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## Complete Summary

#### GUIDELINE TITLE

Plexopathy.

#### BIBLIOGRAPHIC SOURCE(S)

Bowen B, Seidenwurm DJ, Davis PC, Brunberg JA, De La Paz RL, Dormont PD,
Hackney DB, Jordan JE, Karis JP, Mukherji SK, Turski PA, Wippold FJ III,
Zimmerman RD, McDermott MW, Sloan MA, Expert Panel on Neurologic
Imaging. Plexopathy. \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2006. \[44 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

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)

Plexopathy

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Neurology\
Oncology\
Radiology\
Surgery

#### 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 plexopathy

#### TARGET POPULATION

Patients with plexopathy

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Magnetic resonance imaging (MRI) without and with contrast

    -   Neck

    -   Chest

    -   Upper extremity

    -   Abdomen

    -   Pelvis

2.  Computed tomography (CT), without and with contrast

    -   Neck

    -   Chest

    -   Upper extremity

    -   Abdomen

    -   Pelvis

3.  X-ray

    -   Chest

    -   Cervical spine

    -   Myelography

    -   Thoracic spine

    -   Lumbosacral spine

    -   Pelvis

4.  Fluorodeoxyglucose positron emission tomography (FDG-PET), whole
    body

5.  CT myelography

    -   Cervical

    -   Thoracic spine

#### 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 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 for reaching 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 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. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

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: Plexopathy**

**Variant 1: Brachial \-- sudden onset.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, neck, and/or    8                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  and with contrast                        circumstances.

  MRI, neck, and/or    7                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  contrast                                 circumstances.

  CT, neck, and/or     5                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  and with contrast                        circumstances.

  CT, neck, and/or     4                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  contrast                                 circumstances.

  X-ray, chest         3                    

  X-ray, cervical      3                    
  spine                                    

  FDG-PET, whole body  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: Brachial \-- chronic.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, neck, and/or    8                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  and with contrast                        circumstances.

  MRI, neck, and/or    7                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  contrast                                 circumstances.

  CT, neck, and/or     5                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  and with contrast                        circumstances.

  CT, neck, and/or     4                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  contrast                                 circumstances.

  X-ray, cervical      4                    
  spine                                    

  X-ray, chest         3                    

  FDG-PET, whole body  2                   May be appropriate if malignancy
                                           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 3: Brachial \-- post-traumatic, nonacute.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, neck, and/or    8                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  and with contrast                        circumstances.

  MRI, neck, and/or    7                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  contrast                                 circumstances.

  CT myelography,      6                    
  cervical and/or                          
  thoracic spine                           

  X-ray, myelography,  5                   Usually performed with CT.
  cervical and/or                          
  thoracic spine                           

  CT, neck, and/or     5                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  contrast                                 circumstances.

  CT, neck, and/or     4                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  and with contrast                        circumstances.

  X-ray, chest         3                    

  X-ray, cervical      3                    
  spine                                    

  FDG-PET, whole body  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: Brachial \-- cancer patient. No history of local radiation
therapy.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, neck, and/or    8                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  and with contrast                        circumstances.

  MRI, neck, and/or    7                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  contrast                                 circumstances.

  FDG-PET, whole body  7                   May be useful for staging and
                                           characterizing local lesion.

  CT, neck, and/or     5                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  and with contrast                        circumstances.

  CT, neck, and/or     4                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  contrast                                 circumstances.

  X-ray, chest         4                    

  X-ray, cervical      3                    
  spine                                    

  ***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: Brachial \-- cancer patient, post-radiation therapy.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, neck, and/or    8                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  and with contrast                        circumstances.

  MRI, neck, and/or    7                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  contrast                                 circumstances.

  FDG-PET, whole body  7                   Best imaging tool to distinguish
                                           between tumor recurrence and
                                           radiation plexopathy.

  CT, neck, and/or     5                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  and with contrast                        circumstances.

  CT, neck, and/or     4                   One or more anatomically
  chest, and/or upper                      contiguous studies may be
  extremity, without                       appropriate depending on clinical
  contrast                                 circumstances.

  X-ray, chest         4                    

  X-ray, cervical      3                    
  spine                                    

  ***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: Lumbar \-- sudden onset.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, abdomen and/or  8                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  MRI, abdomen and/or  7                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   5                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   4                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  X-ray, lumbosacral   3                    
  spine                                    

  FDG-PET, whole body  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 7: Lumbar \-- chronic.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, abdomen and/or  8                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  MRI, abdomen and/or  7                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   5                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   4                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  X-ray, lumbosacral   4                    
  spine                                    

  FDG-PET, whole body  2                   May be appropriate if malignancy
                                           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 8: Lumbar \-- post-traumatic, nonacute.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, abdomen and/or  8                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  MRI, abdomen and/or  7                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   5                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   4                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  X-ray, lumbosacral   3                    
  spine                                    

  FDG-PET, whole body  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 9: Lumbar \-- cancer patient. No history of local radiation
therapy.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, abdomen and/or  8                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  MRI, abdomen and/or  7                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  FDG-PET, whole body  7                   May be useful for staging and
                                           characterizing local lesion.

  CT, abdomen and/or   5                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   4                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  X-ray, lumbosacral   3                    
  spine                                    

  ***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 10: Lumbar \-- cancer patient, post-radiation therapy.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, abdomen and/or  8                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  MRI, abdomen and/or  7                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  FDG-PET, whole body  7                   Best imaging tool to distinguish
                                           between tumor recurrence and
                                           radiation plexopathy.

  CT, abdomen and/or   5                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   4                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  X-ray, lumbosacral   3                    
  spine                                    

  ***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 11: Sacral \-- sudden onset.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, abdomen and/or  8                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  MRI, abdomen and/or  7                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   5                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   4                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  X-ray, lumbosacral   3                    
  spine                                    

  X-ray, pelvis        3                    

  FDG-PET, whole body  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 12: Sacral \-- chronic.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, abdomen and/or  8                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  MRI, abdomen and/or  7                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   5                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   4                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  X-ray, lumbosacral   4                    
  spine                                    

  X-ray, pelvis        3                    

  FDG-PET, whole body  2                   May be appropriate if malignancy
                                           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 13: Sacral \-- post-traumatic, nonacute.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, abdomen and/or  8                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  MRI, abdomen and/or  7                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   5                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   4                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  X-ray, lumbosacral   3                    
  spine                                    

  X-ray, pelvis        3                    

  FDG-PET, whole body  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 14: Sacral \-- cancer patient. No history of local radiation
therapy.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, abdomen and/or  8                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  MRI, abdomen and/or  7                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  FDG-PET, whole body  7                   May be useful for staging and
                                           characterizing local lesion.

  CT, abdomen and/or   5                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   4                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  X-ray, lumbosacral   3                    
  spine                                    

  X-ray, pelvis        3                    

  ***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 15: Sacral \-- cancer patient, post-radiation therapy.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  MRI, abdomen and/or  8                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  MRI, abdomen and/or  7                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  FDG-PET, whole body  7                   Best imaging tool to distinguish
                                           between tumor recurrence and
                                           radiation plexopathy.

  CT, abdomen and/or   5                   One or more anatomically
  pelvis, without and                      contiguous studies may be
  with contrast                            appropriate depending on clinical
                                           circumstances.

  CT, abdomen and/or   4                   One or more anatomically
  pelvis, without                          contiguous studies may be
  contrast                                 appropriate depending on clinical
                                           circumstances.

  X-ray, lumbosacral   3                    
  spine                                    

  X-ray, pelvis        3                    

  ***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.

**Summary of Literature Review**

**Introduction**

Plexopathy is the manifestation of abnormal neurological findings by an
anatomically defined network of nerves, which are derived from the
ventral rami of a set of spinal nerves. Pain (shoulder and arm, or back
and leg) with a neuropathic character, dysethesias, burning or electric
sensation, occurring in more than one peripheral nerve distribution is
characteristic of plexopathy. Pain that radiates in a dermatomal
distribution and sensory loss or motor loss in a spinal nerve root
distribution are characteristic of radiculopathy.

Magnetic resonance imaging (MRI) of peripheral nerves at high spatial
resolution, with and without fat suppression, has been shown to detect
features of intraneural anatomy not previously seen on diagnostic
imaging studies and to localize pathologic lesions in conditions where
electrophysiologic and physical findings are nonspecific or
nonlocalizing.

The use of phased arrays and integrated arrays of radiofrequency (RF)
coils for dedicated brachial plexus imaging has made it possible to
directly evaluate the plexus components---roots, trunks, divisions, and
cords---and frequently to distinguish between intrinsic and extrinsic
pathological changes.

Evaluation of the plexus focuses on evidence for a mass lesion
infiltrating perineural fat and assessment of the intrinsic magnetic
resonance (MR) features of nerves, such as signal intensity on short tau
inversion recovery (STIR) or fat-saturated T2-weighted fast-spin-echo
(FSE) images, the appearance of the intraneural fascicular pattern,
and/or the pattern of post-contrast enhancement on fat-saturated
T1-weighted images. If an MRI is of diagnostic quality, an accompanying
CT study or positron emission tomography (PET) study is only rarely
necessary. An exception may be made for post-traumatic brachial
plexopathy, for which MRI and post-myelographic CT are complementary in
the evaluation of foraminal, paraspinal, and peripheral plexus injuries.

Mastery of anatomy and availability of anatomical references are useful
in interpreting studies of the brachial and lumbosacral plexus.

**MR Techniques and Image Contrast**

The goal is usually to image either the right or left brachial plexus at
high spatial resolution; a bilateral examination may also be employed. A
comprehensive MRI study of the brachial plexus extends from the roots
and trunks, located in the supraclavicular region, to the terminal
branches of the cords, located in the infraclavicular region just
lateral to the pectoralis minor muscle. For optimal results, the MRI
study is targeted to a specific region of the plexus by a careful
clinical examination and electrophysiological studies.

*Pulse Sequences*

At field strengths of 1.0 to 1.5 tesla, the plexus is commonly evaluated
based on its appearance on T1- and T2-weighted images. Conventional
two-dimensional (2D) spin-echo or FSE sequences are used to generate the
T1-weighted images, although some investigators prefer T1-weighted 3D
gradient-echo images. The T1-weighted images display regional anatomy,
including the various muscles, blood vessels, and nerves outlined by
tissue fat planes. The 2D T2- weighted images are generated with FSE
sequences and are useful to detect pathologic changes within components
of the plexus. Since abnormal intraneural signal from one component,
such as a root or a cord, of the plexus may be obscured by adjacent fat
signal, fat suppression is used. The two most common methods are STIR
and frequency-selective saturation of the fat resonance.

Contrast-enhanced images of the plexus are obtained routinely in
patients being evaluated for suspected neoplasm, radiation injury,
inflammation, or abscess formation, and following peripheral nerve
surgery. In addition to these indications, contrast-enhanced images have
also proven useful in some cases of nerve entrapment and stretch injury.
In cases of acute severe traumatic nerve injury and simple compressive
neuropathy, a noncontrast exam can be sufficient.

**MR Imaging: Normal versus Abnormal Plexus**

Abnormal plexus findings include the following: loss of fat planes
around all or part of a plexus component, diffuse or focal enlargement
of a component (especially, the presence of an eccentric or nodular
mass), marked hyperintensity on T2-weighted images and/or enhancement on
T1-weighted images with fat suppression. An altered fascicular pattern
is also abnormal, although this may not always be apparent.
Demonstration of a fascicular pattern may be more difficult for plexus
components than for individual peripheral nerves, like the sciatic and
tibial nerves, because of the lower spatial resolution of plexus images
and because of the difficulty in obtaining true cross-sectional views of
most plexus components.

**Indications for MR Imaging of the Brachial Plexus**

A 1994 study found conventional spin-echo MRI without gadolinium to be
63% sensitive, 100% specific, and 77% accurate compared to
clinicopathologic results in the evaluation of 43 patients with
suspected brachial plexopathy. Accuracy increased to 88% when evaluation
involved only the subset of patients (n=34) with neoplastic or traumatic
disorders. With current high-resolution MRI and the use of gadolinium
contrast agents, accuracy is likely to be increased further.

*Mass Involving the Plexus*

MRI can often determine whether a mass is intrinsic or extrinsic to a
component nerve of the plexus and, for extrinsic masses, determine the
site of the displaced and compressed nerve fibers prior to surgical
intervention. Such information is valuable in the diagnosis and
management of patients with plexopathy due to neoplastic processes (such
as nerve sheath tumors, metastases, direct extension of non-neurogenic
primary tumor, and lymphoma) or benign processes (such as aggressive
fibromatosis \[desmoid tumor\] and nodular fasciitis). In a series of 48
reported tumors, 44% were benign and included fibromatosis (most
common), lipoma, myositis ossificans, ganglioneuroma, hemangioma, and
lymphangioma. The information from MRI aids in preoperative planning and
may help to shorten the surgical procedure.

High-resolution coronal and sagittal images of the symptomatic brachial
plexus are especially beneficial in cases where clinical examination and
lower resolution imaging studies (covering both right and left plexuses
in a single field of view are not able to distinguish whether a
patient\'s symptoms are due to recurrent tumor, to postoperative or
post-treatment changes associated with scarring, or to compressive
neuropathy resulting from regional deformity. In patients with
plexopathy and Horner\'s syndrome, axial images are useful to
demonstrate paraspinal extension of tumor. If a mass is contiguous with
the longus colli muscle, the sympathetic chain is usually invaded. (For
lumbosacral imaging, high-resolution coronal and axial images of the
bilateral lumbar plexus or sacral plexus are typically obtained).

Brachial plexopathy caused by metastatic disease is most often seen in
patients with carcinoma of the breast or lung. Metastases from breast
carcinoma are the most common and involve the plexus mainly by lymphatic
spread. Other primary malignancies, such as melanoma, gastrointestinal
or genitourinary carcinomas, that metastasized to lymph nodes, soft
tissue, or bone and resulted in plexopathy, have been reported.

Lymphoma can involve the plexus in two ways. First, enlarged lymph nodes
can compress and/or infiltrate the plexus. Second, neurolymphomatosis,
which is a rare manifestation of lymphoma primarily involving the
peripheral nerves, can affect the plexus.

The differential diagnosis of infiltrative lesions of the plexus also
includes soft tissue tumors, such as sarcomas and fibromatosis.
Aggressive fibromatosis is a benign fibroblastic proliferation that
occurs in the deep soft tissues, mimics fibrosarcoma, but does not
metastasize. It tends to invade or surround muscles, tensions, nerves,
and vessels and to recur locally following excision.

The most common neurogenic tumors of the plexus are the benign nerve
sheath tumors: neurofibroma (50% to 65%), and schwannoma (18% to 20%).
Malignant peripheral nerve sheath tumors account for 14% of the
neurogenic tumors. Nerve sheath tumors may involve any component of the
plexus, although the roots are the most frequent site.

Malignant peripheral nerve sheath tumors (MPNSTs) occur less frequently
than benign tumors, and are found mainly in patients with
neurofibromatosis or a history of previous radiation therapy to the
brachial plexus region.

*Traumatic Injury*

Injury to a peripheral nerve due to trauma can range from disruption of
axonal conduction with preservation of anatomical continuity of the
connective tissue sheaths (neurapraxic injury) to severed nerve with
complete loss of continuity of the nerve (neurotmesis injury). By
demonstrating the location and severity of injury and the morphology of
the injured nerve, high-resolution MRI complements the
electrophysiologic studies in determining the exact site and type of
nerve injury, and the potential for surgical treatment versus
spontaneous recovery. In addition, MRI can show the relationship of the
intact nerve to posttraumatic lesions such as spindle, lateral, and
stump neuromas, as well as focal or diffuse perineural fibrosis.

Brachial, lumbar, or sacral plexopathy following trauma can result from
compression, stretching, or laceration of plexal components, perineural
fibrosis, or avulsion of nerve roots from the spinal cord.

It is important to distinguish intraspinal nerve root avulsion
(preganglionic lesion) from brachial plexus interruption (postganglionic
lesion) since the surgical treatment differs. Nerve root avulsion cannot
be repaired directly, and neurotization by nerve-crossing using the
intercostal nerves and/or spinal accessory nerve has been recommended.
Brachial plexus interruption can be treated by local repair, and nerve
grafting is the usual method of plexus reconstruction. Differentiation
of nerve root avulsion from plexus injury is aided by electromyography
(EMG) studies, since abnormalities of the paraspinal muscles indicate
that an injury is proximal to the plexal trunks. Somatosensory evoked
potentials have been routinely used to diagnose nerve root avulsion;
however, because these do not enable one to discriminate between
incomplete avulsion and intact roots, or between intraforminal root
avulsion and rootlet avulsion from the spinal cord, the inclusion of
imaging studies (myelography, CT myelography, high-resolution MRI, and
MR myelography) in the diagnostic evaluation has been recommended.

The two major causes of cervical nerve root avulsion are motorcycle
accidents and traumatic delivery at birth. In the detection of nerve
root avulsion, some studies found that myelography/CT myelography was
the most accurate approach (\>90%), confirming separate reports of the
reliable demonstration of root avulsion with CT myelography and a 92%
accuracy of MR myelography compared to CT myelography. Other studies,
however, found that myelography/CT myelography and MRI achieved similar
accuracy. In the detection of traumatic pseudomeningocele, conventional
spin-echo MRI is equivalent to CT myelography, which is more accurate
than myelography. For overall characterization of traumatic brachial
plexopathy, MRI has an advantage over CT and myelography, because it is
better able to show plexus lesions (postganglionic), in addition to
detecting pseudomeningocele. Examples of posttraumatic lesions of the
plexus that have been demonstrated on spin-echo images include neuromas
(tangles of regenerating nerve fibers), focal or diffuse fibrosis, and
masses that compress or stretch the plexus, such as hematoma, clavicular
fracture, and humeral dislocation.

*Entrapment Syndromes*

Guided to the location of entrapment/compression by the clinical and
neurological examination, the MRI study is used to detect objective
findings of nerve compression. The brachial plexus and/or the
subclavian/axillary artery or vein encounter three possible sites of
compression along their course: the interscalene triangle, the
costoclavicular space between the first thoracic rib and the clavicle,
and the retropectoralis minor space posterior to the pectoralis minor
muscle near its insertion on the coracoid process. There is some
disagreement regarding the value of MRI in diagnosing neurologic or
combined neurovascular thoracic outlet syndrome (TOS).

*Post-treatment Evaluation*

Patients with a history of cancer and clinical evidence of plexopathy
following radiation therapy may have, predominantly or exclusively,
recurrent tumor or radiation-induced plexopathy. Imaging features that
favor recurrent tumor are nonuniform, asymmetric diffuse, or focal
enlargement, especially the presence of an eccentric mass with
post-contrast enhancement. Imaging features that favor post-radiation
injury of the brachial plexus are diffuse, uniform, symmetric swelling
and T2 hyperintensity of the plexus nerves within the radiation field.
Diffuse, uniform post-contrast enhancement for months to years after
treatment may also result from radiation injury. Radiation fibrosis
often has low signal intensity on T1-weighted and T2-weighted images,
and this may represent the more common appearance for chronic radiation
injury, although a correlation between the time interval following
radiation therapy and T2 signal intensity has not been reported.

When diffuse enlargement, T2 hyperintensity, and post-contrast
enhancement of the plexus (as well as surrounding tissues) are present
on MRI of patients with a history of breast cancer and radiation
therapy, differentiation between radiation injury and local/regional
recurrent cancer with axillary/supraclavicular metastases may not be
possible. Preliminary results suggest that
Flourine-18-2-fluoro-2-deoxy-D-glucose (FDG) PET helps to confirm
metastases in patients with indeterminate MRI findings and is useful for
depicting metastases outside the axilla.

*Miscellaneous*

When the clinical examination does not reveal an etiology for the
patient\'s neuropathy, MRI may identify a focal or diffuse peripheral
nerve or plexus structural abnormality, such as occurs in chronic
inflammatory demyelinating polyneuropathy (CIDP), multifocal motor
neuropathy (MMN), hereditary hypertrophic motor and sensory neuropathies
(HMSN), and inflammatory pseudotumor. Idiopathic brachial plexus
neuritis, or plexitis, presents with sudden onset of severe, constant
pain in the lateral neck, shoulder, scapula, or upper arm. Involvement
is bilateral in 10% to 30% of cases. The pain is exacerbated by arm or
shoulder movement. In one study, 4 of 64 consecutive patients who
underwent MRI for suspected brachial plexus abnormalities had a clinical
diagnosis of idiopathic or viral plexitis. In all four patients,
spin-echo MRI findings were normal. Another study reported a case of
brachial neuritis in which the nerves of the plexus were diffusely
enlarged and hyperintense on T2-weighted images. These findings were
attributed to inflammation and edema, but not corroborated by subsequent
imaging or other methods.

**Conclusion**

High-resolution MRI of peripheral nerves and nerve plexuses is an area
of rapidly growing clinical interest and importance. The number of
studies performed is rapidly increasing in response to the need for more
detailed in vivo information about neuropathic changes and regional
neural anatomy prior to treatment planning by peripheral nerve
specialists. Specific information gained from peripheral nerve imaging
studies is being used to determine need for biopsy or surgical
treatment. In patients with small tumors, peripheral nerve imaging has
proven useful in planning the surgical approach and in predicting the
prognosis for preservation of nerve function postoperatively. In cases
of traumatic nerve injury, MRI results are being considered as part of
the clinical assessment regarding 1) the likelihood of spontaneous
recovery versus the need for surgical repair, and 2) the progression of
nerve recovery postoperatively.

**Abbreviations**

-   CT, computed tomography

-   FDG-PET, fluorodeoxyglucose positron emission tomography

-   MRI, magnetic resonance imaging

#### 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 plexopathy

#### POTENTIAL HARMS

Not stated

### 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

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Bowen B, Seidenwurm DJ, Davis PC, Brunberg JA, De La Paz RL, Dormont PD,
Hackney DB, Jordan JE, Karis JP, Mukherji SK, Turski PA, Wippold FJ III,
Zimmerman RD, McDermott MW, Sloan MA, Expert Panel on Neurologic
Imaging. Plexopathy. \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2006. \[44 references\]

#### ADAPTATION

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

#### DATE RELEASED

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*: Brian Bowen, MD, PhD; David J. Seidenwurm, MD; Patricia
C. Davis, MD; James A. Brunberg, MD; Robert L. 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; Michael A. Sloan, MD,
MS

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

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/PlexopathyDoc12.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 NGC summary was completed by ECRI Institute on April 25, 2007. 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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