Description
Magnetic resonance imaging (MRI) is used in the evaluation, diagnosis, and management of spine-related conditions, e.g., degenerative disc disease, cauda equine compression, radiculopathy, infections, or cancer in the lumbar spine. MRI provides high quality multiplanar images of organs and structures within the body without the use of X-rays or radiation. In the lumbar area where gonadal exposure may occur, MRI’s lack of radiation is an advantage.

OVERVIEW
Ankylosing Spondylitis/Spondyloarthropathies is a cause of back or sacroiliac pain of insidious onset (usually > 3 months), associated with morning stiffness not relieved with rest (usually age at onset < 40). It is associated with any of the following (Akgul, 2011; Bennett, 2010; Ostergaard, 2012; Sieper, 2014): 

• Sedimentation rate and/or C-reactive protein (not an essential criteria)
• HLA B27 (not an essential criteria)
• Non-diagnostic or indeterminate X-ray
• Personal or family history of sacroilitis, peripheral inflammatory arthritis, and/or inflammatory bowel disease

Table 1: Gait and spine imaging‡ 

(‡References: Chhetri, 2014; Clinch, 2021; Gait, 2021; Haynes, 2018; Marshall, 2012; Pirker, 2017)

*Conservative Therapy: (Spine) should include a multimodality approach consisting of a combination of active and inactive components. Inactive components, such as rest, ice, heat, modified activities, medical devices, acupuncture and/or stimulators, medications, injections (epidural, facet, bursal, and/or joint, not including trigger point), and diathermy can be utilized. Active modalities may consist of physical therapy, a physician-supervised home exercise program**, and/or osteopathic manipulative medicine (OMT) or chiropractic care.

**Home Exercise Program — (HEP)/Therapy — The following elements are required to meet guidelines for completion of conservative therapy (ACR, 2015; Last, 2009): 

• Information provided on exercise prescription/plan; AND
• Follow-up with member with documentation provided regarding lack of improvement (failed) after completion of HEP (after suitable 6-week period), or inability to complete HEP due to physical reason, i.e., increased pain, inability to physically perform exercises. (Patient inconvenience or noncompliance without explanation does not constitute "inability to complete" HEP).
• Dates and duration of failed PT, physician-supervised HEP, or chiropractic treatment should be documented in the original office notes or an addendum to the notes.

Table 2: MRI and Cutaneous Stigmata (Dias, 2015) 

Infection, Abscess, or Inflammatory disease 

• Most common site is the lumbar spine (58%), followed by the thoracic spine (30%) and the cervical spine (11%) (Graeber, 2019)
• High risk populations (indwelling hardware, history of endocarditis, IVDA, recent procedures) with appropriate signs/symptoms

MRI and Back Pain — MRI is the initial imaging modality of choice in the evaluation of complicated low back pain. Contrast administration may be used to evaluate suspected inflammatory disorders, e.g., discitis, and it is useful in evaluating suspected malignancy. Radiculopathy, disease of the nerve roots, is the most common indication for MRI of patients with low back pain. The nerve roots become irritated and inflamed, due to direct pressure from degenerative changes in the lumbar spine, creating pain and numbness. Symptoms of radiculopathy also include muscle weakness. MRI is indicated for this condition if the symptoms do not improve after conservative treatment over six weeks. MRI is also performed to evaluate Cauda equina syndrome, severe spinal compression.

Sacral Dimples — Simple midline dimples are the most commonly encountered dorsal cutaneous stigmata in neonates and indicate low risk for spinal dysraphism. Only atypical dimples are associated with a high risk for spinal dysraphism, particularly those that are large (> 5 mm), high on the back (> 2.5 cm from the anus) or appear in combination with other lesions (D’Alessandro, 2009). High-risk cutaneous stigmata in neonates include hemangiomas, upraised lesions (i.e., masses, tails, and hairy patches), and multiple cutaneous stigmata (Table 2).

Tethered spinal cord syndrome — This is a neurological disorder caused by tissue attachments that limit the movement of the spinal cord within the spinal column. Although this condition is rare, it can continue undiagnosed into adulthood. The primary cause is myelomeningocele and lipomyelomeningocele; the following are other associations that vary in severity of symptoms and treatment.

• Dermal sinus tract (a rare congenital deformity)
• Diastematomyelia (split spinal cord)
• Lipoma
• Tumor
• Thickened/tight filum terminale
• History of spine trauma/surgery
• Arnold-Chiari Malformation

Magnetic resonance imaging (MRI) can display the low level of the spinal cord and a thickened filum terminale, the thread-like extension of the spinal cord in the lower back. Treatment depends upon the underlying cause of the tethering. If the only abnormality is a thickened, shortened filum then limited surgical treatment may suffice.

Spina Bifida Occulta (AANS, 2020)  

• Called the hidden spina bifida, as the spinal cord and the nerves are usually normal and there is no opening on the skin on the back.
• This subtype occurs in about 12% of the population and the majority of people are not aware that they have spina bifida occulta unless it is discovered on an X-ray performed for an unrelated reason.
• Approximately 1 in 1,000 individuals can have an occult structural finding that leads to neurological deficits or disabilities as bowel or bladder dysfunction, back pain, leg weakness or scoliosis.

Back Pain with Cancer — History Radiographic (X-ray) examination should be performed in cases of back pain when a patient has a cancer history. This can make a diagnosis in many cases. This may occasionally allow for selection of bone scan in lieu of MRI. When radiographs do not answer the clinical question, then MRI may be appropriate after a consideration of conservative care.

Neoplasms causing VCF (vertebral compression fractures) include primary bone neoplasms, such as hemangioma or giant cell tumors, and tumor-like conditions causing bony and cellular remodeling, such as aneurysmal bone cysts, or Paget’s disease (osteitis deformans); infiltrative neoplasms, including and not limited to, multiple myeloma and lymphoma, and metastatic neoplasms (ACR, 2018).

Most common spine metastasis involving primary metastasis originate from the following tumors in descending order: breast (21%), lung (19%), prostate (7.5%), renal (5%), gastrointestinal (4.5%), and thyroid (2.5%). While all tumors can seed to the spine, the cancers mentioned above metastasize to the spinal column early in the disease process (Ziu, 2019).

CAUDA EQUINA SYNDROME 

• Symptoms include severe back pain or sciatica along with one or more of the following:
  • Saddle anesthesia — loss of sensation restricted to the area of the buttocks, perineum, and inner surfaces of the thighs (areas that would sit on a saddle)
  • Recent bladder/bowel dysfunction (as listed above)
  • Achilles reflex absent on both sides
  • Sexual dysfunction that can come on suddenly
  • Absent anal reflex and bulbocavernosus reflex

MRI and Neurocutaneous Syndromes 

• In NF-1, clinical evaluation appears to be more useful to detect complications than is screening imaging in asymptomatic patients. Imaging is indicated in evaluation of suspected tumors based on clinical evaluation and for follow-up of known intracranial tumors (Borofsky, 2013).
• Conversely in NF-2, routine MR imaging screening is always indicated, given the high prevalence of CNS tumors, especially vestibular schwannomas. In patients with NF-2, routine screening brain/IAC imaging is indicated annually starting from age 10, if asymptomatic, or earlier with clinical signs/symptoms. Most individuals with NF2 eventually develop a spinal tumor, mostly commonly schwannomas, but meningioma and ependymomas are also seen. Spinal imaging at baseline and every 2 to 3 years is also advised with more frequent imaging, if warranted, based on sites of tumor involvement (Evans, 2017).
• In patients with Tuberous Sclerosis, Brain MRI should be obtained every 1 – 3 years up until age 25 for surveillance for CNS abnormalities (Krueger, 2013).
• In Von Hippel Lindau Syndrome, imaging of the brain and spinal cord for hemangioblastomas is recommended every 2 years (Varshney, 2017).
• In Sturge Weber Syndrome, Brain MRI can rule out intracranial involvement only after age 1 and is recommended in patients < 1 year only if symptomatic (Comi, 2011).

Policy
LUMBAR SPINE MRI is considered MEDICALLY NECESSARY for the following indications:

+If there is a combination request* for an overlapping body part, either requested at the same time or sequentially (within the past 3 months) the results of the prior study should be:

• Inconclusive or show a need for additional or follow up imaging evaluation OR
• The office notes should clearly document an indication why overlapping imaging is needed and how it will change management for the patient.

(*Unless approvable in the combination section as noted in the guidelines)

For evaluation of neurologic deficits^1,2,3,4

• With any of the following new neurological deficits documented on physical exam
  • Extremity muscular weakness (and not likely caused by plexopathy, or peripheral neuropathy)^5,6
  • Pathologic or abnormal reflexes
  • Absent/decreased sensory changes along a particular lumbar dermatome (nerve distribution): pin prick, touch, vibration, proprioception or temperature
  • Lower extremity increased muscle tone/spasticity
  • New onset bowel or bladder dysfunction (e.g., retention or incontinence)- not related to an inherent bowel or bladder process
  • Gait abnormalities (see Table 1 for more details)
  • New onset foot drop (Not related to a peripheral nerve injury, e.g., peroneal nerve)
• Cauda Equina Syndrome as evidence by severe back pain/sciatica along with one of the defined symptoms (see Overview section)

For evaluation of back pain with any of the following^{7,8,9,10,11,12,13,14,15,16}

• With new or worsening objective neurologic deficits on exam, as above
• Failure of conservative treatment* for at least six (6) weeks within the last six (6) months¹⁶
• With progression or worsening of symptoms during the course of conservative treatment*
• With an abnormal electromyography (EMG) or nerve conduction study (if performed) indicating a lumbar radiculopathy. (EMG is not recommended to determine the cause of axial lumbar, thoracic, or cervical spine pain.)¹⁵
• Isolated back pain in pediatric population¹⁷ — conservative care not required if red flags present
  • Red flags that prompt imaging should include the presence of: age 5 or younger, constant pain, pain lasting > 4 weeks, abnormal neurologic examination, early morning stiffness and/or gelling; night pain that prevents or disrupts sleep; radicular pain; fever; weight loss; malaise; postural changes (e.g., kyphosis or scoliosis); and limp (or refusal to walk in a younger child < 5yo) AND initial radiographs have been performed^18,19

As part of initial pre-operative/post-operative/procedural evaluation (“CT best examination to assess for hardware complication, extent of fusion”^16,20 and MRI for cord, nerve root compression, disc pathology or post-op infection)

• For preoperative evaluation/planning
• CSF leak highly suspected and supported by patient history and/or physical exam findings (leak [known or suspected spontaneous (idiopathic) intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula])
• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery in the last 6 months. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested (routine surveillance post-op not indicated without symptoms)
• Surgical infection as evidenced by signs/symptoms, laboratory, or prior imaging findings
• New or changing neurological deficits or symptoms post-operatively ^20,21 — see neurological deficit section above
• When combo requests (see above statement+) are submitted (i.e., MRI and CT of the spine), the office notes should clearly document the need for both studies to be done simultaneously, i.e., the need for both soft tissue and bony anatomy is required²²
  • Combination requests where both lumbar spine CT and MRI lumbar spine are both approvable (not an all-inclusive list)
    • Pathologic or complex fractures
    • Malignant process of spine with both bony and soft tissue involvement
    • Clearly documented indication for bony and soft tissue abnormality where assessment will change management for the patient

For evaluation of trauma or acute injury²³

• Presents with any of the neurological deficits as above
• With progression or worsening of symptoms during the course of conservative treatment*
• History of underlying spinal abnormalities (i.e., ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis) (Both MRI and CT would be approvable)²⁴
• When the patient is clinically unevaluable or there are preliminary imaging findings (X-ray or CT) needing further evaluation

(“MRI and CT provide complementary information. When indicated it is appropriate to perform both examinations”).²³

Pars defect (spondylolysis) or spondylolisthesis

• Pars defect (spondylolysis) or spondylolisthesis in adults when Flexion/Extension X-rays show instability
• Clinically suspected Pars defect (spondylolysis) which is not seen on plain films in pediatric population (< 18 yr) (flexion extension instability not required) and imaging would change treatment^25,26,27

NOTE: Initial imaging (X-ray, or planar bone scan without SPECT; Bone scan with SPECT is superior to MRI and CT in the detection of pars intrarticularis pathology including spondylolysis).²⁸

For evaluation of known or new compression fractures with worsening back pain²⁹

• With history of malignancy
  • To aid in differentiation of benign osteoporotic fractures from metastatic disease
    • A follow up MRI in 6 – 8 weeks after initial MRI when initial imaging cannot decipher benign osteoporotic fracture from metastatic disease
• With an associated new focal neurologic deficit as above
• Prior to a planned surgery/intervention or if the results of the MRI will change management.

For evaluation of tumor, cancer, or metastasis with any of the following:
(MRI is usually the preferred study, but CT may be needed to further characterize solitary indeterminate lesions seen on MRI)^30,31,32

• Primary tumor
  • Initial staging or re-staging of a known primary spinal tumor³³
  • Known primary tumor with new signs or symptoms (e.g., new or increasing nontraumatic pain, physical, laboratory, and/or imaging findings)
  • With an associated new focal neurologic deficit as above³⁴
• Metastatic tumor
  • With evidence of metastasis on bone scan needing further clarification OR inconclusive findings on a prior imaging exam
  • With an associated new focal neurologic deficit³⁴
  • Known malignancy with new signs or symptoms (e.g., new or increasing nontraumatic pain, radiculopathy or back pain that occurs at night and wakes the patient from sleep with known active cancer, physical, laboratory, and/or imaging findings) in a tumor that tends to metastasize to the spine^35,36
• For evaluation of inconclusive/indeterminate finding on prior imaging that requires further clarification:
  • One follow-up exam to ensure no suspicious change has occurred in prior imaging finding. No further surveillance unless specified as highly suspicious or change was found on last follow-up exam³⁶

Indication for combination studies for the initial pre-therapy staging of cancer, OR active monitoring for recurrence as clinically indicated OR evaluation of suspected metastases

• < 5 concurrent studies to include CT or MRI of any of the following areas as appropriate depending on the cancer: Neck, Abdomen, Pelvis, Chest, Brain, Cervical Spine, Thoracic Spine or Lumbar Spine

For evaluation of known or suspected infection, abscess, or inflammatory disease^37,38

• Infection
  • As evidenced by signs and/or symptoms, laboratory (i.e., abnormal white blood cell count, ESR and/or CRP) or prior imaging findings³⁹
  • Follow-up imaging of infection
    • With worsening symptoms/laboratory values (i.e., white blood cell count, ESR/CRP) or radiographic findings⁴⁰
• Spondyloarthropathies
  • Ankylosing Spondylitis/Spondyloarthropathies with non-diagnostic or indeterminate X-ray and rheumatology workup

For evaluation of spine abnormalities related to immune system suppression, e.g., HIV, chemotherapy, leukemia, or lymphoma³⁸

• As evidenced by signs/symptoms, laboratory, or prior imaging findings

Other Indications for a Lumbar Spine MRI
(Note: See combination requests, below, for initial advanced imaging assessment and pre-operatively)

• Tethered cord, or spinal dysraphism (known or suspected) based on preliminary imaging, neurological exam, and/or high-risk cutaneous stigmata^41,42,43
• Known anorectal malformations^44,45
• Suspicious sacral dimple (those that are deep, larger than 0.5 cm, located within the superior portion of the gluteal crease or above the gluteal crease, multiple dimples, or associated with other cutaneous markers)⁴⁶ or duplicated or deviated gluteal cleft⁴⁷
  • in patients < 3 months should have ultrasound
• Toe walking in a child when associated with upper motor neuron signs, including hyperreflexia, spasticity; or orthopedic deformity with concern for spinal cord pathology (e.g., pes cavus, clawed toes, leg or foot length deformity (excluding tight heel cords))
• Known Chiari II ( Arnold-Chiari syndrome), III, or IV malformation.
• For follow-up/repeat evaluation of Arnold-Chiari I with new signs or symptoms suggesting recurrent spinal cord tethering (For initial diagnosis see below)
• Suspected neuroinflammatory Conditions/Diseases (e.g., sarcoidosis, Behcet’s)
  • After detailed neurological exam and basic testing completed

COMBINATION OF STUDIES WITH LUMBAR SPINE MRI

Any combination of Cervical and/or Thoracic and/or Lumbar MRIs
Note: These body regions might be evaluated separately or in combination as documented in the clinical notes by physical examination findings (e.g., localization to a particular segment of the spinal cord), patient history, and other available information, including prior imaging.

Exception- Indications for combination studies^48,49: Are approved indications as noted below and being performed in children who will need anesthesia for the procedure

• Any combination of these studies for:
  • Survey/complete initial assessment of infant/child with congenital scoliosis or juvenile idiopathic scoliosis under the age of 10^50,51,52 (e.g., congenital scoliosis, idiopathic scoliosis, scoliosis with vertebral anomalies)
  • In the presence of neurological deficit, progressive spinal deformity, or for preoperative planning⁵³
  • Back pain with known vertebral anomalies (hemivertebrae, hypoplasia, agenesis, butterfly, segmentation defect, bars, or congenital wedging) in a child on preliminary imaging
  • Scoliosis with any of the following⁵⁴:
    • Progressive spinal deformity;
    • Neurologic deficit (new or unexplained);
    • Early onset;
    • Atypical curve (e.g., short segment, > 30’ kyphosis, left thoracic curve,
    • associated organ anomalies);
    • Pre-operative planning; OR
    • When office notes clearly document how imaging will change management
• Arnold-Chiari malformations^55,56
  • Arnold-Chiari I
    • For evaluation of spinal abnormalities associated with initial diagnosis of Arnold-Chiari Malformation. (C/T/L spine due to association with tethered cord and syringomyelia), and initial imaging has not been completed^42,50
  • Arnold-Chiari II – IV — For initial evaluation and follow-up as appropriate
    • Usually associated with open and closed spinal dysraphism, particularly meningomyelocele)
• Tethered cord, or spinal dysraphism (known or suspected) based on preliminary imaging, neurological exam, and/or high-risk cutaneous stigmata,^41,42,43 when anesthesia required for imaging⁵⁷ (e.g., meningomyelocele, lipomeningomyelocele, diastematomyelia, fatty/thickened filum terminale, and other spinal cord malformations)
• Oncological Applications (e.g., primary nervous system, metastatic)
  • Drop metastasis from brain or spine (imaging also includes brain) — see Overview
  • Suspected leptomeningeal carcinomatosis (LC)⁵⁸ — see Overview
  • Any combination of these for spinal survey in patient with metastases
  • Tumor evaluation and monitoring in neurocutaneous syndromes — See Overview
• CSF leak highly suspected and supported by patient history and/or physical exam findings (leak [known or suspected spontaneous (idiopathic) intracranial hypotension (SIH), post lumbar puncture headache, post spinal surgery headache, orthostatic headache, rhinorrhea or otorrhea, or cerebrospinal-venous fistula])

References 

1. Acharya AB, Fowler JB. Chaddock Reflex. Updated 2019 Dec 15. In: StatPearls (Internet). Treasure Island (FL): StatPearls Publishing; 2020 Jan.
2. Akgul O, Ozgocmen S. Classification criteria for spondyloarthropathies. World J Orthop. December 18, 2011; 2(12):107-115. doi: 10.5312/wjo.v2.i12.07. Retrieved March 29, 2018.
3. Alexandru D. Evaluation and management of vertebral compression fractures. Perm J. Published online October 30, 2012:46-51. doi:10.7812/TPP/12-037.
4. Allegri M, Montella S, Salici F, et al. Mechanisms of low back pain: A guide for diagnosis and therapy. F1000Res. 2016 Jun 28; 5:F1000 Faculty Rev-1530. doi:10.12688/f1000research.8105.2.
5. Ammendolia C, Chow N. Clinical outcomes for neurogenic claudication using a multimodal program for lumbar spinal stenosis: A retrospective study. J Manip Physiol Ther. 2015; 38:188-194.
6. American Academy of Family Physicians (AAFP). Choosing Wisely®. http://www.choosingwisely.org/clinician-lists/#keyword=spine&topic-area=Radiology&service=Imaging. Released April 4, 2012. Retrieved March 27, 2018.
7. American Association of Neurological Surgeons (AANS). Spina Bifida. 2020.
8. American Association of Neurological Surgeons (AANS). Tethered Spinal Cord Syndrome. http://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Tethered-Spinal-Cord-Syndrome. 2019.
9. American Association of Neurological Surgeons and Congress of Neurological Surgeons (AANSCNS). Choosing Wisely®. http://www.choosingwisely.org/clinician-lists/american-association-neurological-surgeons-imaging-for-nonspecific-acute-low-back-pain/. Released June 24, 2014.
10. American Chiropractic Association (ACA). Five Things Physicians and Patients Should Question. Choosing Wisely®. http://www.choosingwisely.org/societies/american-chiropractic-association/. Published August 15, 2017.
11. American College of Emergency Physicians (ACEP). Ten Things Physicians and Patients Should Question. Choosing Wisely®. http://www.choosingwisely.org/societies/american-college-of-emergency-physicians/. Published October 27, 2014.
12. American College of Radiology (ACR). ACR Appropriateness Criteria® - Back Pain–Child. 2016.
13. American College of Radiology (ACR). ACR Appropriateness Criteria® - Low Back Pain. https://acsearch.acr.org/list. Published 2018.
14. American Institute of Ultrasound in Medicine (AIUM) Practice Parameter for the Performance of an Ultrasound Examination of the Neonatal and Infant Spine. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/US-NeonatalSpine.pdf. Revised 2016.
15. Bennett AN, Marzo-Ortega H, Rehman A, et al. The evidence for whole-spine MRI in the assessment of axial spondyloarthropathy. Rheumatology. March 1, 2010; 49(3):426-432. https://doi.org/10.1093/rheumatology/kep427. Retrieved May 12, 2018.
16. Berbari EF, Kanj SS, Kowalski TJ, et al. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin Infect Dis. 2015 Sep 15; 61(6):e26–e46.
17. Bernstein RM, Cozen H. Evaluation of back pain in children and adolescents. Am Fam Physician. 2007;76(11):1669-1676.
18. Bond A, Manian FA. Spinal epidural abscess: A review with special emphasis on earlier diagnosis. Biomed Res Int. 2016; 2016:1614328.
19. Borofsky S, Levy LM. Neurofibromatosis: Types 1 and 2. Am J Neuroradiol. 2013 Dec; 34(12): 2250- 2251.
20. Chhetri SK, Gow D, Shaunak S, Varma A. Clinical assessment of the sensory ataxias; diagnostic algorithm with illustrative cases. Pract Neurol. 2014;14(4):242-251. doi:10.1136/practneurol-2013-000764.
21. Clinch J, Wood M, Driscoll S. Evaluation of gait disorders in children. BMJ Best Practice. Published February 23, 2021. Accessed July 14, 2021. https://bestpractice.bmj.com/topics/en-us/709.
22. Cohen E, Stuecker RD. Magnetic resonance imaging in diagnosis and follow-up of impending spondylolysis in children and adolescents: Early treatment may prevent pars defects. J Pediatr Orthop B. 2005; 14(2):63-67.
23. Comi AM. Presentation, diagnosis, pathophysiology, and treatment of the neurological features of Sturge-Weber syndrome. Neurologist. 2011; 17(4):179.
24. D’ Alessandro D. Does This Sacral Dimple Need to be Evaluated? PediatricEducation.org™. Iowa City, IA: July 20, 2009. https://pediatriceducation.org/2009/07/20/does-this-sacral-dimple-need-to-be-evaluated/. Retrieved March 29, 2018.
25. Davis PC, Wippold FJ, Brunberg JA, et al. ACR Appropriateness Criteria on low back pain. J Am Coll Radiol. 2009; 6:401-407. doi: 10.1016/j.jacr.2009.02.008.
26. Diab M, Landman Z, Lubicky J, et al. Use and outcome of MRI in the surgical treatment of adolescent idiopathic scoliosis. Spine (Phila Pa 1976). April 15, 2011; 36(8):667-671. doi: 10.1097/BRS.0b013e3181da218c.
27. Dias M, Partington M. Congenital brain and spinal cord malformations and their associated cutaneous markers. Pediatrics. 2015; 136(4):e1105-19.
28. De Vries M, Van Drumpt A, Van Royen B, et al. Discovertebral (Andersson) lesions in severe ankylosing spondylitis: a study using MRI and conventional radiography. Clinical Rheumatology. 2010; 29(12):1433-1438. doi: 10.1007/s10067-010-1480-9.
29. Duz B, Gocmen S, Secer HI, et al. Tethered cord syndrome in adulthood. J Spinal Cord Med. 2008; 31(3):272-278. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565560/. Retrieved March 29, 2018.
30. Evans DGR, Salvador H, Chang VY, et al. Cancer and Central Nervous System Tumor Surveillance in Pediatric Neurofibromatosis 2 and Related Disorders. Clin Cancer Res. 2017; 23(12):e54.
31. Family Practice Notebook. Cutaneous Signs of Dysraphism. http://www.fpnotebook.com/nicu/Derm/CtnsSgnsOfDysrphsm.htm. Published 2015.
32. Feldman DS, Straight JJ, Badra MI, Mohaideen A, Madan SS. Evaluation of an algorithmic approach to pediatric back pain. J Pediatr Orthop. 2006;26(3):353-357. doi:10.1097/01.bpo.0000214928.25809.f9.
33. Fisher BM, Cowles S, Matulich JR, Evanson BG, Vega D, Dissanaike S. Is magnetic resonance imaging in addition to a computed tomographic scan necessary to identify clinically significant cervical spine injuries in obtunded blunt trauma patients? Am J Surg. 2013;206(6):987-993; discussion 993-994. doi:10.1016/j.amjsurg.2013.08.021.
34. Gait abnormalities. Stanford Medicine 25. Published 2021. Accessed July 14, 2021. https://stanfordmedicine25.stanford.edu/the25/gait.html.
35. Goh C, Phal PM, Desmond PM. Neuroimaging in acute transverse myelitis. Neuroimaging Clin N Am. 2011 Nov; 21(4):951-73.
36. Graeber A, Cecava ND. Vertebral Osteomyelitis. [Updated 2019 Jun 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.
37. Haynes KB, Wimberly RL, VanPelt JM, Jo C-H, Riccio AI, Delgado MR. Toe walking: A neurological perspective after referral from pediatric orthopaedic surgeons. Journal of Pediatric Orthopaedics. 2018;38(3):152-156. doi:10.1097/BPO.0000000000001115.
38. Hertzler DA, DePowell JJ, Stevenson CB, Mangano FT. Tethered cord syndrome: A review of the literature from embryology to adult presentation. Neurosurg Focus. 2010;29(1):E1. doi:10.3171/2010.3.FOCUS1079.
39. Jarvik JG, Gold LS, Comstock BA, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 2015; 313(11):1143-1153. doi: 10.1001/jama.2015.1871.
40. Jensen AO, Jacobsen JB, Norgaard M, et al. Incidence of bone metastases and skeletal-related events in breast cancer patients: a population-based cohort study in Denmark. BMC Cancer. January 24, 2011; 11:29. http://www.ncbi.nlm.nih.gov/pubmed/21261987.
41. Kim SM, Chang HK, Lee MJ, et al. Spinal dysraphism with anorectal malformation: Lumbosacral magnetic resonance imaging evaluation of 120 patients. Journal of Pediatric Surgery. 2010a;45(4):769-776. doi:10.1016/j.jpedsurg.2009.10.094.
42. Kim H, Kim HS, Moon ES, et al. Scoliosis imaging: What radiologists should know. RadioGraphics. 2010b; 30:1823-1842. http://pubs.rsna.org/doi/pdf/10.1148/rg.307105061.
43. Kim YS, Han IH Lee IS, et al. Imaging findings of solitary spinal bony lesions and the differential diagnosis of benign and malignant lesions. J Korean Neurosurg Soc. August 2012; 52(2):126-132. doi: 10.3340/jkns.2012.52.2.126. Retrieved March 29, 2018.
44. Kobayashi A, Kobayashi T, Kato K, et al. Diagnosis of radiographically occult lumbar spondylolysis in young athletes by magnetic resonance imaging. Am J Sports Med. 2013; 41(1):169-176.
45. Koivikko MP, Koskinen SK. MRI of cervical spine injuries complicating ankylosing spondylitis. Skeletal Radiol. 2008 Sep; 37(9):813-9. doi:10.1007/s00256-008-0484-x. Epub 2008 Apr 18.
46. Krueger DA, Northrup H. International Tuberous Sclerosis Complex Consensus Group. Tuberous sclerosis complex surveillance and management: Recommendations of the 2012 International Tuberous Sclerosis Complex Consensus Conference. Pediatr Neurol. 2013; 49(4):255.
47. Last AR, Hulbert K. Chronic low back pain: Evaluation and management. Am Fam Physician. 2009; 79(12):1067-74.
48. Lerner S, Hartmann S, Barbagallo GMV, et al. Management of spinal infection: A review of the literature. Acta Neurochir (Wien). 2018; 160(3):487–496. doi: 10.1007/s00701-018-3467-2.
49. Lee C, Dorcil J, Radomisli TE. Nonunion of the spine: A review. Clin Orthop Relat Res. 2004; 419:71-75. https://www.ncbi.nlm.nih.gov/pubmed/15021134.
50. Malfair D, Flemming AK, Dvorak MF, et al. Radiographic evaluation of scoliosis: Review. AJR Am J Roentgenol. March 2010; 194(3 Suppl):S8-22. doi: 10.2214/AJR.07.7145.
51. Machado P, Landewé R, Braun J, et al. Both structural damage and inflammation of the spine contribute to impairment of spinal mobility in patients with ankylosing spondylitis. Ann Rheum Dis. 2010; 69(8):1465-1470. doi:10.1136/ard.2009.124206.
52. Marshall FJ. Approach to the elderly patient with gait disturbance. Neurol Clin Pract. 2012;2(2):103-111. doi:10.1212/CPJ.0b013e31825a7823.
53. Matesan M, Behnia F, Bermo M, et al. SPECT/CT bone scintigraphy to evaluate low back pain in young athletes: common and uncommon etiologies. J Orthop Surg Res. 2016; 11:76.
54. McDonald MA, Kirsch CFE, Amin BY, et al. ACR Appropriateness Criteria® cervical neck pain or cervical radiculopathy. J Am Coll Radiol. 2019;16(5S):S57-S76. doi:10.1016/j.jacr.2019.02.023.
55. Milhorat TH, Bolognese PA, Nishikawa M, et al. Association of Chiari malformation type I and tethered cord syndrome: Preliminary results of sectioning filum terminale. Surg Neurol. July 1, 2009; 72(1):20-35. http://europepmc.org/abstract/med/19559924. Retrieved March 29, 2018.
56. Morimoto K, Takemoto O, Wakayama A. Tethered cord associated with anorectal malformation. Pediatr Neurosurg. 2003;38(2):79-82. doi:10.1159/000068048.
57. National Institute of Neurological Disorder and Stroke (NINDS). Tethered Spinal Cord Syndrome Information Page. https://www.ninds.nih.gov/Disorders/All-Disorders/Tethered-Spinal-Cord-Syndrome-Information-Page. Published 2011.
58. North American Spine Society (NASS). Clinician Lists. Choosing Wisely® . http://www.choosingwisely.org/clinician-lists/nass-emg-nerve-conduction-studies-to-determinecause-of-spine-pain/. Released October 9, 2013.
59. North American Spine Society (NASS). Five Things Physicians and Patients Should Question. Choosing Wisely®. http://www.choosingwisely.org/doctor-patient-lists/north-american-spine-society/. Published 2014.
60. North American Spine Society (NASS). Evidence-based Clinical Guidlines for Multidisciplinary Spine Care. Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders. 2010 North American Spine Society. https://www.spine.org/Portals/0/Assets/Downloads/ResearchClinicalCare/Guidelines/CervicalRadiculo pathy.pdf
61. Ostergaard M, Lambert RG. Imaging in ankylosing spondylitis. Ther Adv Musculoskelet Dis. August 2012; 4(4):301-311. doi: 10.1177/1759720X11436240. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3403247/. Retrieved March 29, 2018.
62. Ozturk C, Karadereler S, Ornek I, Enercan M, Ganiyusufoglu K, Hamzaoglu A. The role of routine magnetic resonance imaging in the preoperative evaluation of adolescent idiopathic scoliosis. Int Orthop. 2010;34(4):543-546. doi:10.1007/s00264-009-0817-y.
63. Pirker W, Katzenschlager R. Gait disorders in adults and the elderly : A clinical guide. Wien Klin Wochenschr. 2017;129(3-4):81-95. doi:10.1007/s00508-016-1096-4.
64. Pomerantz SR. Myelography: modern technique and indications. Handb Clin Neurol. 2016; 135:193-208.
65. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017 April 4.
66. Radic JAE, Cochrane DD. Choosing wisely canada: pediatric neurosurgery recommendations. Paediatr Child Health. 2018;23(6):383-387. doi:10.1093/pch/pxy012.
67. Rajasekaran S, Kamath F, Kiran R, et al. Intraspinal anomalies in scoliosis: An MRI analysis of 177 consecutive scoliosis patients. Indian J Orthop. January-March 2010; 44(1): 57-63. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2822421/.
68. Rao D, Scuderi G, Scuderi C, Grewal R, et al. The use of imaging in management of patients with low back pain. J Clin Imaging Sci. 2018 Aug 24; 8:30.
69. Roberts CC, Daffner RH, Weissman BN, et al. ACR Appropriateness Criteria® on metastatic bone disease. J Am Coll Radiol. 2010;7(6):400-409. doi:10.1016/j.jacr.2010.02.015.
70. Rush JK, Astur N, Scott S, et al. Use of magnetic resonance imaging in the evaluation of spondylolysis. J Pediatr Orthop. 2015 Apr-May; 35(3):271-5.
71. Schneider MJ, Ammendolia C, Murphy DR, et al. Comparative clinical effectiveness of nonsurgical treatment methods in patients with lumbar spinal stenosis: A randomized clinical trial. JAMA Netw Open. 2019 Jan 4; 2(1):e186828.
72. Scoliosis Research Society (SRS). Conditions and treatments: Juvenile scoliosis. 2019
73. Shah LM, Salzman KL. Imaging of spinal metastatic disease. Int J Surg Oncol. 2011; 2011:769753.
74. Sieper J, Rudwaleit M, Baraliakos X, et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis. June 2009; 68 Suppl 2:ii1-44. Retrieved March 29, 2018.
75. Stolper K, Haug JC, Christensen CT, et al. Prevalence of thoracic spine lesions masquerading as cauda equina syndrome: Yield of a novel magnetic resonance imaging protocol. Intern Emerg Med. 2017 Dec; 12(8):1259-1264. doi: 10.1007/s11739-016-1565-9.
76. Strahle J, Muraszko KM, Kapurch J, Bapuraj JR, Garton HJL, Maher CO. Chiari malformation Type I and syrinx in children undergoing magnetic resonance imaging. J Neurosurg Pediatr. 2011;8(2):205-213. doi:10.3171/2011.5.PEDS1121.
77. Strahle J, Smith BW, Martinez, et al. The association between Chiari malformation Type I, spinal syrinx, and scoliosis. J Neurosurg Pediatr. June 2015; 15(6):607-611. http://thejns.org/doi/pdf/10.3171/2014.11.PEDS14135. Retrieved March 29, 2018.
78. Spondylitis Association of America (SAA). https://www.spondylitis.org/Ankylosing-Spondylitis/Diagnosis. Retrieved March 29, 2018.
79. Trenga AP, Singla A, Feger MA, et al. Patterns of congenital bony spinal deformity and associated neural anomalies on X-ray and magnetic resonance imaging. J Child Orthop. August 2016; 10(4):343-352. doi: 10.1007/s11832-016-0752-6. Retrieved March 29, 2018.
80. Varshney N, Kebede AA, Owusu-Dapaah H, Lather J, Kaushik M, Bhullar JS. A review of Von Hippel-Lindau Syndrome. J Kidney Cancer VHL. 2017;4(3):20-29. doi:10.15586/jkcvhl.2017.88.
81. Ziu E, Viswanathan VK, Mesfin FB. Cancer, Spinal Metastasis. [Updated 2020 Mar 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441950/.
82. Zywicke HA, Rozzelle CJ. Sacral dimples. Pediatr Rev. 2011;32(3):109-113; quiz 114, 151. doi:10.1542/pir.32-3-109

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

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