biopsied with MRI guidance to allow for single-stage definitive surgical management (if malignant) or potentially to avoid unnecessary surgical excision for some benign lesions. In general, MRI may be considered in cases in which mammography and US have failed to identify an underlying cause of pathologic nipple discharge [3,44,48-50]. The sensitivities of breast MRI for detecting the cause of the pathologic nipple discharge are 86% to 100% for invasive cancer and 40% to 100% for noninvasive disease [3,12,44,49,51,52]. Bahl et al [52] reported the sensitivity, specificity, PPV, and NPV of MRI for detecting malignancy in patients with pathologic nipple discharge to be 100%, 68%, 37%, and 100%, respectively. Several studies have shown that MRI has higher sensitivity and specificity than US and ductography for lesion detection and may be an alternative to ductography [12,32,48,49]. However, a study by van Gelder et al [51] asserted that MRI has limited added value in patients with unilateral bloody nipple discharge who showed no signs of a malignancy on conventional diagnostic examinations, because malignancy was demonstrated in <2% of their cases. Despite the high sensitivity of breast MRI, it is not indicated as initial imaging in a patient with pathologic nipple discharge. FDG-PET Breast Dedicated High-resolution cameras specifically designed for breast imaging have improved detection of small and noninvasive carcinomas. However, specific research evaluating women with nipple discharge is lacking [41,53].

Evaluation of Nipple Discharge. Contrast-enhanced breast MRI has high sensitivity for detecting benign papillary lesions as well as in situ and invasive carcinoma [3]. Furthermore, MRI allows identification of index lesions in peripheral ducts that are beyond the area normally encompassed by terminal duct excision, ductography, or targeted US [44]. Index or synchronous lesions found on MRI alone can be percutaneously biopsied with MRI guidance to allow for single-stage definitive surgical management (if malignant) or potentially to avoid unnecessary surgical excision for some benign lesions. In general, MRI may be considered in cases in which mammography and US have failed to identify an underlying cause of pathologic nipple discharge [3,44,48-50]. The sensitivities of breast MRI for detecting the cause of the pathologic nipple discharge are 86% to 100% for invasive cancer and 40% to 100% for noninvasive disease [3,12,44,49,51,52]. Bahl et al [52] reported the sensitivity, specificity, PPV, and NPV of MRI for detecting malignancy in patients with pathologic nipple discharge to be 100%, 68%, 37%, and 100%, respectively. Several studies have shown that MRI has higher sensitivity and specificity than US and ductography for lesion detection and may be an alternative to ductography [12,32,48,49]. However, a study by van Gelder et al [51] asserted that MRI has limited added value in patients with unilateral bloody nipple discharge who showed no signs of a malignancy on conventional diagnostic examinations, because malignancy was demonstrated in <2% of their cases. Despite the high sensitivity of breast MRI, it is not indicated as initial imaging in a patient with pathologic nipple discharge. FDG-PET Breast Dedicated High-resolution cameras specifically designed for breast imaging have improved detection of small and noninvasive carcinomas. However, specific research evaluating women with nipple discharge is lacking [41,53].

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Currently, there is no relevant literature for the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET in the evaluation of a male or female patient with pathologic nipple discharge. Image-Guided Core Biopsy Breast Previous studies showed that mammography, US, and ductography are unreliable in predicting histology in patients with pathologic nipple discharge [17,23,44], which underscores the importance of histological diagnosis of lesions identified on imaging. The biopsy procedures may be guided by stereotactic mammography, US, ductography, or MRI, depending on the imaging modality that best depicts the lesion. CNB is preferred over FNA because the larger gauge needle improves sampling [54,55]. Placement of a tissue marker at the end of the biopsy allows for needle Evaluation of Nipple Discharge localization and excision if the biopsied lesion yields malignant or high-risk histology. Vacuum-assisted CNB is particularly useful in assuring complete sampling of small intraductal papillary lesions [24]. Although biopsy is a diagnostic procedure, the process of removing enough of the intraductal papillary lesion during vacuum-assisted core biopsy may be therapeutic and will lead to permanent cessation of nipple discharge in 90% to 97.2% of patients [24,56]. However, Reiner et al [57] cautioned that ductography-guided 11-gauge vacuum-assisted stereotactic biopsy should not be used as a substitute for surgical duct excision in cases of pathologic nipple discharge with abnormalities on ductography because of the high underestimation rate (50%) for high-risk lesions and DCIS, false- negative rate (7%), and histopathological detection of lesion remnants in every case. Papillomas are historically considered high-risk lesions, with reported rates of upgrade to malignancy between 3% and 14% [58,59]. The management of papillomas diagnosed on CNB is controversial and varies by institution [60].

Evaluation of Nipple Discharge. Currently, there is no relevant literature for the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET in the evaluation of a male or female patient with pathologic nipple discharge. Image-Guided Core Biopsy Breast Previous studies showed that mammography, US, and ductography are unreliable in predicting histology in patients with pathologic nipple discharge [17,23,44], which underscores the importance of histological diagnosis of lesions identified on imaging. The biopsy procedures may be guided by stereotactic mammography, US, ductography, or MRI, depending on the imaging modality that best depicts the lesion. CNB is preferred over FNA because the larger gauge needle improves sampling [54,55]. Placement of a tissue marker at the end of the biopsy allows for needle Evaluation of Nipple Discharge localization and excision if the biopsied lesion yields malignant or high-risk histology. Vacuum-assisted CNB is particularly useful in assuring complete sampling of small intraductal papillary lesions [24]. Although biopsy is a diagnostic procedure, the process of removing enough of the intraductal papillary lesion during vacuum-assisted core biopsy may be therapeutic and will lead to permanent cessation of nipple discharge in 90% to 97.2% of patients [24,56]. However, Reiner et al [57] cautioned that ductography-guided 11-gauge vacuum-assisted stereotactic biopsy should not be used as a substitute for surgical duct excision in cases of pathologic nipple discharge with abnormalities on ductography because of the high underestimation rate (50%) for high-risk lesions and DCIS, false- negative rate (7%), and histopathological detection of lesion remnants in every case. Papillomas are historically considered high-risk lesions, with reported rates of upgrade to malignancy between 3% and 14% [58,59]. The management of papillomas diagnosed on CNB is controversial and varies by institution [60].

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Because papillomas diagnosed on CNB are often excised, excisional biopsy instead of CNB may be useful when a papillary lesion is anticipated based on imaging findings. A recent study suggests that patients with nonbloody pathologic nipple discharge, a benign CNB, or normal imaging (cancer risk <2%) may be considered for nonoperative management if they do not have risk factors such as prior ipsilateral breast cancer, BRCA mutation, or atypia on CNB [61]. In addition, US does not reliably distinguish between benign and malignant small intraductal lesions [9]. Therefore, the decision to perform percutaneous biopsy versus major duct excision should involve the patient and their health care provider. Image-guided CNB is equally useful in male patients for obtaining tissue diagnosis and assisting in patient management [40]. Image-guided CNB is not indicated as the initial examination to evaluate pathologic nipple discharge. Image-Guided Fine Needle Aspiration Breast Once a suspicious lesion that is likely responsible for the pathologic nipple discharge is identified on imaging, image-guided FNA or CNB can be performed for histological diagnosis. Although some institutions demonstrate good results using FNA, larger series have shown that core biopsy is superior to FNA in terms of sensitivity, specificity, and correct histological grading of a lesion [54,55]. Image-guided FNA is not indicated as the initial examination to evaluate pathologic nipple discharge. Sestamibi MBI There is no relevant literature to support the use of molecular breast imaging (MBI) in the evaluation of a male or female patient with pathologic nipple discharge. Mammography Diagnostic The sensitivity of US for palpable or nonpalpable breast cancer is higher than that of mammography (95.7% versus 60.9%) for women 30 to 39 years of age [63,64]. Either mammography or US may be used as the initial imaging modality, on the basis of institutional preference and case-by-case consideration.

Evaluation of Nipple Discharge. Because papillomas diagnosed on CNB are often excised, excisional biopsy instead of CNB may be useful when a papillary lesion is anticipated based on imaging findings. A recent study suggests that patients with nonbloody pathologic nipple discharge, a benign CNB, or normal imaging (cancer risk <2%) may be considered for nonoperative management if they do not have risk factors such as prior ipsilateral breast cancer, BRCA mutation, or atypia on CNB [61]. In addition, US does not reliably distinguish between benign and malignant small intraductal lesions [9]. Therefore, the decision to perform percutaneous biopsy versus major duct excision should involve the patient and their health care provider. Image-guided CNB is equally useful in male patients for obtaining tissue diagnosis and assisting in patient management [40]. Image-guided CNB is not indicated as the initial examination to evaluate pathologic nipple discharge. Image-Guided Fine Needle Aspiration Breast Once a suspicious lesion that is likely responsible for the pathologic nipple discharge is identified on imaging, image-guided FNA or CNB can be performed for histological diagnosis. Although some institutions demonstrate good results using FNA, larger series have shown that core biopsy is superior to FNA in terms of sensitivity, specificity, and correct histological grading of a lesion [54,55]. Image-guided FNA is not indicated as the initial examination to evaluate pathologic nipple discharge. Sestamibi MBI There is no relevant literature to support the use of molecular breast imaging (MBI) in the evaluation of a male or female patient with pathologic nipple discharge. Mammography Diagnostic The sensitivity of US for palpable or nonpalpable breast cancer is higher than that of mammography (95.7% versus 60.9%) for women 30 to 39 years of age [63,64]. Either mammography or US may be used as the initial imaging modality, on the basis of institutional preference and case-by-case consideration.

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However, mammography has its value in detecting suspicious microcalcifications, given the high incidence of patients with DCIS presenting with nipple discharge. Evaluation of Nipple Discharge Digital Breast Tomosynthesis Diagnostic Although there is no relevant literature to support the use of DBT alone in assessing nipple discharge, mammography is useful for evaluating pathologic nipple discharge in male and female patients in this age group [30]. Early studies with DBT demonstrate promise is assessing the symptomatic breast [35,36]. US Breast The sensitivity of US for palpable or nonpalpable breast cancer is higher than that of mammography (95.7% versus 60.9%) for women 30 to 39 years of age [63,64]. Hence, US may be useful as the initial imaging modality, with mammography added when necessary. Ductography Ductography may demonstrate small lesions and localize the duct responsible for the nipple discharge. Ductography is minimally invasive, may be uncomfortable, and can be time-consuming. The procedure is technically challenging with 10% to 15% of cases resulting in inadequate or incomplete results [41,42]. The discharge must be present on the day of ductography so that a cannula can be placed in the appropriate duct. Failure to cannulate the discharging duct may lead to a false negative [43]. Ductography is not recommended in lactating women or patients with active mastitis. Known hypersensitivity to iodinated contrast agents is a relative contraindication. Findings on ductography suggestive of malignant or papillary lesions include intraductal filling defect, partial or complete obstruction of a duct, duct expansion or distortion, and duct wall irregularity [1]. In patients with pathologic nipple discharge and a negative mammogram and US, Morrogh et al [44] reported the PPV and NPV of ductography for the detection of cancer and high-risk lesions to be 19% and 63%, respectively.

Evaluation of Nipple Discharge. However, mammography has its value in detecting suspicious microcalcifications, given the high incidence of patients with DCIS presenting with nipple discharge. Evaluation of Nipple Discharge Digital Breast Tomosynthesis Diagnostic Although there is no relevant literature to support the use of DBT alone in assessing nipple discharge, mammography is useful for evaluating pathologic nipple discharge in male and female patients in this age group [30]. Early studies with DBT demonstrate promise is assessing the symptomatic breast [35,36]. US Breast The sensitivity of US for palpable or nonpalpable breast cancer is higher than that of mammography (95.7% versus 60.9%) for women 30 to 39 years of age [63,64]. Hence, US may be useful as the initial imaging modality, with mammography added when necessary. Ductography Ductography may demonstrate small lesions and localize the duct responsible for the nipple discharge. Ductography is minimally invasive, may be uncomfortable, and can be time-consuming. The procedure is technically challenging with 10% to 15% of cases resulting in inadequate or incomplete results [41,42]. The discharge must be present on the day of ductography so that a cannula can be placed in the appropriate duct. Failure to cannulate the discharging duct may lead to a false negative [43]. Ductography is not recommended in lactating women or patients with active mastitis. Known hypersensitivity to iodinated contrast agents is a relative contraindication. Findings on ductography suggestive of malignant or papillary lesions include intraductal filling defect, partial or complete obstruction of a duct, duct expansion or distortion, and duct wall irregularity [1]. In patients with pathologic nipple discharge and a negative mammogram and US, Morrogh et al [44] reported the PPV and NPV of ductography for the detection of cancer and high-risk lesions to be 19% and 63%, respectively.

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Evaluation of Nipple Discharge

In the setting of negative standard evaluations, ductography localized 76% of otherwise occult malignant/high-risk lesions and 91% of benign lesions [39]. When the standard evaluation is positive, ductography facilitated preoperative localization of the causative lesion in 78% of cases [39]. For detection of cancer in patients with pathologic nipple discharge, 2 studies showed the sensitivity, specificity, PPV, and NPV of ductography to be 75% to 100%, 6% to 49%, 16% to 18%, and 93% to 100%, respectively [16,23]. For detection of high-risk lesions, Adepoju et al [16] reported the sensitivity, specificity, PPV, and NPV of ductography to be 75%, 53%, 22%, and 92%, respectively. Ductography is more sensitive than mammography and US but has a lower specificity than both modalities. A negative ductogram does not reliably exclude an underlying cancer or high-risk lesion, with the false-negative rate reported to be as high as 20% to 30% [44]. As such, the primary value of ductography is to localize intraductal lesions and assist in surgery [45]. A study found that patients who underwent ductography-guided operations or any other surgical procedure with image guidance of the lesion were significantly more likely to have a specific underlying lesion identified than patients who underwent central duct excision alone [23,42]. At this time, there is no relevant literature available for use of ductography for evaluation of a male patient with nipple discharge. Contrast-enhanced breast MRI has a high sensitivity for detecting benign papillary lesions as well as in situ and invasive carcinoma [3]. Furthermore, MRI allows for the identification of index lesions in peripheral ducts that are beyond the area normally encompassed by terminal duct excision, ductography, or targeted US [44].

Evaluation of Nipple Discharge. In the setting of negative standard evaluations, ductography localized 76% of otherwise occult malignant/high-risk lesions and 91% of benign lesions [39]. When the standard evaluation is positive, ductography facilitated preoperative localization of the causative lesion in 78% of cases [39]. For detection of cancer in patients with pathologic nipple discharge, 2 studies showed the sensitivity, specificity, PPV, and NPV of ductography to be 75% to 100%, 6% to 49%, 16% to 18%, and 93% to 100%, respectively [16,23]. For detection of high-risk lesions, Adepoju et al [16] reported the sensitivity, specificity, PPV, and NPV of ductography to be 75%, 53%, 22%, and 92%, respectively. Ductography is more sensitive than mammography and US but has a lower specificity than both modalities. A negative ductogram does not reliably exclude an underlying cancer or high-risk lesion, with the false-negative rate reported to be as high as 20% to 30% [44]. As such, the primary value of ductography is to localize intraductal lesions and assist in surgery [45]. A study found that patients who underwent ductography-guided operations or any other surgical procedure with image guidance of the lesion were significantly more likely to have a specific underlying lesion identified than patients who underwent central duct excision alone [23,42]. At this time, there is no relevant literature available for use of ductography for evaluation of a male patient with nipple discharge. Contrast-enhanced breast MRI has a high sensitivity for detecting benign papillary lesions as well as in situ and invasive carcinoma [3]. Furthermore, MRI allows for the identification of index lesions in peripheral ducts that are beyond the area normally encompassed by terminal duct excision, ductography, or targeted US [44].

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acrac_3099312_10

Evaluation of Nipple Discharge

Index or synchronous lesions found on MRI alone can be percutaneously biopsied with MRI guidance to allow for single- stage definitive surgical management (if malignant) or potentially to avoid unnecessary surgical excision for some benign lesions. In general, MRI should be considered in cases in which mammography and US have failed to identify an underlying cause of pathologic nipple discharge [3,44,48-50]. The sensitivities of breast MRI for detecting the cause of the pathologic nipple discharge are 86% to 100% for invasive cancer and 40% to 100% for noninvasive disease [3,12,44,49,51,52]. Bahl et al [52] reported the sensitivity, specificity, PPV, and NPV of MRI for detecting malignancy in patients with pathologic nipple discharge to be 100%, 68%, 37%, and 100%, respectively. Several Evaluation of Nipple Discharge studies have shown that MRI has a higher sensitivity and specificity than US and ductography for lesion detection and may be an alternative to ductography [12,32,48,49]. However, a study by van Gelder et al [51] asserted that MRI has limited added value in patients with unilateral bloody nipple discharge who showed no signs of a malignancy on conventional diagnostic examinations, because malignancy was demonstrated in <2% of their cases. At this time, there is no relevant literature available for use of MRI for evaluation of a male patient with nipple discharge. FDG-PET Breast Dedicated High-resolution cameras specifically designed for breast imaging have improved detection of small and noninvasive carcinomas. However, specific research evaluating women with nipple discharge is lacking [41,53]. Currently, there is no relevant literature for the use of FDG-PET in the evaluation of a male or female patient with pathologic nipple discharge.

Evaluation of Nipple Discharge. Index or synchronous lesions found on MRI alone can be percutaneously biopsied with MRI guidance to allow for single- stage definitive surgical management (if malignant) or potentially to avoid unnecessary surgical excision for some benign lesions. In general, MRI should be considered in cases in which mammography and US have failed to identify an underlying cause of pathologic nipple discharge [3,44,48-50]. The sensitivities of breast MRI for detecting the cause of the pathologic nipple discharge are 86% to 100% for invasive cancer and 40% to 100% for noninvasive disease [3,12,44,49,51,52]. Bahl et al [52] reported the sensitivity, specificity, PPV, and NPV of MRI for detecting malignancy in patients with pathologic nipple discharge to be 100%, 68%, 37%, and 100%, respectively. Several Evaluation of Nipple Discharge studies have shown that MRI has a higher sensitivity and specificity than US and ductography for lesion detection and may be an alternative to ductography [12,32,48,49]. However, a study by van Gelder et al [51] asserted that MRI has limited added value in patients with unilateral bloody nipple discharge who showed no signs of a malignancy on conventional diagnostic examinations, because malignancy was demonstrated in <2% of their cases. At this time, there is no relevant literature available for use of MRI for evaluation of a male patient with nipple discharge. FDG-PET Breast Dedicated High-resolution cameras specifically designed for breast imaging have improved detection of small and noninvasive carcinomas. However, specific research evaluating women with nipple discharge is lacking [41,53]. Currently, there is no relevant literature for the use of FDG-PET in the evaluation of a male or female patient with pathologic nipple discharge.

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acrac_3099312_11

Evaluation of Nipple Discharge

Image-Guided Core Biopsy Breast Previous studies showed that mammography, US, and ductography are unreliable in predicting histology in patients with pathologic nipple discharge [17,23,44], which underscores the importance of histological diagnosis of lesions identified on imaging. The biopsy procedures may be guided by stereotactic mammography, US, ductography, or MRI, depending on the imaging modality that best depicts the lesion. CNB is preferred over FNA because the larger gauge needle improves sampling [54,55]. Placement of a tissue marker at the end of the biopsy allows for needle localization and excision if the biopsied lesion yields malignant or high-risk histology. Vacuum-assisted CNB is particularly useful in assuring complete sampling of small intraductal papillary lesions [24]. Although biopsy is a diagnostic procedure, the process of removing enough of the intraductal papillary lesion during vacuum-assisted core biopsy may be therapeutic and will lead to permanent cessation of nipple discharge in 90% to 97.2% of patients [24,56]. However, Reiner et al [57] cautioned that ductography-guided 11-gauge vacuum-assisted stereotactic biopsy should not be used as a substitute for surgical duct excision in cases of pathologic nipple discharge with abnormalities on ductography because of the high underestimation rate (50%) for high-risk lesions and DCIS, false- negative rate (7%), and histopathological detection of lesion remnants in every case. Papillomas are historically considered high-risk lesions, with reported rates of upgrade to malignancy between 3% and 14% [58,59]. The management of papillomas diagnosed on CNB is controversial and varies by institution [60]. Because papillomas diagnosed on CNB are often excised, excisional biopsy instead of CNB may be useful when a papillary lesion is anticipated based on imaging findings.

Evaluation of Nipple Discharge. Image-Guided Core Biopsy Breast Previous studies showed that mammography, US, and ductography are unreliable in predicting histology in patients with pathologic nipple discharge [17,23,44], which underscores the importance of histological diagnosis of lesions identified on imaging. The biopsy procedures may be guided by stereotactic mammography, US, ductography, or MRI, depending on the imaging modality that best depicts the lesion. CNB is preferred over FNA because the larger gauge needle improves sampling [54,55]. Placement of a tissue marker at the end of the biopsy allows for needle localization and excision if the biopsied lesion yields malignant or high-risk histology. Vacuum-assisted CNB is particularly useful in assuring complete sampling of small intraductal papillary lesions [24]. Although biopsy is a diagnostic procedure, the process of removing enough of the intraductal papillary lesion during vacuum-assisted core biopsy may be therapeutic and will lead to permanent cessation of nipple discharge in 90% to 97.2% of patients [24,56]. However, Reiner et al [57] cautioned that ductography-guided 11-gauge vacuum-assisted stereotactic biopsy should not be used as a substitute for surgical duct excision in cases of pathologic nipple discharge with abnormalities on ductography because of the high underestimation rate (50%) for high-risk lesions and DCIS, false- negative rate (7%), and histopathological detection of lesion remnants in every case. Papillomas are historically considered high-risk lesions, with reported rates of upgrade to malignancy between 3% and 14% [58,59]. The management of papillomas diagnosed on CNB is controversial and varies by institution [60]. Because papillomas diagnosed on CNB are often excised, excisional biopsy instead of CNB may be useful when a papillary lesion is anticipated based on imaging findings.

3099312

acrac_3099312_12

Evaluation of Nipple Discharge

A recent study suggests that patients with nonbloody pathologic nipple discharge, a benign CNB, or normal imaging (cancer risk <2%) may be considered for nonoperative management if they do not have risk factors such as prior ipsilateral breast cancer, BRCA mutation, or atypia on CNB [61]. In addition, US does not reliably distinguish between benign and malignant small intraductal lesions [9]. Therefore, the decision to perform percutaneous biopsy versus major duct excision should involve the patient and their health care provider. Image-guided CNB is equally useful in male patients for obtaining tissue diagnosis and assisting in patient management [40]. Image-guided CNB is not indicated as the initial examination to evaluate pathological nipple discharge. Image-Guided Fine Needle Aspiration Breast Once a suspicious lesion that is likely responsible for the pathologic nipple discharge is identified on imaging, image-guided FNA or CNB can be performed for histological diagnosis. Although some institutions demonstrate good results using FNA, larger series have shown that core biopsy is superior to FNA in terms of sensitivity, specificity, and correct histological grading of a lesion [54,55]. Image-guided FNA is not indicated as the initial examination to evaluate pathological nipple discharge. Sestamibi MBI There is no relevant literature to support the use of MBI in the evaluation of a male or female patient with pathologic nipple discharge. Digital Breast Tomosynthesis Diagnostic Although there is no relevant literature to support the use of DBT alone in assessing nipple discharge, mammography is useful for evaluating pathologic nipple discharge in male and female patients in this age group [30]. Early studies with DBT demonstrate promise in assessing the symptomatic breast [35,36]. Ductography There is no relevant literature to support the use of ductography for the evaluation of male patients with nipple discharge.

Evaluation of Nipple Discharge. A recent study suggests that patients with nonbloody pathologic nipple discharge, a benign CNB, or normal imaging (cancer risk <2%) may be considered for nonoperative management if they do not have risk factors such as prior ipsilateral breast cancer, BRCA mutation, or atypia on CNB [61]. In addition, US does not reliably distinguish between benign and malignant small intraductal lesions [9]. Therefore, the decision to perform percutaneous biopsy versus major duct excision should involve the patient and their health care provider. Image-guided CNB is equally useful in male patients for obtaining tissue diagnosis and assisting in patient management [40]. Image-guided CNB is not indicated as the initial examination to evaluate pathological nipple discharge. Image-Guided Fine Needle Aspiration Breast Once a suspicious lesion that is likely responsible for the pathologic nipple discharge is identified on imaging, image-guided FNA or CNB can be performed for histological diagnosis. Although some institutions demonstrate good results using FNA, larger series have shown that core biopsy is superior to FNA in terms of sensitivity, specificity, and correct histological grading of a lesion [54,55]. Image-guided FNA is not indicated as the initial examination to evaluate pathological nipple discharge. Sestamibi MBI There is no relevant literature to support the use of MBI in the evaluation of a male or female patient with pathologic nipple discharge. Digital Breast Tomosynthesis Diagnostic Although there is no relevant literature to support the use of DBT alone in assessing nipple discharge, mammography is useful for evaluating pathologic nipple discharge in male and female patients in this age group [30]. Early studies with DBT demonstrate promise in assessing the symptomatic breast [35,36]. Ductography There is no relevant literature to support the use of ductography for the evaluation of male patients with nipple discharge.

3099312

acrac_3099312_13

Evaluation of Nipple Discharge

MRI Breast There is no relevant literature to support the use of MRI for the evaluation of male patients with nipple discharge. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET for the evaluation of male patients with nipple discharge. Image-guided Core Biopsy Breast There is no relevant literature to support the use of core biopsy for the evaluation of male patients with nipple discharge. However, if an imaging abnormality is identified, US may be used to direct biopsy. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNA for the evaluation of male patients with nipple discharge. Sestamibi MBI There is no relevant literature to support the use of MBI for the evaluation of male patients with nipple discharge. Variant 5: Adult female younger than 30 years of age. Pathologic nipple discharge. Initial imaging. The probability of a woman developing breast cancer over the next decade increases with age; the risk is 1 in 1,681 at 20 years of age, 1 in 232 at 30 years of age, and 1 in 69 at 40 years of age [62]. Breast cancer is rare in women <30 years of age, with the exception of those with a genetic predisposition or prior mantle radiation to the chest. In a study by Seltzer et al [66] on the significance of age in patients with nipple discharge, malignancy was found in 1 of 10 patients <30 years of age. However, caution should be exercised interpreting these results given a very small sample size and the possible inclusion of high-risk patients. Mammography Diagnostic Most breast lesions in young women are not visualized on mammography [67,68] because of the low incidence of breast cancer (0.4% or lower) in women <30 years of age. US is most useful for initial imaging in this population; however, diagnostic mammography may be useful when US shows a suspicious finding.

Evaluation of Nipple Discharge. MRI Breast There is no relevant literature to support the use of MRI for the evaluation of male patients with nipple discharge. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET for the evaluation of male patients with nipple discharge. Image-guided Core Biopsy Breast There is no relevant literature to support the use of core biopsy for the evaluation of male patients with nipple discharge. However, if an imaging abnormality is identified, US may be used to direct biopsy. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNA for the evaluation of male patients with nipple discharge. Sestamibi MBI There is no relevant literature to support the use of MBI for the evaluation of male patients with nipple discharge. Variant 5: Adult female younger than 30 years of age. Pathologic nipple discharge. Initial imaging. The probability of a woman developing breast cancer over the next decade increases with age; the risk is 1 in 1,681 at 20 years of age, 1 in 232 at 30 years of age, and 1 in 69 at 40 years of age [62]. Breast cancer is rare in women <30 years of age, with the exception of those with a genetic predisposition or prior mantle radiation to the chest. In a study by Seltzer et al [66] on the significance of age in patients with nipple discharge, malignancy was found in 1 of 10 patients <30 years of age. However, caution should be exercised interpreting these results given a very small sample size and the possible inclusion of high-risk patients. Mammography Diagnostic Most breast lesions in young women are not visualized on mammography [67,68] because of the low incidence of breast cancer (0.4% or lower) in women <30 years of age. US is most useful for initial imaging in this population; however, diagnostic mammography may be useful when US shows a suspicious finding.

3099312

acrac_3099312_14

Evaluation of Nipple Discharge

Digital Breast Tomosynthesis Diagnostic Although there is no relevant literature to support the use of DBT alone in assessing nipple discharge, mammography is useful for evaluating pathologic nipple discharge in male and female patients in this age group [30]. Early studies with DBT demonstrate promise in assessing the symptomatic breast [35,36]. Evaluation of Nipple Discharge US Breast Yue et al [69] studied 955 women <25 years of age who presented with breast symptoms including palpable mass, pain, and nipple discharge. US was performed in 692 patients and was normal/negative in 671 patients and indeterminate in 21 patients. No cancer was found in this group via biopsy or clinical follow-up. However, it is unknown how many of these patients had pathologic or physiologic discharge. Ductography There is no relevant literature to support the use of ductography in women <30 years of age with symptoms of pathologic nipple discharge. MRI Breast There is no relevant literature to support the use of MRI in women <30 years of age with symptoms of pathologic nipple discharge. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET in women <30 years of age with symptoms of pathologic nipple discharge. Image-guided Core Biopsy Breast There is no relevant literature to support the use of image-guided core biopsy in women <30 years of age with symptoms of pathologic nipple discharge. However, if an imaging abnormality is identified, US may be used to direct biopsy. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNA in women <30 years of age with symptoms of pathologic nipple discharge. Sestamibi MBI There is no relevant literature to support the use of MBI in women <30 years of age with symptoms of pathologic nipple discharge.

Evaluation of Nipple Discharge. Digital Breast Tomosynthesis Diagnostic Although there is no relevant literature to support the use of DBT alone in assessing nipple discharge, mammography is useful for evaluating pathologic nipple discharge in male and female patients in this age group [30]. Early studies with DBT demonstrate promise in assessing the symptomatic breast [35,36]. Evaluation of Nipple Discharge US Breast Yue et al [69] studied 955 women <25 years of age who presented with breast symptoms including palpable mass, pain, and nipple discharge. US was performed in 692 patients and was normal/negative in 671 patients and indeterminate in 21 patients. No cancer was found in this group via biopsy or clinical follow-up. However, it is unknown how many of these patients had pathologic or physiologic discharge. Ductography There is no relevant literature to support the use of ductography in women <30 years of age with symptoms of pathologic nipple discharge. MRI Breast There is no relevant literature to support the use of MRI in women <30 years of age with symptoms of pathologic nipple discharge. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET in women <30 years of age with symptoms of pathologic nipple discharge. Image-guided Core Biopsy Breast There is no relevant literature to support the use of image-guided core biopsy in women <30 years of age with symptoms of pathologic nipple discharge. However, if an imaging abnormality is identified, US may be used to direct biopsy. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNA in women <30 years of age with symptoms of pathologic nipple discharge. Sestamibi MBI There is no relevant literature to support the use of MBI in women <30 years of age with symptoms of pathologic nipple discharge.

3099312

acrac_3099312_15

Evaluation of Nipple Discharge

Digital Breast Tomosynthesis Diagnostic Although there is no relevant literature to support the use of DBT alone in assessing nipple discharge, mammography is useful for evaluating pathologic nipple discharge in male and female patients in this age group [30]. Early studies with DBT demonstrate promise is assessing the symptomatic breast [35,36]. Ductography There is no relevant literature to support the use of ductography for evaluation of transgender patients with nipple discharge. MRI Breast There is no relevant literature to support the use of MRI for evaluation of transgender patients with nipple discharge. Evaluation of Nipple Discharge FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET for evaluation of transgender patients with nipple discharge. Image-guided Core Biopsy Breast There is no relevant literature to support the use of image-guided core biopsy for evaluation of transgender patients with nipple discharge. However, if an imaging abnormality is identified, US may be used to direct biopsy. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNA for evaluation of transgender patients with nipple discharge. Sestamibi MBI There is no relevant literature to support the use of MBI for evaluation of transgender patients with nipple discharge. Digital Breast Tomosynthesis Diagnostic Although there is no relevant literature to support the use of DBT alone in assessing nipple discharge, mammography is useful for evaluating pathologic nipple discharge in male and female patients in this age group [30]. Early studies with DBT demonstrate promise is assessing the symptomatic breast [35,36]. Ductography There is no relevant literature to support the use of ductography for evaluation of transgender patients with nipple discharge. MRI Breast There is no relevant literature to support the use of MRI for evaluation of transgender patients with nipple discharge.

Evaluation of Nipple Discharge. Digital Breast Tomosynthesis Diagnostic Although there is no relevant literature to support the use of DBT alone in assessing nipple discharge, mammography is useful for evaluating pathologic nipple discharge in male and female patients in this age group [30]. Early studies with DBT demonstrate promise is assessing the symptomatic breast [35,36]. Ductography There is no relevant literature to support the use of ductography for evaluation of transgender patients with nipple discharge. MRI Breast There is no relevant literature to support the use of MRI for evaluation of transgender patients with nipple discharge. Evaluation of Nipple Discharge FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET for evaluation of transgender patients with nipple discharge. Image-guided Core Biopsy Breast There is no relevant literature to support the use of image-guided core biopsy for evaluation of transgender patients with nipple discharge. However, if an imaging abnormality is identified, US may be used to direct biopsy. Image-Guided Fine Needle Aspiration Breast There is no relevant literature to support the use of image-guided FNA for evaluation of transgender patients with nipple discharge. Sestamibi MBI There is no relevant literature to support the use of MBI for evaluation of transgender patients with nipple discharge. Digital Breast Tomosynthesis Diagnostic Although there is no relevant literature to support the use of DBT alone in assessing nipple discharge, mammography is useful for evaluating pathologic nipple discharge in male and female patients in this age group [30]. Early studies with DBT demonstrate promise is assessing the symptomatic breast [35,36]. Ductography There is no relevant literature to support the use of ductography for evaluation of transgender patients with nipple discharge. MRI Breast There is no relevant literature to support the use of MRI for evaluation of transgender patients with nipple discharge.

3099312

acrac_69464_0

Assessment of Gravid Cervix

In addition to CL screening for those at risk for PTB, other clinical scenarios may arise in which imaging assessment of the gravid cervix may be of interest. These include suspected preterm labor, induction of labor, and active term labor. Additional clinical scenarios, which may require a focused assessment of the gravid cervix, include suspected abnormal placentation including placenta previa, vasa previa, and lower uterine segment and/or cervical fibroids that may impede progression of labor and potential umbilical cord prolapse. 3-D Transvaginal US Three-dimensional TVUS acquires a volumetric data set that can be reformatted and analyzed in any plane. Three- dimensional TVUS may eventually be of benefit for certain clinical scenarios; however, there is currently insufficient data to recommend its routine use. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] Assessment of Gravid Cervix US Elastography Cervix US elastography is an imaging technique that assesses tissue stiffness. Although the available data suggest that US elastography may be beneficial in evaluating the gravid cervix [14-17], technical standards and normal reference values are lacking, and the technique remains investigational. As such, there is currently insufficient data to recommend its use in routine screening for PTB in low-risk and high-risk women, suspected preterm labor, and predicting successful induction of labor [18-22].

Assessment of Gravid Cervix. In addition to CL screening for those at risk for PTB, other clinical scenarios may arise in which imaging assessment of the gravid cervix may be of interest. These include suspected preterm labor, induction of labor, and active term labor. Additional clinical scenarios, which may require a focused assessment of the gravid cervix, include suspected abnormal placentation including placenta previa, vasa previa, and lower uterine segment and/or cervical fibroids that may impede progression of labor and potential umbilical cord prolapse. 3-D Transvaginal US Three-dimensional TVUS acquires a volumetric data set that can be reformatted and analyzed in any plane. Three- dimensional TVUS may eventually be of benefit for certain clinical scenarios; however, there is currently insufficient data to recommend its routine use. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] Assessment of Gravid Cervix US Elastography Cervix US elastography is an imaging technique that assesses tissue stiffness. Although the available data suggest that US elastography may be beneficial in evaluating the gravid cervix [14-17], technical standards and normal reference values are lacking, and the technique remains investigational. As such, there is currently insufficient data to recommend its use in routine screening for PTB in low-risk and high-risk women, suspected preterm labor, and predicting successful induction of labor [18-22].

69464

acrac_69464_1

Assessment of Gravid Cervix

US Cervix Transperineal Transperineal US is an alternate approach to transvaginal evaluation of the gravid cervix and may be a complementary method to transabdominal US in certain clinical situations, such as large body habitus or when incomplete distention of the bladder limits transabdominal cervical assessment. The transperineal approach is superior to transabdominal US, although inadequate visualization of the cervix has been reported in up to 22% of patients [26]. An inability to adequately assess the cervix via the transperineal approach may result from shadowing from the symphysis pubis and rectal gas and stool. Adequate assessment by transperineal US is also dependent on sonographer experience. Transperineal assessment of the gravid cervix has been shown to be comparable to TVUS by several studies. Good correlation between CL measurements obtained transperineally and transvaginally have been reported in normal gravid cervix patients at each trimester, and the accuracy improves as the pregnancy progresses [27]. In a study by Hertzberg et al [28], similar levels of diagnostic confidence were achieved via the transperineal and transvaginal approaches, although there was a clear preference expressed by the interpreting physician for the latter. CLs were found to be comparable after 20 weeks gestational age, and CL measured between 14 and 20 weeks gestational age were statistically shorter via the transperineal approach. In a study of women between 22 and 24 weeks gestational age, Cicero et al [26] reported transperineal CL comparable to those obtained transvaginally. Standard second and third trimester transabdominal US evaluation may inadequately visualize the cervix or demonstrate findings suspicious for shortening. In such cases, transvaginal or transperineal US have been recommended for further evaluation [23].

Assessment of Gravid Cervix. US Cervix Transperineal Transperineal US is an alternate approach to transvaginal evaluation of the gravid cervix and may be a complementary method to transabdominal US in certain clinical situations, such as large body habitus or when incomplete distention of the bladder limits transabdominal cervical assessment. The transperineal approach is superior to transabdominal US, although inadequate visualization of the cervix has been reported in up to 22% of patients [26]. An inability to adequately assess the cervix via the transperineal approach may result from shadowing from the symphysis pubis and rectal gas and stool. Adequate assessment by transperineal US is also dependent on sonographer experience. Transperineal assessment of the gravid cervix has been shown to be comparable to TVUS by several studies. Good correlation between CL measurements obtained transperineally and transvaginally have been reported in normal gravid cervix patients at each trimester, and the accuracy improves as the pregnancy progresses [27]. In a study by Hertzberg et al [28], similar levels of diagnostic confidence were achieved via the transperineal and transvaginal approaches, although there was a clear preference expressed by the interpreting physician for the latter. CLs were found to be comparable after 20 weeks gestational age, and CL measured between 14 and 20 weeks gestational age were statistically shorter via the transperineal approach. In a study of women between 22 and 24 weeks gestational age, Cicero et al [26] reported transperineal CL comparable to those obtained transvaginally. Standard second and third trimester transabdominal US evaluation may inadequately visualize the cervix or demonstrate findings suspicious for shortening. In such cases, transvaginal or transperineal US have been recommended for further evaluation [23].

69464

acrac_69464_2

Assessment of Gravid Cervix

If TVUS is declined by the patient or if the risk of TVUS is deemed too high (eg, placenta previa, suspected preterm premature rupture of membranes), transperineal US is a suitable alternative. If transperineal US is performed, the above caveats regarding CL in the early second trimester should be noted. US Cervix Transvaginal TVUS allows for the most complete assessment of the cervix, yet its use in universal screening of low-risk women remains controversial. Supportive evidence for universal screening comes from two studies evaluating the rates of PTB before and after implementation of a universal transvaginal cervical screening program [29,30]. Following implementation of their screening program, Son et al [29] demonstrated statistically significant decreases in the rates of spontaneous PTB <37 weeks (4.8% versus 4.0%), <34 weeks (1.3% versus 1.0%), and <32 weeks (0.7% versus 0.5%). Temming et al [30] demonstrated similar findings following implementation of their screening program; however, statistically significant decreases only were observed in the rates of spontaneous PTB <28 weeks (2.0% versus 0.7%) and <24 weeks (1.5% versus 0.35%). Other studies demonstrate no clear benefit to transvaginal screening, thereby calling into question its appropriateness. In one study evaluating a CL screening program in nulliparous women, no statistical difference was observed in the rate of spontaneous PTB in patients who underwent screening compared with those who did not [31]. In a separate study of nulliparous women, the predictive accuracy of serial TVUS for spontaneous PTB Although TVUS is not contraindicated in the setting of placenta previa, it should be performed using real-time imaging as the probe is advanced.

Assessment of Gravid Cervix. If TVUS is declined by the patient or if the risk of TVUS is deemed too high (eg, placenta previa, suspected preterm premature rupture of membranes), transperineal US is a suitable alternative. If transperineal US is performed, the above caveats regarding CL in the early second trimester should be noted. US Cervix Transvaginal TVUS allows for the most complete assessment of the cervix, yet its use in universal screening of low-risk women remains controversial. Supportive evidence for universal screening comes from two studies evaluating the rates of PTB before and after implementation of a universal transvaginal cervical screening program [29,30]. Following implementation of their screening program, Son et al [29] demonstrated statistically significant decreases in the rates of spontaneous PTB <37 weeks (4.8% versus 4.0%), <34 weeks (1.3% versus 1.0%), and <32 weeks (0.7% versus 0.5%). Temming et al [30] demonstrated similar findings following implementation of their screening program; however, statistically significant decreases only were observed in the rates of spontaneous PTB <28 weeks (2.0% versus 0.7%) and <24 weeks (1.5% versus 0.35%). Other studies demonstrate no clear benefit to transvaginal screening, thereby calling into question its appropriateness. In one study evaluating a CL screening program in nulliparous women, no statistical difference was observed in the rate of spontaneous PTB in patients who underwent screening compared with those who did not [31]. In a separate study of nulliparous women, the predictive accuracy of serial TVUS for spontaneous PTB Although TVUS is not contraindicated in the setting of placenta previa, it should be performed using real-time imaging as the probe is advanced.

69464

acrac_69464_3

Assessment of Gravid Cervix

The safety in this setting is based on the presumption that the angle between the cervix and the vaginal probe is sufficient to prevent the probe from inadvertently slipping into the cervix and that real-time imaging is used throughout the procedure to assess the relationship between the probe tip and the cervix [33]. US Cervix Transperineal Transperineal US is an alternate approach to transvaginal evaluation of the gravid cervix and may be useful in certain clinical scenarios, such as large body habitus or when incomplete distention of the bladder limits the transabdominal cervical assessment. The transperineal approach is superior to transabdominal US, and transperineal assessment of the gravid cervix has been shown to be comparable to TVUS [27]. Good correlation between CL measurements obtained transperineally and transvaginally have been reported in normal gravid patients at each trimester [26-28]. In a study by Hertzberg et al [28], similar levels of diagnostic confidence were achieved with both transperineal and transvaginal approaches, noting a clear preference expressed for the latter. CL was found to be comparable after 20 weeks gestational age; however, CL measured between 14 and 20 weeks gestational age was statistically shorter via the transperineal approach. Given the apparent difference in accuracy of transperineal CL in the early second trimester, the authors suggested performing transvaginal imaging when short CL are obtained transperineally in the early second trimester. In a study of women between 22 and 24 weeks gestational age, Cicero et al [26] reported satisfactory transperineal visualization of the cervix in approximately 80% of cases. CLs obtained by the transperineal approach during this gestational age were also comparable to those obtained transvaginally. TVUS is the preferred approach for assessment of the gravid cervix in high-risk patients, but there may be instances in which TVUS is not possible because of patient discomfort or preference.

Assessment of Gravid Cervix. The safety in this setting is based on the presumption that the angle between the cervix and the vaginal probe is sufficient to prevent the probe from inadvertently slipping into the cervix and that real-time imaging is used throughout the procedure to assess the relationship between the probe tip and the cervix [33]. US Cervix Transperineal Transperineal US is an alternate approach to transvaginal evaluation of the gravid cervix and may be useful in certain clinical scenarios, such as large body habitus or when incomplete distention of the bladder limits the transabdominal cervical assessment. The transperineal approach is superior to transabdominal US, and transperineal assessment of the gravid cervix has been shown to be comparable to TVUS [27]. Good correlation between CL measurements obtained transperineally and transvaginally have been reported in normal gravid patients at each trimester [26-28]. In a study by Hertzberg et al [28], similar levels of diagnostic confidence were achieved with both transperineal and transvaginal approaches, noting a clear preference expressed for the latter. CL was found to be comparable after 20 weeks gestational age; however, CL measured between 14 and 20 weeks gestational age was statistically shorter via the transperineal approach. Given the apparent difference in accuracy of transperineal CL in the early second trimester, the authors suggested performing transvaginal imaging when short CL are obtained transperineally in the early second trimester. In a study of women between 22 and 24 weeks gestational age, Cicero et al [26] reported satisfactory transperineal visualization of the cervix in approximately 80% of cases. CLs obtained by the transperineal approach during this gestational age were also comparable to those obtained transvaginally. TVUS is the preferred approach for assessment of the gravid cervix in high-risk patients, but there may be instances in which TVUS is not possible because of patient discomfort or preference.

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acrac_69464_4

Assessment of Gravid Cervix

If TVUS is declined by the patient or if the risk of TVUS is deemed too high (eg, placenta previa, suspected preterm premature rupture of membranes), transperineal US is a suitable alternative. In such instances, transperineal US would be indicated, noting the above caveats regarding CL in the early second trimester. Assessment of Gravid Cervix US Cervix Transvaginal TVUS is the reference standard of imaging modalities used for assessment of the gravid cervix. The transvaginal approach affords the shortest distance between transducer and cervix, and TVUS transducers typically offer higher frequency evaluation and greater detailed evaluation. The combination of these features allows for complete visualization of the cervix, including the internal os where changes increasing the risk of PTB first occur. Lastly, transvaginal imaging is a highly reproducible test. Several studies have demonstrated that identification of a short CL by TVUS decreases the rate of PTB by directing patients to appropriate interventions. In a randomized placebo-controlled study by Fonseca et al [6], women with a sonographically short cervix who received progesterone demonstrated a 44% reduction in the rate of PTB <34 weeks, as well as a 41% decrease in neonatal morbidity. A separate randomized placebo-controlled study confirmed the benefit of progesterone administration and found a 45% decrease in PTB <33 weeks and a 50% decrease in PTB <28 weeks [8]. Reduction in PTB rates was also observed in patients undergoing cervical pessary placement [7]. When compared with patients undergoing expectant management, pessary placement was associated with a 78% reduction of PTB <34 weeks. Lastly, short CL treated by cerclage has been found to decrease PTB. In a meta- analysis of 5 trials of high-risk patients with short CL, cerclage placement resulted in a 30% decrease in PTB <35 weeks with significantly decreased rates of PTB seen before 37, 32, 28, and 24 weeks [5].

Assessment of Gravid Cervix. If TVUS is declined by the patient or if the risk of TVUS is deemed too high (eg, placenta previa, suspected preterm premature rupture of membranes), transperineal US is a suitable alternative. In such instances, transperineal US would be indicated, noting the above caveats regarding CL in the early second trimester. Assessment of Gravid Cervix US Cervix Transvaginal TVUS is the reference standard of imaging modalities used for assessment of the gravid cervix. The transvaginal approach affords the shortest distance between transducer and cervix, and TVUS transducers typically offer higher frequency evaluation and greater detailed evaluation. The combination of these features allows for complete visualization of the cervix, including the internal os where changes increasing the risk of PTB first occur. Lastly, transvaginal imaging is a highly reproducible test. Several studies have demonstrated that identification of a short CL by TVUS decreases the rate of PTB by directing patients to appropriate interventions. In a randomized placebo-controlled study by Fonseca et al [6], women with a sonographically short cervix who received progesterone demonstrated a 44% reduction in the rate of PTB <34 weeks, as well as a 41% decrease in neonatal morbidity. A separate randomized placebo-controlled study confirmed the benefit of progesterone administration and found a 45% decrease in PTB <33 weeks and a 50% decrease in PTB <28 weeks [8]. Reduction in PTB rates was also observed in patients undergoing cervical pessary placement [7]. When compared with patients undergoing expectant management, pessary placement was associated with a 78% reduction of PTB <34 weeks. Lastly, short CL treated by cerclage has been found to decrease PTB. In a meta- analysis of 5 trials of high-risk patients with short CL, cerclage placement resulted in a 30% decrease in PTB <35 weeks with significantly decreased rates of PTB seen before 37, 32, 28, and 24 weeks [5].

69464

acrac_69464_5

Assessment of Gravid Cervix

Given the availability of several effective interventions for the prevention of PTB, TVUS cervical screening for high-risk patients is recommended. Routine TVUS screening is also supported by the American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine [36,37]. Although TVUS is not contraindicated in the setting of placenta previa, it should be performed using real-time imaging as the probe is advanced. The safety in this setting is based on the presumption that the angle between the cervix and the vaginal probe is sufficient to prevent the probe from inadvertently slipping into the cervix and that real-time imaging is used throughout the procedure to assess the relationship between the probe tip and the cervix [33]. Cervical Cerclage Patients who have undergone history-indicated cerclage for cervical insufficiency represent a subset of high-risk patients. In these patients with a history of one or more second trimester losses, cerclage placement may be offered during the early second trimester. In one recent study screening cerclage patients by TVUS until 26 weeks, a shorter CL below the cerclage and cervical funneling were shown to be associated with a higher rate of PTB [38]. In a separate study evaluating postcerclage patients between 18 and 24 weeks, cervical funneling was the only variable independently associated with increased risk of PTB before 34 weeks [39]. Although these and other studies suggest that short CL and cervical funneling are associated with higher rates of PTB in patients with cerclage, the Society for Maternal-Fetal Medicine does not recommend routine surveillance for this subset of high-risk patients because there is insufficient data supporting a clinical benefit to screening [37].

Assessment of Gravid Cervix. Given the availability of several effective interventions for the prevention of PTB, TVUS cervical screening for high-risk patients is recommended. Routine TVUS screening is also supported by the American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine [36,37]. Although TVUS is not contraindicated in the setting of placenta previa, it should be performed using real-time imaging as the probe is advanced. The safety in this setting is based on the presumption that the angle between the cervix and the vaginal probe is sufficient to prevent the probe from inadvertently slipping into the cervix and that real-time imaging is used throughout the procedure to assess the relationship between the probe tip and the cervix [33]. Cervical Cerclage Patients who have undergone history-indicated cerclage for cervical insufficiency represent a subset of high-risk patients. In these patients with a history of one or more second trimester losses, cerclage placement may be offered during the early second trimester. In one recent study screening cerclage patients by TVUS until 26 weeks, a shorter CL below the cerclage and cervical funneling were shown to be associated with a higher rate of PTB [38]. In a separate study evaluating postcerclage patients between 18 and 24 weeks, cervical funneling was the only variable independently associated with increased risk of PTB before 34 weeks [39]. Although these and other studies suggest that short CL and cervical funneling are associated with higher rates of PTB in patients with cerclage, the Society for Maternal-Fetal Medicine does not recommend routine surveillance for this subset of high-risk patients because there is insufficient data supporting a clinical benefit to screening [37].

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acrac_69464_6

Assessment of Gravid Cervix

If assessment of the cerclage is performed, additional measurements irrespective of approach (eg, transabdominal, transvaginal, or transperineal) may include the total length of closed cervix regardless of cerclage sutures, and if funneling is present, the length of closed cervix from the level of cervical funneling to the level of the cerclage sutures. Variant 3: Assessment of gravid cervix. Suspected preterm labor. Initial imaging. US Cervix Transabdominal To our knowledge, there is no relevant literature regarding the use of transabdominal US in the evaluation of the cervix for suspected preterm labor. US Cervix Transperineal Transperineal US is an alternate approach to transvaginal evaluation of the gravid cervix. In one study, adequate visualization of the cervix was achieved in 82% of patients in preterm labor with good agreement of transperineal and transvaginal measurements with an intraclass correlation coefficient of 0.83 [40]. The mean difference in cervical measurements between transperineal and transvaginal approaches was 1.5 mm, with transperineal US underestimating CL in most cases. No significant disagreement between both methods was observed above or below a length of 25 mm. A study by Dimassi et al [41] also reported a strong correlation in CL obtained by both methods as well as a low mean difference in cervical measurements (0.38 mm). TVUS would be preferred for assessment of the cervix in cases of suspected preterm labor. Nevertheless, transperineal US would be an adequate alternative in the event that TVUS is declined by the patient or if the risk of TVUS is deemed too high (eg, placenta previa, suspected preterm premature rupture of membranes). Assessment of Gravid Cervix US Cervix Transvaginal TVUS is the reference standard of imaging modalities used for assessment of the gravid cervix because it allows for complete visualization of the cervix, including the internal os where changes of PTB first occur. Transvaginal imaging is highly reproducible.

Assessment of Gravid Cervix. If assessment of the cerclage is performed, additional measurements irrespective of approach (eg, transabdominal, transvaginal, or transperineal) may include the total length of closed cervix regardless of cerclage sutures, and if funneling is present, the length of closed cervix from the level of cervical funneling to the level of the cerclage sutures. Variant 3: Assessment of gravid cervix. Suspected preterm labor. Initial imaging. US Cervix Transabdominal To our knowledge, there is no relevant literature regarding the use of transabdominal US in the evaluation of the cervix for suspected preterm labor. US Cervix Transperineal Transperineal US is an alternate approach to transvaginal evaluation of the gravid cervix. In one study, adequate visualization of the cervix was achieved in 82% of patients in preterm labor with good agreement of transperineal and transvaginal measurements with an intraclass correlation coefficient of 0.83 [40]. The mean difference in cervical measurements between transperineal and transvaginal approaches was 1.5 mm, with transperineal US underestimating CL in most cases. No significant disagreement between both methods was observed above or below a length of 25 mm. A study by Dimassi et al [41] also reported a strong correlation in CL obtained by both methods as well as a low mean difference in cervical measurements (0.38 mm). TVUS would be preferred for assessment of the cervix in cases of suspected preterm labor. Nevertheless, transperineal US would be an adequate alternative in the event that TVUS is declined by the patient or if the risk of TVUS is deemed too high (eg, placenta previa, suspected preterm premature rupture of membranes). Assessment of Gravid Cervix US Cervix Transvaginal TVUS is the reference standard of imaging modalities used for assessment of the gravid cervix because it allows for complete visualization of the cervix, including the internal os where changes of PTB first occur. Transvaginal imaging is highly reproducible.

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acrac_69464_7

Assessment of Gravid Cervix

Taken together, the data demonstrate that although TVUS has limitations in its predictive ability in identifying those who will progress to PTB, its greatest value is its high negative predicative value. As such, transvaginal assessment of the gravid cervix would be the preferred approach in cases of suspected preterm labor. Although TVUS is not contraindicated in the setting of placenta previa, it should be performed using real-time imaging as the probe is advanced. The safety in this setting is based on the presumption that the angle between the cervix and the vaginal probe is sufficient to prevent the probe from inadvertently slipping into the cervix and that real-time imaging is used throughout the procedure to assess the relationship between the probe tip and the cervix [33]. Variant 4: Assessment of gravid cervix. Induction of labor or active term labor. Initial imaging. US Cervix Transabdominal To our knowledge, there is no relevant literature regarding the use of transabdominal US in the evaluation of the cervix prior to induction of labor or during active term labor. However, a meta-analysis of 31 studies demonstrated limited value in predicting the outcome of induced labor [49]. Studies that are more recent also report conflicting data. In one study, a shorter CL prior to induction was associated Although TVUS is not contraindicated in the setting of placenta previa, it should be performed using real-time imaging as the probe is advanced. The safety in this setting is based on the presumption that the angle between the cervix and the vaginal probe is sufficient to prevent the probe from inadvertently slipping into the cervix and that real-time imaging is used throughout the procedure to assess the relationship between the probe tip and the cervix [33]. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list.

Assessment of Gravid Cervix. Taken together, the data demonstrate that although TVUS has limitations in its predictive ability in identifying those who will progress to PTB, its greatest value is its high negative predicative value. As such, transvaginal assessment of the gravid cervix would be the preferred approach in cases of suspected preterm labor. Although TVUS is not contraindicated in the setting of placenta previa, it should be performed using real-time imaging as the probe is advanced. The safety in this setting is based on the presumption that the angle between the cervix and the vaginal probe is sufficient to prevent the probe from inadvertently slipping into the cervix and that real-time imaging is used throughout the procedure to assess the relationship between the probe tip and the cervix [33]. Variant 4: Assessment of gravid cervix. Induction of labor or active term labor. Initial imaging. US Cervix Transabdominal To our knowledge, there is no relevant literature regarding the use of transabdominal US in the evaluation of the cervix prior to induction of labor or during active term labor. However, a meta-analysis of 31 studies demonstrated limited value in predicting the outcome of induced labor [49]. Studies that are more recent also report conflicting data. In one study, a shorter CL prior to induction was associated Although TVUS is not contraindicated in the setting of placenta previa, it should be performed using real-time imaging as the probe is advanced. The safety in this setting is based on the presumption that the angle between the cervix and the vaginal probe is sufficient to prevent the probe from inadvertently slipping into the cervix and that real-time imaging is used throughout the procedure to assess the relationship between the probe tip and the cervix [33]. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list.

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acrac_3102405_0

Major Blunt Trauma

Trauma is the leading cause of mortality for people in the United States who are <45 years of age, and it is the fourth leading cause of death overall [3]. Polytrauma can be defined as an injury to at least two body parts, including the head, neck, chest, abdomen, pelvis, and at least one extremity, with any one or a combination of these injuries being potentially fatal. MR urography (MRU) is also tailored to improve imaging of the urinary tract system. Unenhanced MRU relies upon heavily T2-weighted imaging of the intrinsic signal from urine for evaluation of the urinary tract. IV contrast is administered to provide additional information regarding obstruction, urothelial thickening, focal lesions, and stones. A contrast-enhanced T1-weighted series should include corticomedullary, nephrographic, and excretory Reprint requests to: [email protected] Major Blunt Trauma phase. Similar to CTU, hydration or low-dose furosemide can improve urinary tract distension and study quality. Thin slice acquisition and multiplanar imaging should be obtained. MRU is most commonly performed at 1.5T, but imaging at 3T has become more widely used; however, comparison of 3T MRU and CTU has not been published in the literature. Discussion of Procedures by Variant Variant 1: Major blunt trauma. Hemodynamically unstable. Initial imaging. CT Whole Body There is limited literature to support the use of WBCT in patients who are hemodynamically unstable [6,7]. Patients who remain hemodynamically unstable despite initial attempts at resuscitation and who have positive signs for abdominal trauma (eg, a positive FAST) should proceed directly to exploratory laparotomy, with CT imaging deferred until after operative intervention. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8].

Major Blunt Trauma. Trauma is the leading cause of mortality for people in the United States who are <45 years of age, and it is the fourth leading cause of death overall [3]. Polytrauma can be defined as an injury to at least two body parts, including the head, neck, chest, abdomen, pelvis, and at least one extremity, with any one or a combination of these injuries being potentially fatal. MR urography (MRU) is also tailored to improve imaging of the urinary tract system. Unenhanced MRU relies upon heavily T2-weighted imaging of the intrinsic signal from urine for evaluation of the urinary tract. IV contrast is administered to provide additional information regarding obstruction, urothelial thickening, focal lesions, and stones. A contrast-enhanced T1-weighted series should include corticomedullary, nephrographic, and excretory Reprint requests to: [email protected] Major Blunt Trauma phase. Similar to CTU, hydration or low-dose furosemide can improve urinary tract distension and study quality. Thin slice acquisition and multiplanar imaging should be obtained. MRU is most commonly performed at 1.5T, but imaging at 3T has become more widely used; however, comparison of 3T MRU and CTU has not been published in the literature. Discussion of Procedures by Variant Variant 1: Major blunt trauma. Hemodynamically unstable. Initial imaging. CT Whole Body There is limited literature to support the use of WBCT in patients who are hemodynamically unstable [6,7]. Patients who remain hemodynamically unstable despite initial attempts at resuscitation and who have positive signs for abdominal trauma (eg, a positive FAST) should proceed directly to exploratory laparotomy, with CT imaging deferred until after operative intervention. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8].

3102405

acrac_3102405_1

Major Blunt Trauma

US FAST Scan Chest Abdomen Pelvis The role of FAST (or extended-FAST or chest abdominal-FAST in evaluating chest injury) is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT [9,10]. Extended-FAST has been found to be effective in ruling out pneumothorax [11]. Although ultrasound (US) may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to exclude injuries to these areas [5]. FAST has been found to have a high false-negative rate in patients with pelvic fractures [12]. Radiography Trauma Series Trauma series radiographs in the unstable patient typically consist of portable radiographs of the chest and pelvis. A portable anteroposterior (AP) chest radiograph helps screen for immediately life-threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13]. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. MRI Abdomen and Pelvis There is no relevant literature to support the use of MRI in the initial evaluation of the unstable trauma patient. MRI is not performed because of the time required in the emergent setting. Variant 2: Major blunt trauma. Hemodynamically stable. Not otherwise specified. Initial imaging. CT Whole Body Currently, there is no practice consensus or validated decision rules for deciding which patients should receive WBCT versus selective CT imaging for blunt trauma. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no survival benefit [15]. Meta-analyses have yielded conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain WBCT versus selective CT.

Major Blunt Trauma. US FAST Scan Chest Abdomen Pelvis The role of FAST (or extended-FAST or chest abdominal-FAST in evaluating chest injury) is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT [9,10]. Extended-FAST has been found to be effective in ruling out pneumothorax [11]. Although ultrasound (US) may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to exclude injuries to these areas [5]. FAST has been found to have a high false-negative rate in patients with pelvic fractures [12]. Radiography Trauma Series Trauma series radiographs in the unstable patient typically consist of portable radiographs of the chest and pelvis. A portable anteroposterior (AP) chest radiograph helps screen for immediately life-threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13]. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. MRI Abdomen and Pelvis There is no relevant literature to support the use of MRI in the initial evaluation of the unstable trauma patient. MRI is not performed because of the time required in the emergent setting. Variant 2: Major blunt trauma. Hemodynamically stable. Not otherwise specified. Initial imaging. CT Whole Body Currently, there is no practice consensus or validated decision rules for deciding which patients should receive WBCT versus selective CT imaging for blunt trauma. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no survival benefit [15]. Meta-analyses have yielded conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain WBCT versus selective CT.

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acrac_3102405_2

Major Blunt Trauma

Indications that may warrant WBCT imaging as defined above, include high-velocity (>35 mph) motor vehicle collision (MVC), MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC- pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST. CT of the chest, abdomen, and pelvis with IV contrast has greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8]. MRI Abdomen and Pelvis There is no relevant literature to support the initial use of MRI in patients who are hemodynamically stable, not otherwise specified. US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT. Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to fully exclude injuries to these areas [5]. Major Blunt Trauma Fluoroscopy Retrograde Urethrography There is no relevant literature to support the use of retrograde urethrography in patients with major blunt trauma who are hemodynamically stable, not otherwise specified. Refer to Variant 6 if there is suspicion of urinary tract injury. CT Whole Body The decision regarding which patients should receive WBCT versus selective CT imaging for blunt trauma will depend on factors beyond facial injury.

Major Blunt Trauma. Indications that may warrant WBCT imaging as defined above, include high-velocity (>35 mph) motor vehicle collision (MVC), MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC- pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST. CT of the chest, abdomen, and pelvis with IV contrast has greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8]. MRI Abdomen and Pelvis There is no relevant literature to support the initial use of MRI in patients who are hemodynamically stable, not otherwise specified. US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT. Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to fully exclude injuries to these areas [5]. Major Blunt Trauma Fluoroscopy Retrograde Urethrography There is no relevant literature to support the use of retrograde urethrography in patients with major blunt trauma who are hemodynamically stable, not otherwise specified. Refer to Variant 6 if there is suspicion of urinary tract injury. CT Whole Body The decision regarding which patients should receive WBCT versus selective CT imaging for blunt trauma will depend on factors beyond facial injury.

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acrac_3102405_3

Major Blunt Trauma

Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST. CT of the chest, abdomen, and pelvis with IV contrast has greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8]. Radiography Trauma Series In the setting of blunt facial trauma, facial and cervical lateral radiographs may also be part of the initial trauma series radiographs, which also typically consists of portable radiographs of the chest and pelvis. Single cervical radiographs can rapidly evaluate for severe fracture, abnormal alignment, and prevertebral swelling, but it may miss nondisplaced fractures that are evident on CT. The portable AP chest radiograph helps screen for immediately life- threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13]. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. Variant 4: Major blunt trauma. Hemodynamically stable. Suspected extremity trauma.

Major Blunt Trauma. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST. CT of the chest, abdomen, and pelvis with IV contrast has greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8]. Radiography Trauma Series In the setting of blunt facial trauma, facial and cervical lateral radiographs may also be part of the initial trauma series radiographs, which also typically consists of portable radiographs of the chest and pelvis. Single cervical radiographs can rapidly evaluate for severe fracture, abnormal alignment, and prevertebral swelling, but it may miss nondisplaced fractures that are evident on CT. The portable AP chest radiograph helps screen for immediately life- threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13]. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. Variant 4: Major blunt trauma. Hemodynamically stable. Suspected extremity trauma.

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acrac_3102405_4

Major Blunt Trauma

Initial imaging. The body regions covered in this clinical scenario are the upper extremity and lower extremity. CT Whole Body Currently, there is no practice consensus or validated decision rules for deciding which patients should receive WBCT versus selective CT imaging for blunt trauma, and extremity injuries alone will not determine which is Major Blunt Trauma appropriate. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST. CT of the chest, abdomen, and pelvis with IV contrast has greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8]. CT Extremity In certain cases, CT may be appropriate for fracture characterization, detection of radiographically occult fractures, or operative planning. CTA Extremity CT angiography (CTA) of an upper or lower extremity injury may also be considered and could be obtained during the same acquisition period to evaluate for extremity arterial injury when clinically suspected [24].

Major Blunt Trauma. Initial imaging. The body regions covered in this clinical scenario are the upper extremity and lower extremity. CT Whole Body Currently, there is no practice consensus or validated decision rules for deciding which patients should receive WBCT versus selective CT imaging for blunt trauma, and extremity injuries alone will not determine which is Major Blunt Trauma appropriate. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST. CT of the chest, abdomen, and pelvis with IV contrast has greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8]. CT Extremity In certain cases, CT may be appropriate for fracture characterization, detection of radiographically occult fractures, or operative planning. CTA Extremity CT angiography (CTA) of an upper or lower extremity injury may also be considered and could be obtained during the same acquisition period to evaluate for extremity arterial injury when clinically suspected [24].

3102405

acrac_3102405_5

Major Blunt Trauma

US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage regardless of extremity injuries; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT. Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to exclude injuries to these areas [5]. Radiography Extremity Single-view radiographs of the traumatized extremity take little time and are frequently included in this setting. Radiography Trauma Series Trauma series radiographs typically consist of portable radiographs of the chest and pelvis and/or cross table cervical spine. A portable AP chest radiograph helps screen for immediate life-threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13]. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. Radiographs of the suspected injured extremity are the first-line examination to be obtained. Variant 5: Major blunt trauma. Hemodynamically stable. Suspected bowel trauma. Initial imaging. CT Abdomen and Pelvis For blunt trauma, CT of the abdomen and pelvis with IV contrast is recommended, in the portal venous phase 70 seconds after contrast administration, for ideal characterization of solid organ injury. This may be obtained in conjunction with arterial phase images as well as delayed imaging of the abdomen and pelvis. The administration of oral contrast material has not been found to alter the sensitivity or specificity for blunt abdominal injuries and is not recommended because it can delay definitive diagnosis of other injuries [25]. Noncontrast CT of the abdomen and pelvis should ideally be avoided when possible because of its lower sensitivity for detecting both visceral organ and vascular injuries [19].

Major Blunt Trauma. US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage regardless of extremity injuries; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT. Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to exclude injuries to these areas [5]. Radiography Extremity Single-view radiographs of the traumatized extremity take little time and are frequently included in this setting. Radiography Trauma Series Trauma series radiographs typically consist of portable radiographs of the chest and pelvis and/or cross table cervical spine. A portable AP chest radiograph helps screen for immediate life-threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13]. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. Radiographs of the suspected injured extremity are the first-line examination to be obtained. Variant 5: Major blunt trauma. Hemodynamically stable. Suspected bowel trauma. Initial imaging. CT Abdomen and Pelvis For blunt trauma, CT of the abdomen and pelvis with IV contrast is recommended, in the portal venous phase 70 seconds after contrast administration, for ideal characterization of solid organ injury. This may be obtained in conjunction with arterial phase images as well as delayed imaging of the abdomen and pelvis. The administration of oral contrast material has not been found to alter the sensitivity or specificity for blunt abdominal injuries and is not recommended because it can delay definitive diagnosis of other injuries [25]. Noncontrast CT of the abdomen and pelvis should ideally be avoided when possible because of its lower sensitivity for detecting both visceral organ and vascular injuries [19].

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acrac_3102405_6

Major Blunt Trauma

CT Whole Body Currently, there is no consensus for deciding which patients should receive WBCT versus selective CT imaging of the abdomen and pelvis for blunt trauma with concern for bowel injury. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or Major Blunt Trauma FAST. CT of the chest, abdomen, and pelvis with IV contrast has greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8] CTA Abdomen and Pelvis CT in the arterial phase may be carried through the abdomen and pelvis to assess for active arterial bleeding to abdominopelvic viscera and soft tissues. If 3-D reconstructions are included, then it is considered a CTA study to more closely evaluate the arterial structures for findings such as pseudoaneurysm. CTA of the abdomen has been shown to detect more splenic vascular injuries than that of CT of the abdomen in the portal venous phase alone [26].

Major Blunt Trauma. CT Whole Body Currently, there is no consensus for deciding which patients should receive WBCT versus selective CT imaging of the abdomen and pelvis for blunt trauma with concern for bowel injury. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or Major Blunt Trauma FAST. CT of the chest, abdomen, and pelvis with IV contrast has greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8] CTA Abdomen and Pelvis CT in the arterial phase may be carried through the abdomen and pelvis to assess for active arterial bleeding to abdominopelvic viscera and soft tissues. If 3-D reconstructions are included, then it is considered a CTA study to more closely evaluate the arterial structures for findings such as pseudoaneurysm. CTA of the abdomen has been shown to detect more splenic vascular injuries than that of CT of the abdomen in the portal venous phase alone [26].

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acrac_3102405_7

Major Blunt Trauma

Unstable pelvic fractures, such as vertical shear and AP compression injury, are associated with higher rates of active hemorrhage, which can be accurately diagnosed by CTA and may require either surgical or vascular interventional treatment [27]. MRI Abdomen and Pelvis Blunt abdominal trauma is not typically evaluated by MRI because of the time of acquisition. However, some sites are moving toward the use of MRI in selected patients [28]. US Abdomen Although US may be able to diagnose certain abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to fully exclude abdominal injuries [29]. Bowel injury is a specific setting for which US is limited because of bowel gas. US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT. Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to exclude injuries to these areas [5]. US is not well suited for evaluation of bowel injury because significant fluid trapped in the mesentery may not be detected by FAST. Radiography Trauma Series Trauma series radiographs typically consist of portable radiographs of the chest and pelvis. A portable AP chest radiograph helps screen for immediately life-threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13]. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. There is no literature to support the use of trauma series radiographs in the detection of bowel injury. Variant 6: Major blunt trauma. Hemodynamically stable. Suspected urinary system, including urethra trauma. Initial imaging.

Major Blunt Trauma. Unstable pelvic fractures, such as vertical shear and AP compression injury, are associated with higher rates of active hemorrhage, which can be accurately diagnosed by CTA and may require either surgical or vascular interventional treatment [27]. MRI Abdomen and Pelvis Blunt abdominal trauma is not typically evaluated by MRI because of the time of acquisition. However, some sites are moving toward the use of MRI in selected patients [28]. US Abdomen Although US may be able to diagnose certain abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to fully exclude abdominal injuries [29]. Bowel injury is a specific setting for which US is limited because of bowel gas. US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT. Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to exclude injuries to these areas [5]. US is not well suited for evaluation of bowel injury because significant fluid trapped in the mesentery may not be detected by FAST. Radiography Trauma Series Trauma series radiographs typically consist of portable radiographs of the chest and pelvis. A portable AP chest radiograph helps screen for immediately life-threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13]. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. There is no literature to support the use of trauma series radiographs in the detection of bowel injury. Variant 6: Major blunt trauma. Hemodynamically stable. Suspected urinary system, including urethra trauma. Initial imaging.

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acrac_3102405_8

Major Blunt Trauma

CT Abdomen and Pelvis For blunt trauma, CT of the abdomen and pelvis with IV contrast is recommended, in the portal venous phase, 70 seconds after contrast administration for ideal characterization of solid organ injury, including the genitourinary system. This may be obtained in conjunction with CTA if there is a concern for renal infarction or arterial injury, as well as delayed imaging of the abdomen and pelvis if perinephric fluid suggests renal pelvis or ureteral trauma. The administration of oral contrast material has not been found to alter the sensitivity or specificity for blunt abdominal injuries and is not recommended because it can delay definitive diagnosis of other injuries [25]. Noncontrast CT of the abdomen and pelvis should ideally be avoided if there is no contraindication to IV contrast because of its lower sensitivity for detecting both visceral organ and vascular injuries [19]. CT Urography There is no relevant literature to support the use of CTU in the initial evaluation of patients who are hemodynamically stable with suspected urinary system or urethral trauma. CT Pelvis with Bladder Contrast (CT Cystography) Gross hematuria in the setting of blunt traumatic injury necessitates further evaluation with CT cystogram [30]. Urinary bladder injury typically occurs because of trauma to a distended urinary bladder and may or may not be accompanied by pelvic fractures. The absence of gross hematuria generally excludes the possibility of urinary bladder injury [31]. Deck et al [32,33] reported sensitivities of 95% overall but only 78% for intraperitoneal rupture. In another study with 100% sensitivity and 99% specificity for intraperitoneal bladder rupture, the specific sites of Major Blunt Trauma dome injuries in 4 of 18 patients were identified only with multiplanar reconstructed images [34]. A bladder contusion may not be visible by CT cystography.

Major Blunt Trauma. CT Abdomen and Pelvis For blunt trauma, CT of the abdomen and pelvis with IV contrast is recommended, in the portal venous phase, 70 seconds after contrast administration for ideal characterization of solid organ injury, including the genitourinary system. This may be obtained in conjunction with CTA if there is a concern for renal infarction or arterial injury, as well as delayed imaging of the abdomen and pelvis if perinephric fluid suggests renal pelvis or ureteral trauma. The administration of oral contrast material has not been found to alter the sensitivity or specificity for blunt abdominal injuries and is not recommended because it can delay definitive diagnosis of other injuries [25]. Noncontrast CT of the abdomen and pelvis should ideally be avoided if there is no contraindication to IV contrast because of its lower sensitivity for detecting both visceral organ and vascular injuries [19]. CT Urography There is no relevant literature to support the use of CTU in the initial evaluation of patients who are hemodynamically stable with suspected urinary system or urethral trauma. CT Pelvis with Bladder Contrast (CT Cystography) Gross hematuria in the setting of blunt traumatic injury necessitates further evaluation with CT cystogram [30]. Urinary bladder injury typically occurs because of trauma to a distended urinary bladder and may or may not be accompanied by pelvic fractures. The absence of gross hematuria generally excludes the possibility of urinary bladder injury [31]. Deck et al [32,33] reported sensitivities of 95% overall but only 78% for intraperitoneal rupture. In another study with 100% sensitivity and 99% specificity for intraperitoneal bladder rupture, the specific sites of Major Blunt Trauma dome injuries in 4 of 18 patients were identified only with multiplanar reconstructed images [34]. A bladder contusion may not be visible by CT cystography.

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acrac_3102405_9

Major Blunt Trauma

Routine CT, using excreted contrast only, cannot be relied on entirely to diagnose bladder rupture, even with a urethral catheter inserted and clamped [35-37]. CT performed with excreted contrast only can demonstrate intraperitoneal or extraperitoneal fluid, but it cannot differentiate urine from ascites. However, the absence of pelvic ascites is strong evidence against an intraperitoneal bladder rupture [38,39]. As with IV urography (IVU), the bladder is usually inadequately distended to cause extravasation through a bladder laceration or perforation during routine abdominal and pelvic studies. A negative study does not exclude bladder injury [40]. Although CT is not the technique of choice for urethral injuries, it is performed so frequently that urethral injuries are often identified when CT is performed for pelvic trauma. CT Whole Body No practice consensus or validated decision rules currently exist for deciding which patients should receive WBCT versus selective CT imaging of the abdomen and pelvis for blunt trauma. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST.

Major Blunt Trauma. Routine CT, using excreted contrast only, cannot be relied on entirely to diagnose bladder rupture, even with a urethral catheter inserted and clamped [35-37]. CT performed with excreted contrast only can demonstrate intraperitoneal or extraperitoneal fluid, but it cannot differentiate urine from ascites. However, the absence of pelvic ascites is strong evidence against an intraperitoneal bladder rupture [38,39]. As with IV urography (IVU), the bladder is usually inadequately distended to cause extravasation through a bladder laceration or perforation during routine abdominal and pelvic studies. A negative study does not exclude bladder injury [40]. Although CT is not the technique of choice for urethral injuries, it is performed so frequently that urethral injuries are often identified when CT is performed for pelvic trauma. CT Whole Body No practice consensus or validated decision rules currently exist for deciding which patients should receive WBCT versus selective CT imaging of the abdomen and pelvis for blunt trauma. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST.

3102405

acrac_3102405_10

Major Blunt Trauma

CT of the chest, abdomen, and pelvis with IV contrast have greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8]. CTA Abdomen and Pelvis CTA of the abdomen and pelvis may be performed to assess for active arterial bleeding. CTA of the abdomen has been shown to detect splenic vascular injuries more often than CT of the abdomen in the portal venous phase alone [26]. However, arterial phase imaging without 3-D reformations can also detect bleeding. Unstable pelvic fractures, such as vertical shear and AP compression injury, are associated with higher rates of active hemorrhage and may require either surgical or vascular interventional treatment [27]. MRI Abdomen and Pelvis There is no relevant literature to support the use of MRI of the abdomen and pelvis in the initial evaluation of patients who are hemodynamically stable with suspected urinary system or urethral trauma. MR Urography There is no relevant literature to support the use of MRU in the initial evaluation of patients who are hemodynamically stable with suspected urinary system or urethral trauma. US Abdomen and Pelvis Although US may be able to diagnose certain abdominal injuries, its relatively lower sensitivity compared with CT does not make it a sufficient test to exclude abdominal injuries [29,41,42]. Extraperitoneal and genitourinary injuries are more likely to be missed than intraperitoneal injuries [41,42]. US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT.

Major Blunt Trauma. CT of the chest, abdomen, and pelvis with IV contrast have greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8]. CTA Abdomen and Pelvis CTA of the abdomen and pelvis may be performed to assess for active arterial bleeding. CTA of the abdomen has been shown to detect splenic vascular injuries more often than CT of the abdomen in the portal venous phase alone [26]. However, arterial phase imaging without 3-D reformations can also detect bleeding. Unstable pelvic fractures, such as vertical shear and AP compression injury, are associated with higher rates of active hemorrhage and may require either surgical or vascular interventional treatment [27]. MRI Abdomen and Pelvis There is no relevant literature to support the use of MRI of the abdomen and pelvis in the initial evaluation of patients who are hemodynamically stable with suspected urinary system or urethral trauma. MR Urography There is no relevant literature to support the use of MRU in the initial evaluation of patients who are hemodynamically stable with suspected urinary system or urethral trauma. US Abdomen and Pelvis Although US may be able to diagnose certain abdominal injuries, its relatively lower sensitivity compared with CT does not make it a sufficient test to exclude abdominal injuries [29,41,42]. Extraperitoneal and genitourinary injuries are more likely to be missed than intraperitoneal injuries [41,42]. US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT.

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acrac_3102405_11

Major Blunt Trauma

Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower sensitivity compared with CT does not make it a sufficient test to exclude injuries to these areas, particularly extraperitoneal or genitourinary injuries [5,41,42]. In a series of 128 acute trauma patients, 11 of 19 injuries that were missed by emergent US involved the genitourinary system [41]. The detection of peritoneal fluid in the presence of normal viscera or the failure to visualize the bladder after the transurethral introduction of saline is considered highly suggestive of bladder rupture [35]. As a practical matter, US is not definitive in bladder or urethral trauma and is almost never used for this indication. Radiography Intravenous Urography There is no relevant literature to support the use of IVU in patients who are hemodynamically stable with suspected urinary system or urethral trauma. IVU has a low accuracy, on the order of 15% to 25% [43]. In one study, an Major Blunt Trauma accurate diagnosis of bladder rupture was made with IVU in only 5 of 23 (22%) patients [44]. Carroll and McAninch [45] found an accurate diagnosis for only 5 of 32 (16%) patients, and Werkman et al [46] found an accuracy rate for only 4 of 11 (36%) patients. Fluoroscopy Retrograde Urethrography In a male, gross blood at the urethral meatus may indicate a urethral injury, which warrants further evaluation with a retrograde urethrogram to evaluate urethral integrity [47]. Radiography Trauma Series Trauma series radiographs typically consist of portable radiographs of the chest and pelvis. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. A pelvic injury is associated with genitourinary trauma. A portable AP chest radiograph helps screen for immediately life-threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13]. Variant 7: Major blunt trauma. Hemodynamically stable.

Major Blunt Trauma. Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower sensitivity compared with CT does not make it a sufficient test to exclude injuries to these areas, particularly extraperitoneal or genitourinary injuries [5,41,42]. In a series of 128 acute trauma patients, 11 of 19 injuries that were missed by emergent US involved the genitourinary system [41]. The detection of peritoneal fluid in the presence of normal viscera or the failure to visualize the bladder after the transurethral introduction of saline is considered highly suggestive of bladder rupture [35]. As a practical matter, US is not definitive in bladder or urethral trauma and is almost never used for this indication. Radiography Intravenous Urography There is no relevant literature to support the use of IVU in patients who are hemodynamically stable with suspected urinary system or urethral trauma. IVU has a low accuracy, on the order of 15% to 25% [43]. In one study, an Major Blunt Trauma accurate diagnosis of bladder rupture was made with IVU in only 5 of 23 (22%) patients [44]. Carroll and McAninch [45] found an accurate diagnosis for only 5 of 32 (16%) patients, and Werkman et al [46] found an accuracy rate for only 4 of 11 (36%) patients. Fluoroscopy Retrograde Urethrography In a male, gross blood at the urethral meatus may indicate a urethral injury, which warrants further evaluation with a retrograde urethrogram to evaluate urethral integrity [47]. Radiography Trauma Series Trauma series radiographs typically consist of portable radiographs of the chest and pelvis. A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. A pelvic injury is associated with genitourinary trauma. A portable AP chest radiograph helps screen for immediately life-threatening findings, such as tension pneumothorax and significant mediastinal injury, as well as confirms line placement [13]. Variant 7: Major blunt trauma. Hemodynamically stable.

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acrac_3102405_12

Major Blunt Trauma

Suspected chest trauma. Initial imaging. CT Chest Noncontrast CT of the chest can detect most injuries, including rib fractures, pneumothorax, hemothorax, and pulmonary contusion, but has a lower sensitivity for detecting vascular injuries [20]. Contrast-enhanced CT of the chest is the preferred imaging workup of suspected chest trauma. Regardless of contrast administration, CT is more sensitive and specific for chest trauma than conventional radiographs [48,49]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8]. CT Whole Body Currently, there is no practice consensus or validated decision rules for deciding which patients should receive WBCT versus selective chest CT imaging for blunt trauma with concern for a chest injury. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST. CT of the chest, abdomen, and pelvis with IV contrast have greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20].

Major Blunt Trauma. Suspected chest trauma. Initial imaging. CT Chest Noncontrast CT of the chest can detect most injuries, including rib fractures, pneumothorax, hemothorax, and pulmonary contusion, but has a lower sensitivity for detecting vascular injuries [20]. Contrast-enhanced CT of the chest is the preferred imaging workup of suspected chest trauma. Regardless of contrast administration, CT is more sensitive and specific for chest trauma than conventional radiographs [48,49]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8]. CT Whole Body Currently, there is no practice consensus or validated decision rules for deciding which patients should receive WBCT versus selective chest CT imaging for blunt trauma with concern for a chest injury. Some studies have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST. CT of the chest, abdomen, and pelvis with IV contrast have greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20].

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acrac_3102405_13

Major Blunt Trauma

CTA Chest CT of the chest is warranted in the arterial phase primarily when there is a concern for aortic or other major vessel injury [20]. A delayed scan may be obtained, depending on the findings on the arterial phase CT. US Chest There is no relevant literature to support the use of non-US FAST of the chest in patients who are hemodynamically stable with suspected chest trauma. Its use in detection of pleural fluid and pneumothorax is increasing, but it has not gained acceptance for comprehensive evaluation of blunt chest trauma because of its lack of sensitivity for pulmonary, aortic, cardiac, and musculoskeletal injury [49]. US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT. Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to exclude injuries to these areas [5]. Its use in detection of pleural fluid and pneumothorax is increasing, but it has not gained acceptance for a comprehensive evaluation of blunt chest trauma because of its lack of sensitivity for pulmonary, aortic, cardiac, and musculoskeletal injury. Radiography Trauma Series Trauma series radiographs typically consist of portable radiographs of the chest and pelvis. In a patient with suspicion of chest trauma, a rapid assessment with chest radiographs plays a key role in initial workup. A portable AP chest radiograph helps screen for immediate life-threatening findings, such as tension pneumothorax and Major Blunt Trauma A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. Compared with CT, pelvic radiographs also have lower sensitivity for detecting injury. In a study of 509 consecutive trauma patients, the sensitivity of the AP pelvic radiographs was 77% using CT as the reference standard [53].

Major Blunt Trauma. CTA Chest CT of the chest is warranted in the arterial phase primarily when there is a concern for aortic or other major vessel injury [20]. A delayed scan may be obtained, depending on the findings on the arterial phase CT. US Chest There is no relevant literature to support the use of non-US FAST of the chest in patients who are hemodynamically stable with suspected chest trauma. Its use in detection of pleural fluid and pneumothorax is increasing, but it has not gained acceptance for comprehensive evaluation of blunt chest trauma because of its lack of sensitivity for pulmonary, aortic, cardiac, and musculoskeletal injury [49]. US FAST Scan Chest Abdomen Pelvis The role of FAST is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT. Although US may be able to diagnose certain thoracic and abdominal injuries, its relatively lower specificity compared with CT does not make it a sufficient test to exclude injuries to these areas [5]. Its use in detection of pleural fluid and pneumothorax is increasing, but it has not gained acceptance for a comprehensive evaluation of blunt chest trauma because of its lack of sensitivity for pulmonary, aortic, cardiac, and musculoskeletal injury. Radiography Trauma Series Trauma series radiographs typically consist of portable radiographs of the chest and pelvis. In a patient with suspicion of chest trauma, a rapid assessment with chest radiographs plays a key role in initial workup. A portable AP chest radiograph helps screen for immediate life-threatening findings, such as tension pneumothorax and Major Blunt Trauma A portable radiograph of the pelvis can evaluate for unstable pelvic injuries and hip dislocation [4]. Compared with CT, pelvic radiographs also have lower sensitivity for detecting injury. In a study of 509 consecutive trauma patients, the sensitivity of the AP pelvic radiographs was 77% using CT as the reference standard [53].

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acrac_3102405_14

Major Blunt Trauma

The most common injury misses were the ones to the sacrum, sacroiliac joints, and loose bodies in the hip joints. MRI Chest There is no relevant literature to support the use of MRI for the initial evaluation of blunt chest trauma. It is not routinely performed because of the time required in the emergent setting. Use of MRI is mainly reserved for problem solving of findings identified on initial imaging studies. Variant 8: Major blunt trauma. Hemodynamically stable. Pregnant patient. Initial imaging. CT Abdomen and Pelvis For blunt trauma in a pregnant woman, CT of the abdomen and pelvis with IV contrast may still be recommended when there is a life-threatening concern for the mother or fetus. The study is typically performed in the portal venous phase, 70 seconds after contrast administration, for ideal characterization of solid organ injury. This may be obtained in conjunction with CTA as well as delayed imaging of the abdomen and pelvis. The administration of oral contrast material has not been found to alter the sensitivity or specificity for blunt abdominal injuries and is not recommended because it can delay definitive diagnosis of other injuries [25]. Noncontrast CT of the abdomen and pelvis should ideally be avoided because of its lower sensitivity for detecting both visceral organ and vascular injuries [19]. CT Whole Body Risks and benefits must be specifically weighed regarding CT imaging of the pregnant patient. No practice consensus or validated decision rules currently exist for deciding which patients should receive WBCT versus selective CT imaging for blunt trauma. Some studies in nonpregnant patients have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT.

Major Blunt Trauma. The most common injury misses were the ones to the sacrum, sacroiliac joints, and loose bodies in the hip joints. MRI Chest There is no relevant literature to support the use of MRI for the initial evaluation of blunt chest trauma. It is not routinely performed because of the time required in the emergent setting. Use of MRI is mainly reserved for problem solving of findings identified on initial imaging studies. Variant 8: Major blunt trauma. Hemodynamically stable. Pregnant patient. Initial imaging. CT Abdomen and Pelvis For blunt trauma in a pregnant woman, CT of the abdomen and pelvis with IV contrast may still be recommended when there is a life-threatening concern for the mother or fetus. The study is typically performed in the portal venous phase, 70 seconds after contrast administration, for ideal characterization of solid organ injury. This may be obtained in conjunction with CTA as well as delayed imaging of the abdomen and pelvis. The administration of oral contrast material has not been found to alter the sensitivity or specificity for blunt abdominal injuries and is not recommended because it can delay definitive diagnosis of other injuries [25]. Noncontrast CT of the abdomen and pelvis should ideally be avoided because of its lower sensitivity for detecting both visceral organ and vascular injuries [19]. CT Whole Body Risks and benefits must be specifically weighed regarding CT imaging of the pregnant patient. No practice consensus or validated decision rules currently exist for deciding which patients should receive WBCT versus selective CT imaging for blunt trauma. Some studies in nonpregnant patients have found a survival benefit to WBCT compared with selective CT [14], whereas others have found no mortality benefit [15]. Meta-analyses have found conflicting results with respect to improvements in mortality [16-18]. Therefore, clinical judgement remains vital for determining which patients should obtain selective CT versus WBCT.

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acrac_3102405_15

Major Blunt Trauma

Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST. CT of the chest, abdomen, and pelvis with IV contrast has greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8]. CTA Abdomen and Pelvis CTA may be carried through the abdomen and pelvis to assess for active arterial bleeding to abdominopelvic viscera and soft tissues. CTA of the abdomen has been shown to detect more splenic vascular injuries than CT of the abdomen in the portal venous phase alone [26]. Unstable pelvic fractures, such as vertical shear and AP compression injury, are associated with higher rates of active hemorrhage and may require either surgical or vascular interventional treatment [27]. Major Blunt Trauma CTA Chest CTA of the chest is warranted in the arterial phase primarily to assess for aortic or other major vessel injury, in addition to other injuries within the chest [20]. Noncontrast CT of the chest should be avoided because of its lower sensitivity for detecting vascular injuries [20]. MRI Abdomen and Pelvis There is no relevant literature to support the use of MRI abdomen and pelvis in patients who are hemodynamically stable and pregnant.

Major Blunt Trauma. Indications that may warrant WBCT imaging as defined above include high-velocity (>35 mph) MVC, MVC resulting in rollover or passenger ejection, motorcycle trauma, bicycle injury, MVC-pedestrian collision, and a fall from a height of >15 feet. Additional considerations include patient age and functional status, hemodynamic stability, neurological status, and results of initial imaging from portable radiographs of the chest and pelvis, and/or FAST. CT of the chest, abdomen, and pelvis with IV contrast has greater sensitivity for detecting visceral organ and vascular injury compared with noncontrast CT, and contrast-enhanced CT of these areas should be primarily considered unless absolutely contraindicated [19,20]. Patients who have an abnormal chest radiograph in the setting of trauma have clinically significant rates of major injury on CT chest [8]. CTA Abdomen and Pelvis CTA may be carried through the abdomen and pelvis to assess for active arterial bleeding to abdominopelvic viscera and soft tissues. CTA of the abdomen has been shown to detect more splenic vascular injuries than CT of the abdomen in the portal venous phase alone [26]. Unstable pelvic fractures, such as vertical shear and AP compression injury, are associated with higher rates of active hemorrhage and may require either surgical or vascular interventional treatment [27]. Major Blunt Trauma CTA Chest CTA of the chest is warranted in the arterial phase primarily to assess for aortic or other major vessel injury, in addition to other injuries within the chest [20]. Noncontrast CT of the chest should be avoided because of its lower sensitivity for detecting vascular injuries [20]. MRI Abdomen and Pelvis There is no relevant literature to support the use of MRI abdomen and pelvis in patients who are hemodynamically stable and pregnant.

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acrac_69433_0

Shoulder Pain Traumatic PCAs

Introduction/Background Traumatic shoulder pain is shoulder pain believed to be directly attributed to a traumatic event, either acute or chronic. This pain may be the result of either fracture (the clavicle, scapula, or proximal humerus) or soft-tissue injury (most commonly of the rotator cuff, acromioclavicular ligaments, or labroligamentous complex). The incidence of traumatic shoulder injuries is difficult to determine because some injury types, such as low-grade acromioclavicular separations or acute rotator cuff tears, are likely under-reported because patients do not seek immediate medical treatment. However, as with many traumatic injuries, traumatic shoulder pain tends to disproportionately involve young adults and male patients [1,2]. The etiology of traumatic shoulder pain can often be made based on clinical examination, radiographs, and mechanism of injury. Traumatic shoulder injuries can generally be separated into injuries requiring acute surgical management and injuries in which conservative management can be attempted prior to considering surgical treatment. Unstable or significantly displaced fractures and joint instability are injuries most likely requiring acute surgical treatment. Most soft-tissue injuries (such as labral tears and rotator cuff tears) can undergo a period of conservative management prior to considering surgery. However, in addition to the specific imaging findings related to a traumatic injury, indications and timing of surgical treatment of many traumatic shoulder injuries are dependent on patient age, comorbidities, current activity level, and expected activity level. Discussion of Procedures by Variant Discussion of Procedures by Variant Variant 1: Traumatic shoulder pain. Any etiology. Initial imaging. Radiography Shoulder Radiographs are the preferred initial study performed in the setting of traumatic shoulder pain. They can delineate shoulder malalignment and most shoulder fractures [4,5].

Shoulder Pain Traumatic PCAs. Introduction/Background Traumatic shoulder pain is shoulder pain believed to be directly attributed to a traumatic event, either acute or chronic. This pain may be the result of either fracture (the clavicle, scapula, or proximal humerus) or soft-tissue injury (most commonly of the rotator cuff, acromioclavicular ligaments, or labroligamentous complex). The incidence of traumatic shoulder injuries is difficult to determine because some injury types, such as low-grade acromioclavicular separations or acute rotator cuff tears, are likely under-reported because patients do not seek immediate medical treatment. However, as with many traumatic injuries, traumatic shoulder pain tends to disproportionately involve young adults and male patients [1,2]. The etiology of traumatic shoulder pain can often be made based on clinical examination, radiographs, and mechanism of injury. Traumatic shoulder injuries can generally be separated into injuries requiring acute surgical management and injuries in which conservative management can be attempted prior to considering surgical treatment. Unstable or significantly displaced fractures and joint instability are injuries most likely requiring acute surgical treatment. Most soft-tissue injuries (such as labral tears and rotator cuff tears) can undergo a period of conservative management prior to considering surgery. However, in addition to the specific imaging findings related to a traumatic injury, indications and timing of surgical treatment of many traumatic shoulder injuries are dependent on patient age, comorbidities, current activity level, and expected activity level. Discussion of Procedures by Variant Discussion of Procedures by Variant Variant 1: Traumatic shoulder pain. Any etiology. Initial imaging. Radiography Shoulder Radiographs are the preferred initial study performed in the setting of traumatic shoulder pain. They can delineate shoulder malalignment and most shoulder fractures [4,5].

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Shoulder Pain Traumatic PCAs

A standard set of shoulder radiographs for trauma should include at least three views: anterior-posterior (AP) views in internal and external rotation and an axillary or scapula-Y view. Axillary or scapula-Y views are vital in evaluating traumatic shoulder injuries as acromioclavicular and glenohumeral dislocations can be misclassified on AP views [6,7]. Radiographs provide good delineation of bony anatomy to assess for fracture and appropriate shoulder alignment, which are the two primary concerns in management of acute traumatic shoulder pain. Radiographs should also be performed upright since malalignment of the shoulder can be under-represented on supine radiographs [4]. Additional views, such as the Bernageau view, have been shown to be effective in demonstrating the degree of bone loss of the glenoid or humeral head [8]. CT Shoulder Computed tomography (CT) is better able than radiographs to characterize fracture patterns [9-11]. However, radiographs are preferred over CT for initial evaluation because radiographs are able to diagnose displaced The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] fractures and shoulder malalignment, which are the primary concerns in the initial assessment of shoulder trauma. CT is considered inferior to MRI for diagnosing essentially all soft-tissue shoulder injuries. CT Arthrography Shoulder CT arthrogram, although not the initial study of choice, has the advantage of characterizing both bony lesions and significant soft-tissue injuries.

Shoulder Pain Traumatic PCAs. A standard set of shoulder radiographs for trauma should include at least three views: anterior-posterior (AP) views in internal and external rotation and an axillary or scapula-Y view. Axillary or scapula-Y views are vital in evaluating traumatic shoulder injuries as acromioclavicular and glenohumeral dislocations can be misclassified on AP views [6,7]. Radiographs provide good delineation of bony anatomy to assess for fracture and appropriate shoulder alignment, which are the two primary concerns in management of acute traumatic shoulder pain. Radiographs should also be performed upright since malalignment of the shoulder can be under-represented on supine radiographs [4]. Additional views, such as the Bernageau view, have been shown to be effective in demonstrating the degree of bone loss of the glenoid or humeral head [8]. CT Shoulder Computed tomography (CT) is better able than radiographs to characterize fracture patterns [9-11]. However, radiographs are preferred over CT for initial evaluation because radiographs are able to diagnose displaced The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] fractures and shoulder malalignment, which are the primary concerns in the initial assessment of shoulder trauma. CT is considered inferior to MRI for diagnosing essentially all soft-tissue shoulder injuries. CT Arthrography Shoulder CT arthrogram, although not the initial study of choice, has the advantage of characterizing both bony lesions and significant soft-tissue injuries.

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Shoulder Pain Traumatic PCAs

CT arthrograms have been shown to be comparable to magnetic resonance (MR) arthrography in diagnosing Bankart, Hill-Sachs, superior labral anterior-to-posterior (SLAP), and full-thickness rotator cuff tears, but inferior to MR arthrography for diagnosing partial-thickness rotator cuff tears [12], including bursal-sided tears. CT arthrography has also only demonstrated modest agreement between observers in diagnosing anterior capsular laxity of the shoulder [13]. MRI Shoulder Noncontrast MR imaging (MRI) has been shown to be effective in assessing bony morphology and bone loss in patients with traumatic shoulder injuries [14-18], and noncontrast MRI is effective in diagnosing most traumatic soft-tissue pathologies including labral, rotator cuff, and glenohumeral ligament injuries [17,19,20]. MR Arthrography Shoulder MR arthrography is considered the gold standard for imaging traumatic shoulder pain [4,17,19,21]. MR arthrography is comparable to noncontrast MRI in assessment of extra-articular soft tissues, and MR arthrography has been shown to be superior to noncontrast MRI in diagnosing intra-articular pathology like SLAP tears, labroligamentous injuries, and partial rotator cuff tears [17,19]. MR arthrography is comparable to CT in evaluating traumatic osseous lesions, such as bony Bankart and Hill-Sachs lesions [12,18]. However, the need for an invasive procedure makes MR arthrography a suboptimal initial study. US Shoulder Ultrasound (US) has limited usefulness in patients with traumatic shoulder pain that cannot be localized to the rotator cuff or biceps tendon. US is comparable to MRI in evaluating full-thickness rotator cuff tears and rotator cuff atrophy [17,22,23]. However, US is inferior to MRI in evaluating partial-thickness rotator cuff tears and other intra-articular pathology [17,24].

Shoulder Pain Traumatic PCAs. CT arthrograms have been shown to be comparable to magnetic resonance (MR) arthrography in diagnosing Bankart, Hill-Sachs, superior labral anterior-to-posterior (SLAP), and full-thickness rotator cuff tears, but inferior to MR arthrography for diagnosing partial-thickness rotator cuff tears [12], including bursal-sided tears. CT arthrography has also only demonstrated modest agreement between observers in diagnosing anterior capsular laxity of the shoulder [13]. MRI Shoulder Noncontrast MR imaging (MRI) has been shown to be effective in assessing bony morphology and bone loss in patients with traumatic shoulder injuries [14-18], and noncontrast MRI is effective in diagnosing most traumatic soft-tissue pathologies including labral, rotator cuff, and glenohumeral ligament injuries [17,19,20]. MR Arthrography Shoulder MR arthrography is considered the gold standard for imaging traumatic shoulder pain [4,17,19,21]. MR arthrography is comparable to noncontrast MRI in assessment of extra-articular soft tissues, and MR arthrography has been shown to be superior to noncontrast MRI in diagnosing intra-articular pathology like SLAP tears, labroligamentous injuries, and partial rotator cuff tears [17,19]. MR arthrography is comparable to CT in evaluating traumatic osseous lesions, such as bony Bankart and Hill-Sachs lesions [12,18]. However, the need for an invasive procedure makes MR arthrography a suboptimal initial study. US Shoulder Ultrasound (US) has limited usefulness in patients with traumatic shoulder pain that cannot be localized to the rotator cuff or biceps tendon. US is comparable to MRI in evaluating full-thickness rotator cuff tears and rotator cuff atrophy [17,22,23]. However, US is inferior to MRI in evaluating partial-thickness rotator cuff tears and other intra-articular pathology [17,24].

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Shoulder Pain Traumatic PCAs

Diagnosis of proximal humerus fractures by US has been described [25], but US is not generally considered a preferred imaging modality for assessing osseous pathology, which are of primary concern in initial assessment of traumatic shoulder pain. FDG-PET/CT Skull Base to Mid-Thigh Positron emission tomography (PET) (usually using the fluorine-18-2-fluoro-2-deoxy-D-glucose [FDG] tracer) imaging is rarely used in assessment of traumatic shoulder pain. FDG-PET is sensitive for inflammation, and a correlation has been found between radiotracer activity and degree of shoulder pain [26]. However, increased radiotracer activity may be due to infectious, traumatic, inflammatory, or neoplastic processes, making this activity a nonspecific finding. FDG-PET imaging as an isolated modality has relatively poor resolution for pathology localization compared with other imaging modalities; however, FDG-PET imaging can be performed in conjunction with MRI or CT for better localization of radiotracer activity. FDG-PET in combination with CT (FDG-PET/CT) is sensitive for identifying fractures, and it has been shown to be reliable in differentiating benign from malignant pathologic fractures [27]. FDG-PET/CT imaging is not routinely performed for characterization of soft-tissue injuries of the shoulder. Indirect identification of symptomatic rotator cuff tears has been described on FDG-PET/CT by decreased radiotracer activity in the muscles of the torn tendons and increased activity of surrounding shoulder girdle muscles due to muscle recruitment [28,29]. Other soft-tissue injuries, such as labral and cartilage injuries, have not been described using FDG-PET/CT. Bone Scan Shoulder Tc-99m bone scintigraphy is rarely used in the assessment of traumatic shoulder pain. Bone scintigraphy demonstrates increased activity in many post-traumatic shoulder pathologies, such as fracture, rotator cuff tear, or adhesive capsulitis [30].

Shoulder Pain Traumatic PCAs. Diagnosis of proximal humerus fractures by US has been described [25], but US is not generally considered a preferred imaging modality for assessing osseous pathology, which are of primary concern in initial assessment of traumatic shoulder pain. FDG-PET/CT Skull Base to Mid-Thigh Positron emission tomography (PET) (usually using the fluorine-18-2-fluoro-2-deoxy-D-glucose [FDG] tracer) imaging is rarely used in assessment of traumatic shoulder pain. FDG-PET is sensitive for inflammation, and a correlation has been found between radiotracer activity and degree of shoulder pain [26]. However, increased radiotracer activity may be due to infectious, traumatic, inflammatory, or neoplastic processes, making this activity a nonspecific finding. FDG-PET imaging as an isolated modality has relatively poor resolution for pathology localization compared with other imaging modalities; however, FDG-PET imaging can be performed in conjunction with MRI or CT for better localization of radiotracer activity. FDG-PET in combination with CT (FDG-PET/CT) is sensitive for identifying fractures, and it has been shown to be reliable in differentiating benign from malignant pathologic fractures [27]. FDG-PET/CT imaging is not routinely performed for characterization of soft-tissue injuries of the shoulder. Indirect identification of symptomatic rotator cuff tears has been described on FDG-PET/CT by decreased radiotracer activity in the muscles of the torn tendons and increased activity of surrounding shoulder girdle muscles due to muscle recruitment [28,29]. Other soft-tissue injuries, such as labral and cartilage injuries, have not been described using FDG-PET/CT. Bone Scan Shoulder Tc-99m bone scintigraphy is rarely used in the assessment of traumatic shoulder pain. Bone scintigraphy demonstrates increased activity in many post-traumatic shoulder pathologies, such as fracture, rotator cuff tear, or adhesive capsulitis [30].

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Shoulder Pain Traumatic PCAs

Bone scintigraphy as an isolated modality has relatively poor resolution for pathology localization compared with other imaging modalities; however, bone scintigraphy can be performed in conjunction with MRI or CT for better localization of radiotracer activity. Bone scintigraphy has sensitivity and specificity comparable to MRI in diagnosis of occult bone fractures, and it can be used to identify other foci of bone involvement in pathologic fractures due to metastatic disease [31,32]. Increased radiotracer activity has been associated with symptomatic rotator cuff tears, but bone scintigraphy appearance of other soft-tissue injuries of the shoulder have not been well described [33]. Variant 2: Traumatic shoulder pain. Nonlocalized shoulder pain. Negative radiographs. Next imaging study. Appropriately positioned radiographs can exclude shoulder dislocation and most displaced fractures as the etiology for post-traumatic shoulder pain. In the setting of normal shoulder radiographs, the most common causes of post-traumatic shoulder pain are soft-tissue injuries such as rotator cuff and labral tears. MRI Shoulder Noncontrast MRI is a reasonable imaging study in the setting of acute nonlocalized traumatic shoulder pain and noncontributory radiographs. In the acute trauma setting, noncontrast MRI may be preferred to MR arthrography, as acute intra-articular pathology will typically produce significant joint effusion for assessment of intra-articular soft-tissue structures. MRI is the preferred imaging modality in assessing extra-articular soft-tissue traumatic pathology such as capsular and ligament tears [34,35]. MRI is also sensitive for diagnosing bone marrow contusion and has been shown to be beneficial in assessing shoulder physeal injuries in pediatric patients [36,37]. MR Arthrography Shoulder MR arthrography has been found to be superior to noncontrast MRI in the diagnosis of labroligamentous and partial-thickness rotator cuff tears [17,19].

Shoulder Pain Traumatic PCAs. Bone scintigraphy as an isolated modality has relatively poor resolution for pathology localization compared with other imaging modalities; however, bone scintigraphy can be performed in conjunction with MRI or CT for better localization of radiotracer activity. Bone scintigraphy has sensitivity and specificity comparable to MRI in diagnosis of occult bone fractures, and it can be used to identify other foci of bone involvement in pathologic fractures due to metastatic disease [31,32]. Increased radiotracer activity has been associated with symptomatic rotator cuff tears, but bone scintigraphy appearance of other soft-tissue injuries of the shoulder have not been well described [33]. Variant 2: Traumatic shoulder pain. Nonlocalized shoulder pain. Negative radiographs. Next imaging study. Appropriately positioned radiographs can exclude shoulder dislocation and most displaced fractures as the etiology for post-traumatic shoulder pain. In the setting of normal shoulder radiographs, the most common causes of post-traumatic shoulder pain are soft-tissue injuries such as rotator cuff and labral tears. MRI Shoulder Noncontrast MRI is a reasonable imaging study in the setting of acute nonlocalized traumatic shoulder pain and noncontributory radiographs. In the acute trauma setting, noncontrast MRI may be preferred to MR arthrography, as acute intra-articular pathology will typically produce significant joint effusion for assessment of intra-articular soft-tissue structures. MRI is the preferred imaging modality in assessing extra-articular soft-tissue traumatic pathology such as capsular and ligament tears [34,35]. MRI is also sensitive for diagnosing bone marrow contusion and has been shown to be beneficial in assessing shoulder physeal injuries in pediatric patients [36,37]. MR Arthrography Shoulder MR arthrography has been found to be superior to noncontrast MRI in the diagnosis of labroligamentous and partial-thickness rotator cuff tears [17,19].

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Shoulder Pain Traumatic PCAs

In the acute trauma setting, however, noncontrast MRI may be preferred to MR arthrography because acute intra-articular pathology will typically produce significant joint effusion for assessment of intra-articular soft-tissue structures. MRI is the preferred imaging modality in assessing extra-articular soft-tissue traumatic pathology such as capsular and ligament tears [34,35]. MRI is also sensitive for diagnosing bone marrow contusion and has been shown to be beneficial in assessing shoulder physeal injuries in pediatric patients [36,37]. US Shoulder US has limited usefulness in patients with traumatic shoulder pain that cannot be localized to the rotator cuff or biceps tendon. In the post-traumatic setting, US has been shown to detect abnormalities, including proximal humeral fractures [25]; however, recent studies on US performed for nonspecific shoulder pain have had conflicting results. US for persistent shoulder pain after trauma has been found to diagnose significant pathology, primarily fractures and rotator cuff tears, in 90% of patients [25]. However, 40% of patients presenting with nonspecific shoulder pain were found to have no significant pathology on US [38]. Additionally, US has been demonstrated to be inferior to MRI in assessment of labroligamentous, osseous, and rotator cuff pathology [17]. US can be considered as a screening tool in patients with persistent nonspecific shoulder pain after trauma, particularly in an older patient population in whom rotator cuff tears are more common. However, a low threshold should be maintained for performing additional imaging in the setting of a noncontributory shoulder US examination. CT Shoulder CT Shoulder CT has virtually no usefulness in diagnosing common traumatic soft-tissue injuries such as rotator cuff tears, labroligamentous injuries, and muscle tears.

Shoulder Pain Traumatic PCAs. In the acute trauma setting, however, noncontrast MRI may be preferred to MR arthrography because acute intra-articular pathology will typically produce significant joint effusion for assessment of intra-articular soft-tissue structures. MRI is the preferred imaging modality in assessing extra-articular soft-tissue traumatic pathology such as capsular and ligament tears [34,35]. MRI is also sensitive for diagnosing bone marrow contusion and has been shown to be beneficial in assessing shoulder physeal injuries in pediatric patients [36,37]. US Shoulder US has limited usefulness in patients with traumatic shoulder pain that cannot be localized to the rotator cuff or biceps tendon. In the post-traumatic setting, US has been shown to detect abnormalities, including proximal humeral fractures [25]; however, recent studies on US performed for nonspecific shoulder pain have had conflicting results. US for persistent shoulder pain after trauma has been found to diagnose significant pathology, primarily fractures and rotator cuff tears, in 90% of patients [25]. However, 40% of patients presenting with nonspecific shoulder pain were found to have no significant pathology on US [38]. Additionally, US has been demonstrated to be inferior to MRI in assessment of labroligamentous, osseous, and rotator cuff pathology [17]. US can be considered as a screening tool in patients with persistent nonspecific shoulder pain after trauma, particularly in an older patient population in whom rotator cuff tears are more common. However, a low threshold should be maintained for performing additional imaging in the setting of a noncontributory shoulder US examination. CT Shoulder CT Shoulder CT has virtually no usefulness in diagnosing common traumatic soft-tissue injuries such as rotator cuff tears, labroligamentous injuries, and muscle tears.

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Shoulder Pain Traumatic PCAs

Although CT is the gold standard for diagnosing and characterizing fractures, MRI has been shown to be equivalent to CT in diagnosing the nondisplaced fractures that are typically missed on radiographs. CT Arthrography Shoulder CT is inferior to MRI and US in diagnosing virtually all extra-articular traumatic soft-tissues injuries. CT is considered the gold standard in identifying fractures. However, MRI has shown to be equivalent to CT in assessing bone loss [12,18], and MRI is usually adequate for diagnosing the nondisplaced fractures that are typically missed on conventional radiographs. CT arthrography is able to reliably evaluate for glenohumeral cartilage injury, SLAP tears, and labroligamentous injuries [12,39] but is generally considered inferior to MRI in diagnosing rotator cuff and soft-tissue Bankart lesions [12]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT imaging is rarely used in assessment of traumatic shoulder pain. FDG-PET is sensitive for inflammation, and a correlation has been found between radiotracer activity and degree of shoulder pain [26]. However, increased radiotracer activity may be due to infectious, traumatic, inflammatory, or neoplastic processes, making this activity a nonspecific finding. FDG-PET imaging as an isolated modality has relatively poor resolution for pathology localization compared with other imaging modalities, although, FDG-PET imaging can be performed in conjunction with MRI or CT for better localization of radiotracer activity. FDG-PET in combination with CT is sensitive for identifying fractures, and it has been shown to be reliable in differentiating benign from malignant pathologic fractures [27]. FDG-PET/CT imaging is not routinely performed for characterization of soft-tissue injuries of the shoulder.

Shoulder Pain Traumatic PCAs. Although CT is the gold standard for diagnosing and characterizing fractures, MRI has been shown to be equivalent to CT in diagnosing the nondisplaced fractures that are typically missed on radiographs. CT Arthrography Shoulder CT is inferior to MRI and US in diagnosing virtually all extra-articular traumatic soft-tissues injuries. CT is considered the gold standard in identifying fractures. However, MRI has shown to be equivalent to CT in assessing bone loss [12,18], and MRI is usually adequate for diagnosing the nondisplaced fractures that are typically missed on conventional radiographs. CT arthrography is able to reliably evaluate for glenohumeral cartilage injury, SLAP tears, and labroligamentous injuries [12,39] but is generally considered inferior to MRI in diagnosing rotator cuff and soft-tissue Bankart lesions [12]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT imaging is rarely used in assessment of traumatic shoulder pain. FDG-PET is sensitive for inflammation, and a correlation has been found between radiotracer activity and degree of shoulder pain [26]. However, increased radiotracer activity may be due to infectious, traumatic, inflammatory, or neoplastic processes, making this activity a nonspecific finding. FDG-PET imaging as an isolated modality has relatively poor resolution for pathology localization compared with other imaging modalities, although, FDG-PET imaging can be performed in conjunction with MRI or CT for better localization of radiotracer activity. FDG-PET in combination with CT is sensitive for identifying fractures, and it has been shown to be reliable in differentiating benign from malignant pathologic fractures [27]. FDG-PET/CT imaging is not routinely performed for characterization of soft-tissue injuries of the shoulder.

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Shoulder Pain Traumatic PCAs

Indirect identification of symptomatic rotator cuff tears has been described on FDG-PET/CT by decreased radiotracer activity in the muscles of the torn tendons and increased activity of surrounding shoulder girdle muscles due to muscle recruitment [28,29]. Other soft-tissue injuries, such as labral and cartilage injuries, have not been described using FDG-PET/CT. Bone Scan Shoulder Tc-99m bone scintigraphy is rarely used in assessment of traumatic shoulder pain. Bone scintigraphy demonstrates increased activity in many post-traumatic shoulder pathologies such as fracture, rotator cuff tear, or adhesive capsulitis [30]. Bone scintigraphy as an isolated modality has relatively poor resolution for pathology localization compared with other imaging modalities; however, bone scintigraphy can be performed in conjunction with MRI or CT for better localization of radiotracer activity. Bone scintigraphy has sensitivity and specificity comparable to MRI in diagnosis of occult bone fractures, and bone scintigraphy can be used to identify other foci of bone involvement in pathologic fractures due to metastatic disease [31,32]. Increased radiotracer activity has been associated with symptomatic rotator cuff tears, but bone scintigraphy appearance of other soft- tissue injuries of the shoulder have not been well described [33]. Variant 3: Traumatic shoulder pain. Radiographs show humeral head or neck fracture. Next imaging study. Proximal humerus fractures of the head and neck are relatively common. These fractures have a bimodal age distribution, occurring in young patients as the result of high-energy trauma and older patients with low-energy trauma, such as falls from a standing position. The most commonly used classification for humeral head fractures is the Neer classification system. A complete tear of at least one rotator cuff tendon can be seen in up to 40% of humeral head fractures [40].

Shoulder Pain Traumatic PCAs. Indirect identification of symptomatic rotator cuff tears has been described on FDG-PET/CT by decreased radiotracer activity in the muscles of the torn tendons and increased activity of surrounding shoulder girdle muscles due to muscle recruitment [28,29]. Other soft-tissue injuries, such as labral and cartilage injuries, have not been described using FDG-PET/CT. Bone Scan Shoulder Tc-99m bone scintigraphy is rarely used in assessment of traumatic shoulder pain. Bone scintigraphy demonstrates increased activity in many post-traumatic shoulder pathologies such as fracture, rotator cuff tear, or adhesive capsulitis [30]. Bone scintigraphy as an isolated modality has relatively poor resolution for pathology localization compared with other imaging modalities; however, bone scintigraphy can be performed in conjunction with MRI or CT for better localization of radiotracer activity. Bone scintigraphy has sensitivity and specificity comparable to MRI in diagnosis of occult bone fractures, and bone scintigraphy can be used to identify other foci of bone involvement in pathologic fractures due to metastatic disease [31,32]. Increased radiotracer activity has been associated with symptomatic rotator cuff tears, but bone scintigraphy appearance of other soft- tissue injuries of the shoulder have not been well described [33]. Variant 3: Traumatic shoulder pain. Radiographs show humeral head or neck fracture. Next imaging study. Proximal humerus fractures of the head and neck are relatively common. These fractures have a bimodal age distribution, occurring in young patients as the result of high-energy trauma and older patients with low-energy trauma, such as falls from a standing position. The most commonly used classification for humeral head fractures is the Neer classification system. A complete tear of at least one rotator cuff tendon can be seen in up to 40% of humeral head fractures [40].

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Shoulder Pain Traumatic PCAs

However, a delay in repair of rotator cuff tears by up to 4 months has not been shown to have adverse outcomes on rotator cuff repair [41], and immediate diagnosis and treatment of soft-tissue injury in the setting of a proximal humerus fracture may not be required. CT Shoulder Nondisplaced fracture planes and complex bony anatomy can result in underappreciation of the extent of proximal humeral fractures on radiographs. Poor agreement between observers has been shown on grading of humeral head fractures on radiographs [10]. CT is the best examination for delineating fracture patterns and has been shown to be equivocal to MRI in identifying nondisplaced fractures, making it the preferred study for characterizing proximal humeral fractures. Contrast is generally not necessary unless there is concern for arterial injury (see Variant 9). 3-D volume-rendered CT images may be obtained to better characterize fracture patterns and humeral neck angulation, which can affect functional outcomes [42]. CT Arthrography Shoulder CT Arthrography Shoulder Arthrography is not routinely performed in conjunction with CT in the evaluation of proximal humeral fractures. In the acute setting, glenohumeral hemarthrosis can obscure soft-tissue structures typically evaluated on CT arthrography, and intra-articular iodinated contrast can obscure intra-articular humerus fracture planes. Because of the high association between humeral head fractures and rotator cuff tears, there may be a role for CT arthrogram in a patient with remote proximal humeral fracture having a suspected rotator cuff tear and contraindication to MRI. MRI Shoulder MRI Shoulder MRI without contrast is inferior to CT in evaluating fracture planes in complex humerus fracture patterns and is, in general, inferior to CT in characterizing proximal humerus fractures.

Shoulder Pain Traumatic PCAs. However, a delay in repair of rotator cuff tears by up to 4 months has not been shown to have adverse outcomes on rotator cuff repair [41], and immediate diagnosis and treatment of soft-tissue injury in the setting of a proximal humerus fracture may not be required. CT Shoulder Nondisplaced fracture planes and complex bony anatomy can result in underappreciation of the extent of proximal humeral fractures on radiographs. Poor agreement between observers has been shown on grading of humeral head fractures on radiographs [10]. CT is the best examination for delineating fracture patterns and has been shown to be equivocal to MRI in identifying nondisplaced fractures, making it the preferred study for characterizing proximal humeral fractures. Contrast is generally not necessary unless there is concern for arterial injury (see Variant 9). 3-D volume-rendered CT images may be obtained to better characterize fracture patterns and humeral neck angulation, which can affect functional outcomes [42]. CT Arthrography Shoulder CT Arthrography Shoulder Arthrography is not routinely performed in conjunction with CT in the evaluation of proximal humeral fractures. In the acute setting, glenohumeral hemarthrosis can obscure soft-tissue structures typically evaluated on CT arthrography, and intra-articular iodinated contrast can obscure intra-articular humerus fracture planes. Because of the high association between humeral head fractures and rotator cuff tears, there may be a role for CT arthrogram in a patient with remote proximal humeral fracture having a suspected rotator cuff tear and contraindication to MRI. MRI Shoulder MRI Shoulder MRI without contrast is inferior to CT in evaluating fracture planes in complex humerus fracture patterns and is, in general, inferior to CT in characterizing proximal humerus fractures.

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acrac_69433_9

Shoulder Pain Traumatic PCAs

Although MRI can detect rotator cuff tears associated with proximal humeral fracture [43], any significant rotator cuff tear associated with the humeral head fracture is typically addressed during open reduction and internal fixation of the fracture. However, noncontrast MRI may be useful in assessing rotator cuff integrity in patients with proximal humeral fractures that do not undergo surgical fixation. MR Arthrography Shoulder MR arthrography is not indicated in the acute setting of proximal humeral fractures. In the acute setting of proximal humeral fracture, a significant hemarthrosis is typically present, allowing for adequate distention of the glenohumeral joint for identification of intra-articular pathology on noncontrast MRI. MR arthrography is generally preferred over noncontrast MRI for evaluating soft-tissue injuries in patients with remote proximal humeral fracture and persistent pain [17,19]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET in combination with CT has been shown to be reliable in differentiating benign from malignant pathologic fractures [27]. FDG-PET/CT can be used to further assess suspected pathologic fractures of the proximal humerus. Bone Scan Shoulder Bone scintigraphy has sensitivity and specificity comparable to MRI in diagnosis of occult bone fractures, and bone scintigraphy can be used to identify other foci of bone involvement in pathologic fractures due to metastatic disease [31,32]. Bone scintigraphy can be used to characterize proximal humerus fractures suspected to be due to metastatic disease. Variant 4: Traumatic shoulder pain. Radiographs show scapula fracture. Next imaging study. There is no consensus on indications for surgical fixation of scapula fractures. In general, isolated scapula body fractures heal well without surgical fixation, although associated rib fractures or higher injury severity score are associated with worse clinical outcomes and may benefit from more aggressive surgical fixation [45].

Shoulder Pain Traumatic PCAs. Although MRI can detect rotator cuff tears associated with proximal humeral fracture [43], any significant rotator cuff tear associated with the humeral head fracture is typically addressed during open reduction and internal fixation of the fracture. However, noncontrast MRI may be useful in assessing rotator cuff integrity in patients with proximal humeral fractures that do not undergo surgical fixation. MR Arthrography Shoulder MR arthrography is not indicated in the acute setting of proximal humeral fractures. In the acute setting of proximal humeral fracture, a significant hemarthrosis is typically present, allowing for adequate distention of the glenohumeral joint for identification of intra-articular pathology on noncontrast MRI. MR arthrography is generally preferred over noncontrast MRI for evaluating soft-tissue injuries in patients with remote proximal humeral fracture and persistent pain [17,19]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET in combination with CT has been shown to be reliable in differentiating benign from malignant pathologic fractures [27]. FDG-PET/CT can be used to further assess suspected pathologic fractures of the proximal humerus. Bone Scan Shoulder Bone scintigraphy has sensitivity and specificity comparable to MRI in diagnosis of occult bone fractures, and bone scintigraphy can be used to identify other foci of bone involvement in pathologic fractures due to metastatic disease [31,32]. Bone scintigraphy can be used to characterize proximal humerus fractures suspected to be due to metastatic disease. Variant 4: Traumatic shoulder pain. Radiographs show scapula fracture. Next imaging study. There is no consensus on indications for surgical fixation of scapula fractures. In general, isolated scapula body fractures heal well without surgical fixation, although associated rib fractures or higher injury severity score are associated with worse clinical outcomes and may benefit from more aggressive surgical fixation [45].

69433

acrac_69433_10

Shoulder Pain Traumatic PCAs

Scapula fractures involving the glenoid articular surface or glenoid neck may also require surgical fixation. CT Arthrography Shoulder CT Arthrography Shoulder CT arthrography is not routinely performed in the setting of scapula fractures. Intra-articular iodinated contrast can obscure intra-articular fracture lines involving the glenoid neck and articular surface. Acute intra-articular fractures are typically associated with significant hemarthrosis, which can limit evaluation of soft-tissue structures on CT arthrography. MRI Shoulder MRI has limited usefulness in assessing scapular fractures. The thin cortex and sparse medullary cavity of the scapula body can make diagnosis of scapula body fractures difficult on MRI [49]. Typical shoulder-specific coils used for MRI are also unable to cover the entire scapula, requiring use of body coils with a larger field of view, which then results in suboptimal resolution for evaluation of scapular fracture displacement and angulation. MR Arthrography Shoulder There is no role for an MR arthrogram in evaluation of scapula fractures. US Shoulder US Shoulder There is no role for US in evaluation of scapula fractures. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT has been shown to be reliable in differentiating benign from malignant pathologic fractures [27]. FDG-PET/CT can be used to further assess suspected pathologic fractures of the scapula. Bone Scan Shoulder Bone Scan Shoulder Bone scintigraphy has sensitivity and specificity comparable to MRI in diagnosis of occult bone fractures, and bone scintigraphy can be used to identify other foci of bone involvement in pathologic fractures due to metastatic disease [31,32]. Bone scintigraphy can be used to characterize scapula fractures suspected to be due to metastatic disease. MRI Shoulder Similar to MR arthrography, noncontrast MRI is comparable to CT in evaluating glenoid and humeral head bone loss [12,18]. In general, noncontrast MRI performs well in diagnosing labroligamentous injuries [20,52].

Shoulder Pain Traumatic PCAs. Scapula fractures involving the glenoid articular surface or glenoid neck may also require surgical fixation. CT Arthrography Shoulder CT Arthrography Shoulder CT arthrography is not routinely performed in the setting of scapula fractures. Intra-articular iodinated contrast can obscure intra-articular fracture lines involving the glenoid neck and articular surface. Acute intra-articular fractures are typically associated with significant hemarthrosis, which can limit evaluation of soft-tissue structures on CT arthrography. MRI Shoulder MRI has limited usefulness in assessing scapular fractures. The thin cortex and sparse medullary cavity of the scapula body can make diagnosis of scapula body fractures difficult on MRI [49]. Typical shoulder-specific coils used for MRI are also unable to cover the entire scapula, requiring use of body coils with a larger field of view, which then results in suboptimal resolution for evaluation of scapular fracture displacement and angulation. MR Arthrography Shoulder There is no role for an MR arthrogram in evaluation of scapula fractures. US Shoulder US Shoulder There is no role for US in evaluation of scapula fractures. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT has been shown to be reliable in differentiating benign from malignant pathologic fractures [27]. FDG-PET/CT can be used to further assess suspected pathologic fractures of the scapula. Bone Scan Shoulder Bone Scan Shoulder Bone scintigraphy has sensitivity and specificity comparable to MRI in diagnosis of occult bone fractures, and bone scintigraphy can be used to identify other foci of bone involvement in pathologic fractures due to metastatic disease [31,32]. Bone scintigraphy can be used to characterize scapula fractures suspected to be due to metastatic disease. MRI Shoulder Similar to MR arthrography, noncontrast MRI is comparable to CT in evaluating glenoid and humeral head bone loss [12,18]. In general, noncontrast MRI performs well in diagnosing labroligamentous injuries [20,52].

69433

acrac_69433_11

Shoulder Pain Traumatic PCAs

However, noncontrast MRI is considered inferior to MR arthrography for assessing labroligamentous pathology frequently associated with Bankart and Hill-Sachs lesions [17,19]. Noncontrast MRI is a good alternative to MR arthrography in the setting of acute injury when significant glenohumeral joint effusion is present to assist in visualization of intra-articular soft-tissue pathology. MR Arthrography Shoulder MR arthrography is the preferred study for evaluating subacute or chronic Bankart lesions because of its soft- tissue contrast. Multiple studies have shown MR arthrography to be reliable in diagnosing labroligamentous injuries [12,17,52] and superior to noncontrast MRI for this indication [17,19]. MR arthrography has been shown to be equivalent to CT in the assessment of glenoid and humeral head bone loss [12,18], while being superior to CT in assessment of labroligamentous injuries [12]. MR arthrography is also able to delineate humeral head and glenoid cartilage, which can be important because some Hill-Sachs lesions affect cartilage only [11]. CT Shoulder Noncontrast CT has historically been used to assess Hill-Sachs and bony Bankart lesions. However, MRI has been shown to be equivalent to CT for assessing both glenoid and humeral head bone loss [12,18,53], and CT is limited in the assessment of cartilaginous Hill-Sachs lesions [11]. In addition, CT cannot assess injury to soft-tissue structures like the labroligamentous complex, which further limits its usefulness in evaluating Bankart lesions. CT should be reserved for patients with a contraindication to MRI or patients in whom MRI assessment of bone loss is limited. CT Arthrography Shoulder CT Arthrography Shoulder CT arthrography has shown fair agreement between observers and is comparable to MR arthrography in diagnosing Bankart and Hill-Sachs lesions [12,13]. However, CT arthrography is inferior to MRI in diagnosing other soft-tissue pathology [12].

Shoulder Pain Traumatic PCAs. However, noncontrast MRI is considered inferior to MR arthrography for assessing labroligamentous pathology frequently associated with Bankart and Hill-Sachs lesions [17,19]. Noncontrast MRI is a good alternative to MR arthrography in the setting of acute injury when significant glenohumeral joint effusion is present to assist in visualization of intra-articular soft-tissue pathology. MR Arthrography Shoulder MR arthrography is the preferred study for evaluating subacute or chronic Bankart lesions because of its soft- tissue contrast. Multiple studies have shown MR arthrography to be reliable in diagnosing labroligamentous injuries [12,17,52] and superior to noncontrast MRI for this indication [17,19]. MR arthrography has been shown to be equivalent to CT in the assessment of glenoid and humeral head bone loss [12,18], while being superior to CT in assessment of labroligamentous injuries [12]. MR arthrography is also able to delineate humeral head and glenoid cartilage, which can be important because some Hill-Sachs lesions affect cartilage only [11]. CT Shoulder Noncontrast CT has historically been used to assess Hill-Sachs and bony Bankart lesions. However, MRI has been shown to be equivalent to CT for assessing both glenoid and humeral head bone loss [12,18,53], and CT is limited in the assessment of cartilaginous Hill-Sachs lesions [11]. In addition, CT cannot assess injury to soft-tissue structures like the labroligamentous complex, which further limits its usefulness in evaluating Bankart lesions. CT should be reserved for patients with a contraindication to MRI or patients in whom MRI assessment of bone loss is limited. CT Arthrography Shoulder CT Arthrography Shoulder CT arthrography has shown fair agreement between observers and is comparable to MR arthrography in diagnosing Bankart and Hill-Sachs lesions [12,13]. However, CT arthrography is inferior to MRI in diagnosing other soft-tissue pathology [12].

69433

acrac_69433_12

Shoulder Pain Traumatic PCAs

CT arthrography can be considered a reasonable imaging alternative in patients with contraindication to MRI. US Shoulder US Shoulder There is no role for US in assessment of Bankart or Hill-Sachs lesions. US has been demonstrated to be inferior to MRI in diagnosing both labroligamentous injury and Hill-Sachs lesions [17]. FDG-PET/CT Skull Base to Mid-Thigh There is no role for FDG-PET/CT in assessment of Bankart or Hill-Sachs lesions. Bone Scan Shoulder Bone Scan Shoulder There is no role for bone scintigraphy in assessment of Bankart or Hill-Sachs lesions. Variant 6: Traumatic shoulder pain. Radiographs normal. Physical examination and history consistent with dislocation event or instability. Next imaging study. Shoulder dislocation or instability is most common in the anterior direction. Younger patients are more likely to have labroligamentous injury and persistent instability after dislocation compared with older patients [54]. Older patients are more likely to have rotator cuff tears in association with shoulder dislocation [55]. Coexisting humeral avulsion of the glenohumeral ligament and significant glenoid bone loss have been found in up to 10% of patients with recurrent shoulder instability [56], which underscores the need to assess both osseous and labroligamentous pathology in patients with shoulder dislocation or instability. Glenoid morphology and bone loss can play a significant factor in recurrent shoulder dislocations [15,16,57], which may require bone grafting in order to restore stability [57]. MR Arthrography Shoulder MR arthrography is the preferred examination for the evaluation of subacute shoulder dislocations or recurrent shoulder instability. MRI has been shown to have similar performance to CT in the evaluation of Hill-Sachs lesions and glenoid bone loss [12,18]. MR arthrography has also been found to be reliable in diagnosing anterior shoulder instability and labroligamentous injuries [58,59].

Shoulder Pain Traumatic PCAs. CT arthrography can be considered a reasonable imaging alternative in patients with contraindication to MRI. US Shoulder US Shoulder There is no role for US in assessment of Bankart or Hill-Sachs lesions. US has been demonstrated to be inferior to MRI in diagnosing both labroligamentous injury and Hill-Sachs lesions [17]. FDG-PET/CT Skull Base to Mid-Thigh There is no role for FDG-PET/CT in assessment of Bankart or Hill-Sachs lesions. Bone Scan Shoulder Bone Scan Shoulder There is no role for bone scintigraphy in assessment of Bankart or Hill-Sachs lesions. Variant 6: Traumatic shoulder pain. Radiographs normal. Physical examination and history consistent with dislocation event or instability. Next imaging study. Shoulder dislocation or instability is most common in the anterior direction. Younger patients are more likely to have labroligamentous injury and persistent instability after dislocation compared with older patients [54]. Older patients are more likely to have rotator cuff tears in association with shoulder dislocation [55]. Coexisting humeral avulsion of the glenohumeral ligament and significant glenoid bone loss have been found in up to 10% of patients with recurrent shoulder instability [56], which underscores the need to assess both osseous and labroligamentous pathology in patients with shoulder dislocation or instability. Glenoid morphology and bone loss can play a significant factor in recurrent shoulder dislocations [15,16,57], which may require bone grafting in order to restore stability [57]. MR Arthrography Shoulder MR arthrography is the preferred examination for the evaluation of subacute shoulder dislocations or recurrent shoulder instability. MRI has been shown to have similar performance to CT in the evaluation of Hill-Sachs lesions and glenoid bone loss [12,18]. MR arthrography has also been found to be reliable in diagnosing anterior shoulder instability and labroligamentous injuries [58,59].

69433

acrac_69433_13

Shoulder Pain Traumatic PCAs

MR arthrography has specifically outperformed noncontrast MRI in assessment of glenohumeral ligament and anterior labral injuries [17,19], which are commonly seen in shoulder instability. MR arthrography has also outperformed noncontrast MRI in diagnosis of rotator cuff tears [17,19], which is a common associated finding in older patients with shoulder dislocation. However, high sensitivities reported for MR arthrography in the detection of labral pathology may not be applicable to patients with clinically unstable shoulders. A retrospective review of 90 patients with clinically unstable shoulders selected for arthroscopy [60] found that MR arthrography had a sensitivity of 65% for detection of labral tears. The authors proposed that this discrepancy with prior studies was the result of different patient selection criteria (clinically unstable in their study versus less-specific symptoms such as shoulder pain in others) and the interpretation of MR arthrography by experienced musculoskeletal radiologists [60]. For this document, it is assumed the procedure is performed and interpreted by an expert. MRI Shoulder MRI without contrast may be preferred to MR arthrography in the setting of acute shoulder dislocation when a post-traumatic joint effusion is present to provide sufficient visualization of soft-tissue structures. In the subacute or chronic setting, the glenohumeral joint effusion is usually too small to provide adequate joint distention for optimal assessment of soft-tissue structures. Noncontrast MRI has been shown to be inferior to MR arthrography in diagnosing labroligamentous and rotator cuff injuries [17,19]. Noncontrast MRI performs comparably to CT in evaluating glenoid and humeral head bone loss [12,18], which may obviate the need for noncontrast CT. CT Arthrography Shoulder CT Arthrography Shoulder CT arthrography is effective in evaluation of shoulder instability.

Shoulder Pain Traumatic PCAs. MR arthrography has specifically outperformed noncontrast MRI in assessment of glenohumeral ligament and anterior labral injuries [17,19], which are commonly seen in shoulder instability. MR arthrography has also outperformed noncontrast MRI in diagnosis of rotator cuff tears [17,19], which is a common associated finding in older patients with shoulder dislocation. However, high sensitivities reported for MR arthrography in the detection of labral pathology may not be applicable to patients with clinically unstable shoulders. A retrospective review of 90 patients with clinically unstable shoulders selected for arthroscopy [60] found that MR arthrography had a sensitivity of 65% for detection of labral tears. The authors proposed that this discrepancy with prior studies was the result of different patient selection criteria (clinically unstable in their study versus less-specific symptoms such as shoulder pain in others) and the interpretation of MR arthrography by experienced musculoskeletal radiologists [60]. For this document, it is assumed the procedure is performed and interpreted by an expert. MRI Shoulder MRI without contrast may be preferred to MR arthrography in the setting of acute shoulder dislocation when a post-traumatic joint effusion is present to provide sufficient visualization of soft-tissue structures. In the subacute or chronic setting, the glenohumeral joint effusion is usually too small to provide adequate joint distention for optimal assessment of soft-tissue structures. Noncontrast MRI has been shown to be inferior to MR arthrography in diagnosing labroligamentous and rotator cuff injuries [17,19]. Noncontrast MRI performs comparably to CT in evaluating glenoid and humeral head bone loss [12,18], which may obviate the need for noncontrast CT. CT Arthrography Shoulder CT Arthrography Shoulder CT arthrography is effective in evaluation of shoulder instability.

69433

acrac_69433_14

Shoulder Pain Traumatic PCAs

CT arthrography is comparable to MR arthrography in the diagnosis of Bankart and Hill-Sachs lesions [12], and moderate agreement has been found between readers for diagnosing anterior capsule laxity on CT arthrography. However, CT arthrography has been shown to be inferior to MR arthrography in assessing partial-thickness rotator cuff tears [12], which makes CT arthrography less desirable in older patients with dislocation/instability where rotator cuff tears are common. CT arthrography may be considered in a patient with shoulder dislocation/instability and contraindication to MRI. CT Shoulder Noncontrast CT has historically been performed to assess bone loss in patients with recurrent dislocation or chronic instability. However, recent studies have shown MRI to be equivalent to CT in assessment of glenoid and humeral head bone loss [12,18], which places in question the need for noncontrast CT in the assessment of shoulder instability. Noncontrast CT is also unable to assess rotator cuff and labroligamentous pathology commonly seen in shoulder dislocations/instability. In general, CT should be reserved for patients with a contraindication to MRI or patients in whom MRI assessment of bone loss is limited. US Shoulder There is no defined role for US in the assessment of shoulder dislocation or instability. There is a potential limited role for use of dynamic US in assessing Hill-Sachs lesion engagement [61]. However, this is not common practice, and US has been shown to be inferior to MRI in diagnosing the common structural abnormalities associated with shoulder instability, such as labroligamentous injuries, Hill-Sachs lesions, and partial rotator cuff tears [17]. FDG-PET/CT Skull Base to Mid-Thigh There is no role for FDG-PET/CT in assessment of shoulder instability. Bone Scan Shoulder Bone Scan Shoulder There is no role for bone scintigraphy in assessment of shoulder instability. Variant 7: Traumatic shoulder pain. Radiographs normal.

Shoulder Pain Traumatic PCAs. CT arthrography is comparable to MR arthrography in the diagnosis of Bankart and Hill-Sachs lesions [12], and moderate agreement has been found between readers for diagnosing anterior capsule laxity on CT arthrography. However, CT arthrography has been shown to be inferior to MR arthrography in assessing partial-thickness rotator cuff tears [12], which makes CT arthrography less desirable in older patients with dislocation/instability where rotator cuff tears are common. CT arthrography may be considered in a patient with shoulder dislocation/instability and contraindication to MRI. CT Shoulder Noncontrast CT has historically been performed to assess bone loss in patients with recurrent dislocation or chronic instability. However, recent studies have shown MRI to be equivalent to CT in assessment of glenoid and humeral head bone loss [12,18], which places in question the need for noncontrast CT in the assessment of shoulder instability. Noncontrast CT is also unable to assess rotator cuff and labroligamentous pathology commonly seen in shoulder dislocations/instability. In general, CT should be reserved for patients with a contraindication to MRI or patients in whom MRI assessment of bone loss is limited. US Shoulder There is no defined role for US in the assessment of shoulder dislocation or instability. There is a potential limited role for use of dynamic US in assessing Hill-Sachs lesion engagement [61]. However, this is not common practice, and US has been shown to be inferior to MRI in diagnosing the common structural abnormalities associated with shoulder instability, such as labroligamentous injuries, Hill-Sachs lesions, and partial rotator cuff tears [17]. FDG-PET/CT Skull Base to Mid-Thigh There is no role for FDG-PET/CT in assessment of shoulder instability. Bone Scan Shoulder Bone Scan Shoulder There is no role for bone scintigraphy in assessment of shoulder instability. Variant 7: Traumatic shoulder pain. Radiographs normal.

69433

acrac_69433_15

Shoulder Pain Traumatic PCAs

Physical examination findings consistent with labral tear. Next imaging study. MR Arthrography Shoulder MR arthrography has been reported to have a high sensitivity for detection of labral injury, ranging from 86% to 100% [20,59,62-65]; however, the issue of selection bias is inherent in the design of many of these retrospective MRI Shoulder MRI without contrast may be preferred to MR arthrography in the setting of acute shoulder dislocation when a post-traumatic joint effusion is typically present to provide sufficient visualization of soft-tissue structures. In the subacute or chronic setting, the glenohumeral joint effusion is usually too small to provide adequate joint distention to adequately assess soft-tissue structures. Noncontrast MRI has been shown to be inferior to MR arthrography in diagnosing labroligamentous and rotator cuff injuries [17,19]. CT Arthrography Shoulder CT arthrography provides comparable sensitivity and possibly improved specificity in detection of labral lesions compared to MR arthrography [12,67] and can provide improved visualization of the bones in cases of complex trauma. However, interobserver variability in reporting of labral lesions is low [13]. CT arthrography has also been shown to be inferior to MR arthrography in assessing partial-thickness rotator cuff tears [12], which makes CT arthrography less desirable in patients where rotator cuff tears may be suspected. However, CT arthrography may be considered in a patient with shoulder dislocation/instability and contraindication to MRI. CT Shoulder CT Shoulder Noncontrast CT is unable to assess rotator cuff and labroligamentous pathology. US Shoulder Although there have been efforts to use US in diagnosis of labral lesions, it currently has no defined role in this setting. FDG-PET/CT Skull Base to Mid-Thigh There is no role for FDG-PET/CT in assessment of suspected labral tear. Bone Scan Shoulder There is no role for bone scintigraphy in assessment of suspected labral tear.

Shoulder Pain Traumatic PCAs. Physical examination findings consistent with labral tear. Next imaging study. MR Arthrography Shoulder MR arthrography has been reported to have a high sensitivity for detection of labral injury, ranging from 86% to 100% [20,59,62-65]; however, the issue of selection bias is inherent in the design of many of these retrospective MRI Shoulder MRI without contrast may be preferred to MR arthrography in the setting of acute shoulder dislocation when a post-traumatic joint effusion is typically present to provide sufficient visualization of soft-tissue structures. In the subacute or chronic setting, the glenohumeral joint effusion is usually too small to provide adequate joint distention to adequately assess soft-tissue structures. Noncontrast MRI has been shown to be inferior to MR arthrography in diagnosing labroligamentous and rotator cuff injuries [17,19]. CT Arthrography Shoulder CT arthrography provides comparable sensitivity and possibly improved specificity in detection of labral lesions compared to MR arthrography [12,67] and can provide improved visualization of the bones in cases of complex trauma. However, interobserver variability in reporting of labral lesions is low [13]. CT arthrography has also been shown to be inferior to MR arthrography in assessing partial-thickness rotator cuff tears [12], which makes CT arthrography less desirable in patients where rotator cuff tears may be suspected. However, CT arthrography may be considered in a patient with shoulder dislocation/instability and contraindication to MRI. CT Shoulder CT Shoulder Noncontrast CT is unable to assess rotator cuff and labroligamentous pathology. US Shoulder Although there have been efforts to use US in diagnosis of labral lesions, it currently has no defined role in this setting. FDG-PET/CT Skull Base to Mid-Thigh There is no role for FDG-PET/CT in assessment of suspected labral tear. Bone Scan Shoulder There is no role for bone scintigraphy in assessment of suspected labral tear.

69433

acrac_69433_16

Shoulder Pain Traumatic PCAs

Variant 8: Traumatic shoulder pain. Radiographs normal. Physical examination findings consistent with rotator cuff tear. Next imaging study. US, MRI, and MR arthrography have similarly high sensitivity and specificity in detection of full-thickness rotator cuff tears. US and MRI have somewhat lower sensitivity for detection of partial-thickness tears when compared to MR arthrography [68]. However, because full-thickness tears are the main decision point on pursuing surgical repair, institutional preference may be the driving force for the selection of imaging modality for assessment of traumatic rotator cuff pathology. MRI Shoulder MRI Shoulder MRI is generally considered the best modality for adequately assessing most soft-tissue injuries, including labroligamentous, cartilage, and rotator cuff pathology [12,17,69]. It has high sensitivity and specificity in detection of full-thickness rotator cuff tears, but lower sensitivity compared to MR arthrography for detection of partial-thickness tears [68]. MR Arthrography Shoulder MR arthrography is generally preferred to noncontrast MRI for assessing intra-articular pathology, particularly in diagnosing labral and partial-thickness rotator cuff tears [17,19,54]. MR arthrography may have increased sensitivity for detection of partial-thickness articular surface supraspinatus tears compared with conventional MRI [19]. CT Arthrography Shoulder CT Arthrography Shoulder CT arthrography has similar performance as MR arthrography for detection of full-thickness rotator cuff tears, but has significantly poorer performance for partial-thickness cuff tears [12]. CT arthrogram may be a good imaging alternative in patients with suspected intra-articular soft-tissue injury and contraindication to MRI. US Shoulder In the post-traumatic setting, US has been shown to detect abnormalities, including rotator cuff tears [25]. In general, US can have high sensitivity and specificity for the detection of full-thickness rotator cuff tears [70-72].

Shoulder Pain Traumatic PCAs. Variant 8: Traumatic shoulder pain. Radiographs normal. Physical examination findings consistent with rotator cuff tear. Next imaging study. US, MRI, and MR arthrography have similarly high sensitivity and specificity in detection of full-thickness rotator cuff tears. US and MRI have somewhat lower sensitivity for detection of partial-thickness tears when compared to MR arthrography [68]. However, because full-thickness tears are the main decision point on pursuing surgical repair, institutional preference may be the driving force for the selection of imaging modality for assessment of traumatic rotator cuff pathology. MRI Shoulder MRI Shoulder MRI is generally considered the best modality for adequately assessing most soft-tissue injuries, including labroligamentous, cartilage, and rotator cuff pathology [12,17,69]. It has high sensitivity and specificity in detection of full-thickness rotator cuff tears, but lower sensitivity compared to MR arthrography for detection of partial-thickness tears [68]. MR Arthrography Shoulder MR arthrography is generally preferred to noncontrast MRI for assessing intra-articular pathology, particularly in diagnosing labral and partial-thickness rotator cuff tears [17,19,54]. MR arthrography may have increased sensitivity for detection of partial-thickness articular surface supraspinatus tears compared with conventional MRI [19]. CT Arthrography Shoulder CT Arthrography Shoulder CT arthrography has similar performance as MR arthrography for detection of full-thickness rotator cuff tears, but has significantly poorer performance for partial-thickness cuff tears [12]. CT arthrogram may be a good imaging alternative in patients with suspected intra-articular soft-tissue injury and contraindication to MRI. US Shoulder In the post-traumatic setting, US has been shown to detect abnormalities, including rotator cuff tears [25]. In general, US can have high sensitivity and specificity for the detection of full-thickness rotator cuff tears [70-72].

69433

acrac_69433_17

Shoulder Pain Traumatic PCAs

There is conflicting evidence on the ability of US to diagnose partial-thickness rotator cuff tears [17,22,24,44,72]. Similarly, although interobserver agreement in detection of full-thickness rotator cuff tears can be high, it is much more variable for detection of partial-thickness tears [73,74]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is not routinely used for describing rotator cuff tears. Indirect identification of symptomatic rotator cuff tears has been described on FDG-PET/CT by decreased radiotracer activity in the muscles of the torn tendons and increased activity of surrounding shoulder girdle muscles due to muscle recruitment [28,29]. However, FDG- PET/CT cannot describe the extent of rotator cuff tear or degree of rotator cuff atrophy, which are relevant for clinical management. Bone Scan Shoulder Bone scintigraphy is not routinely used for describing rotator cuff tears. Increased radiotracer activity has been associated with symptomatic rotator cuff tears [33]. However, bone scintigraphy cannot describe the extent of rotator cuff tear or degree of rotator cuff atrophy, which are relevant for clinical management. Variant 9: Traumatic shoulder pain. Radiographs already performed. Physical examination consistent with vascular compromise. Next imaging study. The subclavian, axillary, and brachial arteries are uncommonly injured following fractures and dislocations about the shoulder; however, the consequences can be debilitating. Of these, the axillary artery is more likely to be injured in patients with proximal humeral fractures, and the risk increases in the presence of open fractures, shoulder dislocation, and fractures of the scapula and ribs [75]. No systematic or comparative data is available on detection of arterial injuries in the post-traumatic setting. CT Shoulder Noncontrast CT may be able to demonstrate hematomas; however, it is not an adequate modality for evaluation of acute arterial compromise.

Shoulder Pain Traumatic PCAs. There is conflicting evidence on the ability of US to diagnose partial-thickness rotator cuff tears [17,22,24,44,72]. Similarly, although interobserver agreement in detection of full-thickness rotator cuff tears can be high, it is much more variable for detection of partial-thickness tears [73,74]. FDG-PET/CT Skull Base to Mid-Thigh FDG-PET/CT is not routinely used for describing rotator cuff tears. Indirect identification of symptomatic rotator cuff tears has been described on FDG-PET/CT by decreased radiotracer activity in the muscles of the torn tendons and increased activity of surrounding shoulder girdle muscles due to muscle recruitment [28,29]. However, FDG- PET/CT cannot describe the extent of rotator cuff tear or degree of rotator cuff atrophy, which are relevant for clinical management. Bone Scan Shoulder Bone scintigraphy is not routinely used for describing rotator cuff tears. Increased radiotracer activity has been associated with symptomatic rotator cuff tears [33]. However, bone scintigraphy cannot describe the extent of rotator cuff tear or degree of rotator cuff atrophy, which are relevant for clinical management. Variant 9: Traumatic shoulder pain. Radiographs already performed. Physical examination consistent with vascular compromise. Next imaging study. The subclavian, axillary, and brachial arteries are uncommonly injured following fractures and dislocations about the shoulder; however, the consequences can be debilitating. Of these, the axillary artery is more likely to be injured in patients with proximal humeral fractures, and the risk increases in the presence of open fractures, shoulder dislocation, and fractures of the scapula and ribs [75]. No systematic or comparative data is available on detection of arterial injuries in the post-traumatic setting. CT Shoulder Noncontrast CT may be able to demonstrate hematomas; however, it is not an adequate modality for evaluation of acute arterial compromise.

69433

acrac_69433_18

Shoulder Pain Traumatic PCAs

Contrast-enhanced CT using intravenous (IV) contrast can identify some vascular injuries. However, contrast bolus timing and image reformatting using routine contrast-enhanced CT protocols is suboptimal for identifying and characterizing vascular injuries. CTA Shoulder CTA Shoulder CT angiography (CTA) is a specialized protocol for contrast-enhanced CT in which image acquisition occurs during maximum arterial opacification by IV contrast. Thin-slice axial images of the region of interest is performed, which helps in detection of subtle vascular injuries. Maximum intensity projection (MIP) images in multiple planes are also commonly performed, allowing for long segments of vessels to be visualized on a single image. CTA is the preferred examination for evaluation of suspected arterial injury. It can delineate the extent of injury and has the added benefit of providing optimal assessment of osseous injuries [76,77]. MRI Shoulder Because of the length of time required for MRI, it is not the modality of choice for assessment of acute arterial injury. Both routine noncontrast and contrast-enhanced MRI protocols lack the spatial and temporal resolution as well as imaging plane orientation to identify and characterize most arterial injuries. MRA Shoulder MRA Shoulder MR angiography (MRA) is MR imaging tailored to evaluate for arterial compromise using sequences such as time-of-flight, phase-contrast, and dynamic postcontrast imaging. MRA can produce 2D images or dynamic 3D images of the arteries that simulates arteriography. However, the special resolution of MRA is inferior to CTA and arteriography. MRA can be performed with or without IV contrast, although use of IV contrast is generally preferred. Because of the length of time required for MRA, it is not the modality of choice for assessment of acute arterial injury. US Duplex Doppler Shoulder Bedside US can be used to assess the subclavian, axillary, and brachial arteries as permitted by patient condition.

Shoulder Pain Traumatic PCAs. Contrast-enhanced CT using intravenous (IV) contrast can identify some vascular injuries. However, contrast bolus timing and image reformatting using routine contrast-enhanced CT protocols is suboptimal for identifying and characterizing vascular injuries. CTA Shoulder CTA Shoulder CT angiography (CTA) is a specialized protocol for contrast-enhanced CT in which image acquisition occurs during maximum arterial opacification by IV contrast. Thin-slice axial images of the region of interest is performed, which helps in detection of subtle vascular injuries. Maximum intensity projection (MIP) images in multiple planes are also commonly performed, allowing for long segments of vessels to be visualized on a single image. CTA is the preferred examination for evaluation of suspected arterial injury. It can delineate the extent of injury and has the added benefit of providing optimal assessment of osseous injuries [76,77]. MRI Shoulder Because of the length of time required for MRI, it is not the modality of choice for assessment of acute arterial injury. Both routine noncontrast and contrast-enhanced MRI protocols lack the spatial and temporal resolution as well as imaging plane orientation to identify and characterize most arterial injuries. MRA Shoulder MRA Shoulder MR angiography (MRA) is MR imaging tailored to evaluate for arterial compromise using sequences such as time-of-flight, phase-contrast, and dynamic postcontrast imaging. MRA can produce 2D images or dynamic 3D images of the arteries that simulates arteriography. However, the special resolution of MRA is inferior to CTA and arteriography. MRA can be performed with or without IV contrast, although use of IV contrast is generally preferred. Because of the length of time required for MRA, it is not the modality of choice for assessment of acute arterial injury. US Duplex Doppler Shoulder Bedside US can be used to assess the subclavian, axillary, and brachial arteries as permitted by patient condition.

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acrac_69433_19

Shoulder Pain Traumatic PCAs

FDG-PET/CT Skull Base to Mid-Thigh There is no role for FDG-PET/CT in assessment of vascular compromise. 3-phase Bone Scan Shoulder Three-phase bone scintigraphy can demonstrate a lack of blood flow to an extremity, with blood pool and delayed images showing decreased or absent uptake in the affected area [78]. However, limited resolution precludes precise anatomic definition of the site of abnormality [78]. In addition, because of the length of time required for image acquisition, scintigraphy is not the modality of choice for assessing acute vascular compromise. CT Shoulder CT without contrast may be obtained in the setting of trauma for detection or delineation of fracture and can suggest neural injury based on expected course of the nerves. However, CT is not the modality of choice for assessment of the nerves. CT with contrast may be obtained in the setting of trauma for detection or delineation of arterial injury, and may suggest neural injury based on the expected course of the nerves. However, CT is not the modality of choice for assessment of the nerves. There is no role for biphasic CT in the setting of suspected traumatic nerve injury. CT Arthrography Shoulder There is no role for CT arthrography in the setting of suspected traumatic nerve injury. MRI Shoulder Noncontrast MRI may demonstrate discontinuity of nerves, neuromas, or perineural musculofascial edema; however, the imaging planes and resolution of routine noncontrast MRI is not adequate for confident and complete assessment of the nerves that can be injured at the shoulder [81]. There are no systematic studies on MR neurography in assessment of the peripheral nerves about the shoulder in the post-traumatic setting; however, MR neurography is gaining acceptance in assessment of peripheral nerve injuries [82]. Use of 3T imaging allows for high resolution and excellent soft-tissue contrast and can delineate focal nerve discontinuities, neuromas, and musculofascial edema [83].

Shoulder Pain Traumatic PCAs. FDG-PET/CT Skull Base to Mid-Thigh There is no role for FDG-PET/CT in assessment of vascular compromise. 3-phase Bone Scan Shoulder Three-phase bone scintigraphy can demonstrate a lack of blood flow to an extremity, with blood pool and delayed images showing decreased or absent uptake in the affected area [78]. However, limited resolution precludes precise anatomic definition of the site of abnormality [78]. In addition, because of the length of time required for image acquisition, scintigraphy is not the modality of choice for assessing acute vascular compromise. CT Shoulder CT without contrast may be obtained in the setting of trauma for detection or delineation of fracture and can suggest neural injury based on expected course of the nerves. However, CT is not the modality of choice for assessment of the nerves. CT with contrast may be obtained in the setting of trauma for detection or delineation of arterial injury, and may suggest neural injury based on the expected course of the nerves. However, CT is not the modality of choice for assessment of the nerves. There is no role for biphasic CT in the setting of suspected traumatic nerve injury. CT Arthrography Shoulder There is no role for CT arthrography in the setting of suspected traumatic nerve injury. MRI Shoulder Noncontrast MRI may demonstrate discontinuity of nerves, neuromas, or perineural musculofascial edema; however, the imaging planes and resolution of routine noncontrast MRI is not adequate for confident and complete assessment of the nerves that can be injured at the shoulder [81]. There are no systematic studies on MR neurography in assessment of the peripheral nerves about the shoulder in the post-traumatic setting; however, MR neurography is gaining acceptance in assessment of peripheral nerve injuries [82]. Use of 3T imaging allows for high resolution and excellent soft-tissue contrast and can delineate focal nerve discontinuities, neuromas, and musculofascial edema [83].

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acrac_69361_0

Acutely Limping Child Up To Age 5 PCAs

Introduction/Background Acute onset of limp or refusal to walk is a common complaint in children, accounting for approximately 4% of visits in one pediatric emergency department [1]. The acutely limping child can be a diagnostic dilemma for clinicians. Most commonly, the acute limp is caused by minor trauma or self-limiting benign conditions but can also be caused by limb-threatening or life-threatening etiologies [2-6]. The cause of limp can usually be determined by a careful history and physical examination. The differential diagnosis of limping is broad and depends on the presence of signs of infection, localization of pain, and history of trauma [6]. The differential diagnosis in a limping child also depends on age. This discussion relates to the initial imaging of the ambulatory child under the age of 5 years who presents with an acute onset of a limp. The presence of fever, elevated white blood cell count, elevated erythrocyte sedimentation rate, or elevated C- reactive protein suggests infection. Localization of pathology is based on site of pain, tenderness, presence of erythema, swelling, and positive physical maneuvers and signs, such as the Trendelenburg test, Galeazzi sign, Patrick/FABER test, pelvic compression test, and psoas sign [7]. A detailed analysis of gait can suggest the diagnosis [6]. Discussion of Procedures by Variant Variant 1: Child up to age 5. Acute limp. Nonlocalized symptoms. No concern for infection. Initial imaging. The most common noninfectious etiology of acute limping in children is a minor traumatic injury [8]. Unfortunately, particularly in younger children, it is common that the pain cannot be accurately localized to one focal area. When there is no concern for infection and pain cannot be localized through history or physical examination, an imaging strategy designed to first localize the source of the pain and subsequently better characterize the cause is typically pursued. Reprint requests to: [email protected]

Acutely Limping Child Up To Age 5 PCAs. Introduction/Background Acute onset of limp or refusal to walk is a common complaint in children, accounting for approximately 4% of visits in one pediatric emergency department [1]. The acutely limping child can be a diagnostic dilemma for clinicians. Most commonly, the acute limp is caused by minor trauma or self-limiting benign conditions but can also be caused by limb-threatening or life-threatening etiologies [2-6]. The cause of limp can usually be determined by a careful history and physical examination. The differential diagnosis of limping is broad and depends on the presence of signs of infection, localization of pain, and history of trauma [6]. The differential diagnosis in a limping child also depends on age. This discussion relates to the initial imaging of the ambulatory child under the age of 5 years who presents with an acute onset of a limp. The presence of fever, elevated white blood cell count, elevated erythrocyte sedimentation rate, or elevated C- reactive protein suggests infection. Localization of pathology is based on site of pain, tenderness, presence of erythema, swelling, and positive physical maneuvers and signs, such as the Trendelenburg test, Galeazzi sign, Patrick/FABER test, pelvic compression test, and psoas sign [7]. A detailed analysis of gait can suggest the diagnosis [6]. Discussion of Procedures by Variant Variant 1: Child up to age 5. Acute limp. Nonlocalized symptoms. No concern for infection. Initial imaging. The most common noninfectious etiology of acute limping in children is a minor traumatic injury [8]. Unfortunately, particularly in younger children, it is common that the pain cannot be accurately localized to one focal area. When there is no concern for infection and pain cannot be localized through history or physical examination, an imaging strategy designed to first localize the source of the pain and subsequently better characterize the cause is typically pursued. Reprint requests to: [email protected]

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acrac_69361_1

Acutely Limping Child Up To Age 5 PCAs

Acutely Limping Child Up To Age 5 If initial imaging is normal but symptoms persist, follow-up radiographs or radiographs of areas besides the tibia/fibula may be useful. In the Baron et al study [13], approximately 10% of tibial fractures were only visible on follow-up radiographs and not initial imaging. One patient, who was discharged, later returned with worsening symptoms and signs of infection and was found to have spinal discitis and epidural abscess. As these examples illustrate, if the initial evaluation is negative and symptoms persist or worsen, a follow-up clinical reassessment and further imaging evaluation may be necessary. US Hips or Lower Extremity There is no relevant literature regarding the use of ultrasound (US) in the initial evaluation of acute limp with nonlocalized symptoms and no concern for infection. US is sensitive in evaluation of joint effusions and soft-tissue fluid collections; however, the typical field of view is small, limiting the role of US when symptoms and clinical evaluation cannot localize the site of pathology [14]. Because pain that is due to hip pathology can be referred elsewhere in the lower extremity, such as the thigh, knee, or buttock [15], US of the hip could be considered if initial radiographs are negative and symptoms persist. 3-Phase Bone Scan Pelvis and Lower Extremity There is no relevant literature regarding the use of bone scan in the initial evaluation of acute limp with nonlocalized symptoms and no concern for infection. Scintigraphic bone scan is sensitive in detecting bone pathology and could have a role in localizing the pathology in limping children when the examination is nonfocal, radiographs are negative, and symptoms persist [1,10,16,17]. However, a bone scan lacks specificity in this clinical scenario [1,10,16]. CT Lower Extremity There is no relevant literature regarding the use of CT in the initial evaluation of acute limp with nonlocalized symptoms and no concern for infection.

Acutely Limping Child Up To Age 5 PCAs. Acutely Limping Child Up To Age 5 If initial imaging is normal but symptoms persist, follow-up radiographs or radiographs of areas besides the tibia/fibula may be useful. In the Baron et al study [13], approximately 10% of tibial fractures were only visible on follow-up radiographs and not initial imaging. One patient, who was discharged, later returned with worsening symptoms and signs of infection and was found to have spinal discitis and epidural abscess. As these examples illustrate, if the initial evaluation is negative and symptoms persist or worsen, a follow-up clinical reassessment and further imaging evaluation may be necessary. US Hips or Lower Extremity There is no relevant literature regarding the use of ultrasound (US) in the initial evaluation of acute limp with nonlocalized symptoms and no concern for infection. US is sensitive in evaluation of joint effusions and soft-tissue fluid collections; however, the typical field of view is small, limiting the role of US when symptoms and clinical evaluation cannot localize the site of pathology [14]. Because pain that is due to hip pathology can be referred elsewhere in the lower extremity, such as the thigh, knee, or buttock [15], US of the hip could be considered if initial radiographs are negative and symptoms persist. 3-Phase Bone Scan Pelvis and Lower Extremity There is no relevant literature regarding the use of bone scan in the initial evaluation of acute limp with nonlocalized symptoms and no concern for infection. Scintigraphic bone scan is sensitive in detecting bone pathology and could have a role in localizing the pathology in limping children when the examination is nonfocal, radiographs are negative, and symptoms persist [1,10,16,17]. However, a bone scan lacks specificity in this clinical scenario [1,10,16]. CT Lower Extremity There is no relevant literature regarding the use of CT in the initial evaluation of acute limp with nonlocalized symptoms and no concern for infection.

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acrac_69361_2

Acutely Limping Child Up To Age 5 PCAs

CT without intravenous (IV) contrast can be useful in a few selected cases for preoperative planning after radiographs demonstrate a complex fracture [18]. MRI Lower Extremity There is no relevant literature regarding the use of MRI pelvis/hips to feet in the initial evaluation of acute limp with nonlocalized symptoms and no concern for infection. MRI is sensitive and specific for soft-tissue, cartilage, and bony pathology, including detection of stress reaction/fractures [19]. It may be performed in selected children when radiographs, clinical and imaging follow- up, and thorough physical examination fail to provide diagnostic clues about the source of symptoms. MRI Whole-Body There is no relevant literature regarding the use of whole-body MRI in the initial evaluation of acute limp with nonlocalized symptoms and no concern for infection. Because whole-body MRI is sensitive and specific for soft-tissue, joint, and bony pathology, and it allows for coverage of all musculoskeletal anatomy, it could play a role in localizing pathology in the limping child when the examination is nonfocal, the initial imaging workup is negative, and symptoms persist. Whole-body MRI has been shown to have more superior sensitivity than scintigraphic bone scans or radiography in detection of multifocal neoplastic lesions and chronic nonbacterial osteomyelitis/chronic recurrent multifocal osteomyelitis [20-22]. Whole-body MRI may be sensitive for detecting sites of involvement with inflammatory arthritides or osteonecrosis [23-25]. Variant 2: Child up to age 5. Acute limp. Pain. Localized symptoms. No concern for infection. Initial imaging. The body regions covered in this clinical scenario are: hip, femur, knee, tibia/fibula, ankle, and foot. Localized pain may be due to trauma, in which case it is important to exclude an underlying fracture. Clinical examination and history may allow localization of the pain or injury to a specific area, which allows a more focused imaging evaluation [26].

Acutely Limping Child Up To Age 5 PCAs. CT without intravenous (IV) contrast can be useful in a few selected cases for preoperative planning after radiographs demonstrate a complex fracture [18]. MRI Lower Extremity There is no relevant literature regarding the use of MRI pelvis/hips to feet in the initial evaluation of acute limp with nonlocalized symptoms and no concern for infection. MRI is sensitive and specific for soft-tissue, cartilage, and bony pathology, including detection of stress reaction/fractures [19]. It may be performed in selected children when radiographs, clinical and imaging follow- up, and thorough physical examination fail to provide diagnostic clues about the source of symptoms. MRI Whole-Body There is no relevant literature regarding the use of whole-body MRI in the initial evaluation of acute limp with nonlocalized symptoms and no concern for infection. Because whole-body MRI is sensitive and specific for soft-tissue, joint, and bony pathology, and it allows for coverage of all musculoskeletal anatomy, it could play a role in localizing pathology in the limping child when the examination is nonfocal, the initial imaging workup is negative, and symptoms persist. Whole-body MRI has been shown to have more superior sensitivity than scintigraphic bone scans or radiography in detection of multifocal neoplastic lesions and chronic nonbacterial osteomyelitis/chronic recurrent multifocal osteomyelitis [20-22]. Whole-body MRI may be sensitive for detecting sites of involvement with inflammatory arthritides or osteonecrosis [23-25]. Variant 2: Child up to age 5. Acute limp. Pain. Localized symptoms. No concern for infection. Initial imaging. The body regions covered in this clinical scenario are: hip, femur, knee, tibia/fibula, ankle, and foot. Localized pain may be due to trauma, in which case it is important to exclude an underlying fracture. Clinical examination and history may allow localization of the pain or injury to a specific area, which allows a more focused imaging evaluation [26].

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