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## Complete Summary

#### GUIDELINE TITLE

Myelopathy.

#### BIBLIOGRAPHIC SOURCE(S)

Seidenwurm DJ, Brunberg JA, Davis PC, De La Paz RL, Dormont PD, Hackney
DB, Jordan JE, Karis JP, Mukherji SK, Turski PA, Wippold FJ II,
Zimmerman RD, McDermott MW, Sloan MA, Expert Panel on Neurologic
Imaging. Myelopathy. \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2006. 11 p. \[58 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Seidenwurm D, Drayer BP,
Anderson RE, Braffman B, Davis PC, Deck MD, Hasso AN, Johnson BA,
Masaryk T, Pomeranz SJ, Tanenbaum L, Masdeu JC. Myelopathy. American
College of Radiology. ACR Appropriateness Criteria. Radiology 2000
Jun;215(Suppl):495-505.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [May 23, 2007, Gadolinium-based Contrast
    Agents](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Gadolinium):
    The addition of a boxed warning and new warnings about the risk of
    nephrogenic systemic fibrosis (NSF) to the full prescribing
    information for all gadolinium-based contrast agents (GBCAs).

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Myelopathy

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Emergency Medicine\
Infectious Diseases\
Neurological Surgery\
Neurology\
Oncology\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations for
patients with myelopathy

#### TARGET POPULATION

Patients with myelopathy

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Computed tomography (CT), spine

    -   Without contrast

    -   With contrast

    -   Postdiscogram

2.  Computed tomography angiography (CTA), spine

3.  Magnetic resonance imaging (MRI), spine

    -   Without contrast

    -   Without and with contrast

    -   Flow

4.  Magnetic resonance angiography (MRA), spine

5.  CT myelography

6.  Myelography

7.  X-ray, spine

8.  Nuclear medicine (NUC)

    -   Bone scan (include single-photon emission computed tomography
        \[SPECT\])

    -   White blood cell (WBC) scan

    -   Cerebral spinal fluid (CSF) flow scan

9.  Invasive (INV), spinal arteriography

10. Discogram

11. Epidural venography

12. Thermography

13. Ultrasound (US)

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of recent
peer-reviewed medical journals, and the major applicable articles were
identified and collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed to reach agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by the participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Myelopathy**

**Variant 1: Traumatic.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, spine, without   9                   First test for acute management.
  contrast                                 

  MRI, spine without   8                   Problem solving or operative
  contrast                                 planning. Most useful when injury
                                           not explained by bony fracture.

  X-ray, spine         7                   May be first test in multi-system
                                           trauma, especially when CT is
                                           delayed. To assess stability.

  CT myelography       5                   MRI preferable.

  Myelography          3                   Usually performed in conjunction
                                           with CT.

  CTA, spine           3                   For suspected vascular trauma.

  MRA, spine           3                   For suspected vascular trauma.

  CT, spine, with      2                    
  contrast                                 

  MRI, spine, without  2                    
  and with contrast                        

  Flow MRI, spine      2                    

  NUC, bone scan       2                    
  (include SPECT)                          

  NUC, WBC scan        2                    

  NUC, CSF flow scan   2                    

  INV, spinal          2                    
  arteriography                            

  Discogram            1                    

  Postdiscogram CT     1                    

  Epidural venography  1                    

  Thermography         1                    

  US                   1                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 2: Painful.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, spine, without  8                    
  contrast                                 

  MRI, spine, without  7                   If infection or neoplastic
  and with contrast                        disorder suspected.

  CT, spine, without   7                   Most useful for spondylosis.
  contrast                                 

  CT myelography       5                   Problem solving or if MRI
                                           unavailable or contraindicated.

  NUC, bone scan       4                   Search for associated extra spinal
  (include SPECT)                          disease.

  X-ray, spine         3                   To assess stability.

  CT, spine, with      3                   Consider for infection, neoplasm
  contrast                                 or if MRI unavailable or
                                           contraindicated.

  CTA, spine           2                   Problem solving.

  Myelography          2                   Usually performed in conjunction
                                           with CT.

  MRA, spine           2                    

  Flow MRI, spine      2                    

  NUC, WBC scan        2                    

  NUC, CSF flow scan   2                    

  INV, spinal          2                    
  arteriography                            

  Discogram            1                    

  Postdiscogram CT     1                    

  Epidural venography  1                    

  Thermography         1                    

  US                   1                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 3: Sudden onset.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, spine without   9                    
  contrast                                 

  MRI, spine, without  8                    
  and with contrast                        

  CT myelography       6                   Problem solving or if MRI
                                           unavailable or contraindicated.

  Myelography          6                   Usually performed in conjunction
                                           with CT.

  CT, spine, without   5                   Problem solving or if MRI
  contrast                                 unavailable or contraindicated.

  CTA, spine           5                   If AVM is suspected.

  MRA, spine           4                   If AVM is suspected.

  INV, spinal          4                   If AVM is suspected.
  arteriography                            

  X-ray, spine         3                   To assess stability.

  CT, spine, with      3                    
  contrast                                 

  Flow MRI, spine      2                    

  NUC, bone scan       2                    
  (include SPECT)                          

  NUC, WBC scan        2                    

  NUC, CSF flow scan   2                    

  Discogram            1                    

  Postdiscogram CT     1                    

  Epidural venography  1                    

  Thermography         1                    

  US                   1                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 4: Stepwise progressive.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, spine, without  9                    
  contrast                                 

  MRI, spine, without  8                    
  and with contrast                        

  INV, spinal          6                   If AVM is suspected.
  arteriography                            

  CT myelography       6                   Problem solving or if MRI
                                           unavailable or contraindicated.

  Myelography          6                   Usually performed in conjunction
                                           with CT. If AVM is suspected.

  CT, spine, without   5                   Problem solving or if MRI
  contrast                                 unavailable or contraindicated.

  CTA, spine           5                    

  MRA, spine           4                    

  X-ray, spine         3                    

  CT, spine, with      3                    
  contrast                                 

  Flow MRI, spine      2                    

  NUC, bone scan       2                    
  (include SPECT)                          

  NUC, WBC scan        2                    

  NUC, CSF flow scan   2                    

  Discogram            1                    

  Postdiscogram CT     1                    

  Epidural venography  1                    

  Thermography         1                    

  US                   1                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 5: Slowly progressive.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, spine, without  8                    
  contrast                                 

  MRI, spine without   7                    
  and with contrast                        

  CT, spine, without   6                   Most useful for spondylosis.
  contrast                                 

  Myelography          5                   If MRI is not possible or for
                                           preoperative planning and problem
                                           solving. Usually performed in
                                           conjunction with CT.

  CT myelography       5                   Problem solving or if MRI
                                           unavailable or contraindicated.

  NUC, bone scan       4                    
  (include SPECT)                          

  INV, spinal          4                    
  arteriography                            

  X-ray, spine         3                   To assess stability.

  CT, spine, with      3                   Infection or neoplasms suspected,
  contrast                                 or if MRI unavailable or
                                           contraindicated.

  CTA, spine           2                    

  MRA, spine           2                    

  Flow MRI, spine      2                   May be useful in syringomyelia.

  NUC, WBC scan        2                    

  NUC, CSF flow scan   2                    

  Discogram            1                    

  Postdiscogram CT     1                    

  Epidural venography  1                    

  Thermography         1                    

  US                   1                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 6: Infectious disease patient.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, spine, without  9                    
  and with contrast                        

  MRI, spine, without  8                    
  contrast                                 

  CT, spine, without   6                   If MRI unavailable or
  contrast                                 contraindicated.

  CT, spine, with      5                    
  contrast                                 

  CT myelography       5                   Problem solving or if MRI
                                           unavailable or contraindicated.

  Myelography          5                   If MRI not feasible. Usually
                                           performed in conjunction with CT.

  NUC, WBC scan        4                   May be combined with bone scan to
                                           diagnose osteomyelitis.

  X-ray, spine         3                   To assess stability.

  CTA, spine           2                    

  MRA, spine           2                    

  Flow MRI             2                    

  NUC, CSF flow scan   2                    

  INV, spinal          2                    
  arteriography                            

  Discogram            1                    

  Postdiscogram CT     1                    

  Epidural venography  1                    

  Thermography         1                    

  US                   1                    

  Bone scan (include   1                   Indicated if multifocal disease is
  SPECT)                                   suspected.

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 7: Oncology patient.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, spine, without  9                    
  contrast                                 

  MRI, spine, without  8                    
  and with contrast                        

  NUC, bone scan       6                   Search for extraspinal disease.
  (include SPECT)                          

  CT, spine, without   6                   Problem solving or if MRI
  contrast                                 unavailable or contraindicated.

  Myelography          5                   If MRI is not feasible. Usually
                                           performed in conjunction with CT.

  CT myelography       5                   If MRI is not feasible

  CT, spine, with      4                    
  contrast                                 

  X-ray, spine         3                   Assess stability or for treatment
                                           planning.

  CTA, spine           2                   Treatment planning or problem
                                           solving.

  MRA, spine           2                    

  Flow MRI, spine      2                    

  NUC, WBC scan        2                    

  NUC, CSF flow scan   2                    

  INV, spinal          2                    
  arteriography                            

  Discogram            1                    

  Postdiscogram CT     1                    

  Epidural venography  1                    

  Thermography         1                    

  US                   1                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

The term myelopathy is used to describe any neurological deficit related
to the spinal cord itself. Most frequently, myelopathy is due to
compression of the spinal cord by osteophyte or extruded disc material
in the cervical spine. Osteophytic spurring and disc herniation may also
produce myelopathy localized to the thoracic spine, though this is less
common. The next most common sources of myelopathy are spinal cord
compression due to extradural mass caused by carcinoma metastatic to
bone, and blunt or penetrating trauma. Many primary neoplastic,
infectious, inflammatory, neurodegenerative, vascular, nutritional, and
idiopathic disorders may also result in myelopathy, though these are
very much less common than discogenic disease, metastases, and trauma. A
variety of cysts and benign neoplasms may also compress the cord; these
tend to arise intradurally. The most common of these are meningiomas,
nerve sheath tumors, epidermoid cysts, and arachnoid cysts.

In general, disorders of the spinal cord itself are uncommon and
difficult to treat effectively. Therefore, most attention in the
radiological evaluation of myelopathy is focused on extrinsic
compression of the spinal cord. Classically, radiological evaluation of
myelopathic patients consisted of positive contrast myelography. Later,
this evaluation was supplemented by CT and CT myelography. MRI has
become the mainstay in the evaluation of myelopathy. More recently,
imaging of the spinal cord has improved to the point that reliable
diagnosis of nonexpansile spinal cord lesions is routinely possible.

Despite the wide variety of causes of myelopathy, diagnosis and
treatment rest on demonstration of mechanical stability of the spine,
particularly in the cervical region and when tumor or trauma history is
present. Depiction of direct neural involvement by a pathologic process
is then required for more refined diagnosis and specific treatment
decisions. Anatomical diagnosis of myelopathy rests principally in the
distinction between extradural, intradural, and intramedullary lesions.

Clinically, the diagnosis of myelopathy depends on the neurological
localization of the finding to the spinal cord, rather than the brain or
peripheral nervous system, and then to a particular segment of the
spinal cord. The antecedent clinical syndrome and other details of the
patient\'s course help to refine diagnosis, but imaging plays a crucial
role. In general, myelopathy is clinically divided into categories based
on the presence or absence of significant trauma, presence or absence of
pain, and the mode of onset (slowly progressive or insidious onset vs. a
stepwise progression vs. a sudden onset). Patients with known tumor
history and those in whom infectious disease is likely may also be
considered separately.

In the patient with traumatic myelopathy, the first priority for the
spine is mechanical stability. Plain radiographs are useful for this
purpose, but CT may be more useful when a high probability of bony
injury or ligamentous injury is present. At some centers, routine
multidetector CT with sagittal and coronal reconstructions is
supplanting the role of plain radiographs, especially in the setting of
multiple trauma. MRI is widely considered the study of choice when
paralysis is incomplete or under other circumstances where direct
visualization of neural or ligamentous structures is clinically
necessary. If surgery for herniated disc, hematoma, or other cause of
incomplete paralysis is planned, MRI best depicts the relation of
pathology to the cord, and can help predict which patients may benefit
from surgery.

When local or radicular pain accompanies myelopathy, the most likely
diagnoses are spondylosis, tumor, and infection. Plain radiographs may
depict osteophytic narrowing of the spinal canal or bone destruction. CT
improves the depiction of both bony encroachment on the spinal canal and
compression of neural structures by herniated disc material that is
occult to plain radiographic evaluation. Bone destruction and soft
tissue masses are also better seen. MRI has largely replaced CT scanning
in the noninvasive evaluation of patients with painful myelopathy
because of its superior soft tissue resolution and multiplanar
capability. Invasive evaluation by means of myelography and CT
myelography may be supplemental when visualization of neural structures
is required for surgical planning or other specific problem solving,
though this is less frequent.

Although most commonly due to spondylosis and disc herniation, a
significant proportion of painful myelopathy is caused by tumor or
infection. Demyelinating disease may present with pain symptoms as well.
Occasionally, syringomyelia may present with the anesthesia dolorosa
syndrome. The ability of MRI to depict the spinal cord directly and to
assess its contour and internal signal characteristics reliably and
noninvasively has resulted in general acceptance of MRI as the study of
choice in evaluating cervical myelopathy when spondylosis or disc
herniation is the most likely cause. When MRI is not available, or to
answer specific questions before surgical intervention, myelography and
CT myelography may be useful.

In slowly progressive myelopathy, the ability of MRI to depict the
spinal cord noninvasively is most valuable. Some specifically treatable
disorders may be localized and depicted quite well by means of
myelography followed by CT myelography. However, the occasional
complication of myelography in cases of spinal block, difficulty in
visualizing the upper extent of lesions, and relative \"blind spots\" at
the cervical thoracic and craniocervical junctions limit the utility of
myelography. CT myelographic techniques may help avoid these pitfalls
and may be useful to answer specific preoperative questions about bony
anatomy.

Enlargement of the spinal cord by intramedullary mass is well depicted
by myelography only when large masses are present. CT myelography can be
extremely useful in supplementing the plain radiographic examination.
These techniques, however, are less useful than MRI because the
distinction between solid and cystic masses is usually not possible,
even when delayed examination is performed. The distinction of syrinx
from tumor, location of tumor nodule, extent of cyst, and distinction of
nodule and cyst from edema are crucial in treatment planning for
intramedullary disease and virtually necessitate MRI.

When myelopathy progresses stepwise or is of sudden onset, vascular
processes become significant diagnostic possibilities. Vascular
malformations, spinal cord infarct, and epidural hematoma account for
most of vascular lesions of the cord. In practice, they are difficult to
distinguish clinically from other nontraumatic causes of myelopathy
because the classic history is frequently absent or difficult to elicit
from a seriously ill patient. If AVM is considered clinically likely,
gadolinium-enhanced MRI, MRA, and myelography to demonstrate abnormal
vasculature may be useful adjuncts to guide spinal arteriography. More
recently, progress in CT angiography has led to the use of this
technique in preangiographic evaluation of patients with suspected
spinal vascular abnormalities.

If myelopathy is painless and slowly progressive, the differential
diagnosis is quite broad. Neoplastic disease of the spinal cord and
extrinsic compression by epidural or intradural tumor may present in
this manner. Demyelinating disease, degenerative diseases, and metabolic
or deficiency diseases also present in this fashion. Spondylosis may
present painlessly as well, particularly in elderly. In these cases,
visualization of the spine as well as the spinal cord is useful and this
is best accomplished noninvasively by MRI.

In oncology and infectious disease patients, multiple sites of
involvement are possible. In these patients it is often necessary to
study the entire spine or even the entire skeleton despite a
specifically localized myelopathic level. MRI is considered more
sensitive at an individual site, but the convenience of radionuclide
bone scanning makes it useful in this setting as well. Acquired immune
deficiency syndrome (AIDS) patients may present with myelopathy due to
primary cord disease caused by human immunodeficiency virus (HIV)
infection. No high quality evidence supports the use of discography,
thermography, epidural venography, ultrasound, CSF flow studies in the
evaluation of myelopathy. Radionuclide bone scan may play an adjunctive
role, for example, to locate a safer biopsy site in patients with
suspected metastatic cord compression.

An important limitation of MRI in the diagnosis of myelopathy is its
high sensitivity. The ease with which the study depicts expansion and
compression of the spinal cord in the myelopathic patient may lead to
false positive examinations and inappropriately aggressive therapy if
findings are interpreted incorrectly. For example, transverse myelitis
due to demyelinating disease may demonstrate cord enlargement and be
mistaken for tumor. Spondylosis, which occurs with normal aging, may be
mistaken for clinically significant osteophytic compression of the
spinal cord in a patient who is myelopathic for other reasons. These
problems are minimized by experienced observers and meticulous clinical
correlation with radiologic findings. Similar problems are present in
the interpretation of any anatomical study of the spinal cord and are
not unique to MRI. Careful patient selection and clinical correlation
are essential in interpretation of imaging findings everywhere.

**Abbreviations**

-   AVM, arteriovenous malformation

-   CT, computed tomography

-   CTA, computed tomography angiography

-   CSF, cerebrospinal fluid

-   INV, invasive

-   MRA, magnetic resonance angiography

-   MRI, magnetic resonance imaging

-   NUC, nuclear medicine

-   SPECT, single photon emission computed tomography

-   US, ultrasound

-   WBC, white blood cell

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evaluation of
patients with myelopathy

#### POTENTIAL HARMS

-   An important limitation of magnetic resonance imaging in the
    diagnosis of myelopathy is its high sensitivity. The ease with which
    the study depicts expansion and compression of the spinal cord in
    the myelopathic patient may lead to false positive examinations and
    inappropriately aggressive therapy if findings are interpreted
    incorrectly.

-   Similar problems are present in the interpretation of any anatomical
    study of the spinal cord and are not unique to magnetic resonance
    imaging. Careful patient selection and clinical correlation are
    essential in interpretation of imaging findings everywhere.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Seidenwurm DJ, Brunberg JA, Davis PC, De La Paz RL, Dormont PD, Hackney
DB, Jordan JE, Karis JP, Mukherji SK, Turski PA, Wippold FJ II,
Zimmerman RD, McDermott MW, Sloan MA, Expert Panel on Neurologic
Imaging. Myelopathy. \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2006. 11 p. \[58 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1996 (revised 2006)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Neurologic
Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: David J. Seidenwurm, MD; James A. Brunberg, MD;
Patricia C. Davis, MD; Robert Louis De La Paz, MD; Pr. Didier Dormont;
David B. Hackney, MD; John E. Jordan, MD; John P. Karis, MD; Suresh
Kumar Mukherji, MD; Patrick A Turski, MD; Franz J Wippold II, MD; Robert
D Zimmerman, MD; Michael W. McDermott, MD; Michael A. Sloan, MD, MS

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Seidenwurm D, Drayer BP,
Anderson RE, Braffman B, Davis PC, Deck MD, Hasso AN, Johnson BA,
Masaryk T, Pomeranz SJ, Tanenbaum L, Masdeu JC. Myelopathy. American
College of Radiology. ACR Appropriateness Criteria. Radiology 2000
Jun;215(Suppl):495-505.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/MyelopathyDoc8.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on July 31, 2001. The information was
verified by the guideline developer as of August 24, 2001. This summary
was updated by ECRI on August 11, 2006. This summary was updated by ECRI
Institute on May 17, 2007 following the U.S. Food and Drug
Administration (FDA) advisory on Gadolinium-based contrast agents. This
summary was updated by ECRI Institute on June 20, 2007 following the
U.S. Food and Drug Administration (FDA) advisory on gadolinium-based
contrast agents.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008