Clinical guidance for MRI referral

Recommendations

Clinical guidance for MRI referral
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Clinical guidance for MRI referral - Chapter recommendations

Recommendations from each chapter can be found below.

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Explanation
Probably effective, ineffective or harmful (or probably useful/ predictive or not useful/predictive) for the given condition in the specified population. (Level B rating requires at least one Class I study or at least two consistent Class II studies.)

Recommendation
Brain imaging with CT or MRI should be considered as part of the routine neurodiagnostic evaluation of adults presenting with an apparent unprovoked first seizure

  1. Krumholz A, Wiebe S, Gronseth G, et al. Practice parameter: Evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the quality standards subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007;69(21):1996–2007.

Explanation
D – Evidence level 3 or 4 (nonanalytic studies or expert opinion)
or
Extrapolated evidence from studies rated as 2+ (well-conducted case–control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal)

Recommendation
CT has a role in the urgent assessment of seizures, or when MRI is contraindicated or unavailable

  1. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of epilepsy in adults: a national clinical guideline. Edinburgh: SIGN, 2003.

Grade: None given

Recommendation
MRI is the imaging investigation of choice for most unexplained seizures

  1. National Institute for Health and Clinical Excellence (NICE). The epilepsies: diagnosis and management of the epilepsies in adults in primary and secondary care. London: NICE, 2012.

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Explanation
B - High-quality systematic reviews of case–control or cohort studies, directly applicable to the target population, and demonstrating overall consistency of results
or
Extrapolated evidence from high quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias or well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias.

Recommendation
Neuroimaging should be considered in patients with headache and an unexplained abnormal finding on the neurological examination

  1. Frishberg BM, Rosenberg JH, Matchar DB, et al. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. The American Academy of Neurology, 2000.

Explanation
The US Headache Consortium achieved consensus on the recommendation in the absence of relevant RCTs

Recommendation
Neuroimaging could be considered for headache worsened by Valsalva manoeuvre, headache causing awakening from sleep, new headache in an older patient, or progressively worsening headache†

  1. National Clinical Guideline Centre. Headaches: diagnosis and management of headaches in young people and adults. Methods, evidence and recommendations. London: NICE, 2012.

Grade: None given

Recommendation
Neuroimaging is not indicated for people diagnosed with tension-type headache, migraine, cluster headache or medication overuse headache solely for reassurance

  1. Nunes VD, Sawyer L, Neilson J, Sarri G, Cross JH. Diagnosis and management of the epilepsies in adults and children: Summary of updated NICE guidance. BMJ 2012;344:e281.

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Explanation
Fair evidence (Level II or III studies with consistent findings) for or against recommending intervention For more information on levels of evidence see the US National Guideline Clearinghouse

Recommendation
MRI is suggested for the confirmation of correlative compressive lesions† of the cervical spine in patients who have failed a course of conservative therapy and who may be candidates for interventional or surgical treatment

Grade: None given

Explanation
Consider MRI when cervical radiculopathy has been present for 6 weeks and is not improving

  1. Nordin M, Carragee EJ, Hogg-Johnson S, et al. Assessment of neck pain and its associated disorders. Eur Spine J 2008;17(1):101–22.

Grade: None given

Recommendation
Cervical X-rays and other imaging studies and investigations are not routinely required to diagnose or assess neck pain with radiculopathy

  1. Nordin M, Carragee EJ, Hogg-Johnson S, et al. Assessment of neck pain and its associated disorders. Eur Spine J 2008;17(1):101–22.

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Explanation
Level 2 - The recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion. This recommendation is usually supported by Class II data or a preponderance of Class III evidence.

Class II: clinical studies in which data were collected prospectively or retrospective analyses based on clearly reliable data (20 references) Class III: studies based on retrospectively collected data (32 references)

Recommendation
Cervical spine imaging is not indicated in awake, alert patients with trauma without neurological deficit or distracting† injury who have no neck pain or tenderness with full range of motion of the cervical spine

  1. Bussières AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults – an evidence-based approach. Part 3: Spinal disorders. J Manipulative Physiol Ther 2008;31(1):33–88.

Explanation
B - A body of evidence including studies rated as 2++ directly applicable to the target population and demonstrating overall consistency of results

or Extrapolated evidence from studies rated as 1++ or 1+ 1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias 1+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

Recommendation
If a cervical spine fracture is suspected, imaging with CT or X-ray is indicated

  1. Daffner RH, Weissman BN, Angtuaco EJ, et al. ACR appropriateness criteria® – suspected spine trauma Reston, VA: American College of Radiology, 2012. [Online publication].

Explanation
C – A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results

or Extrapolated evidence from studies rated as 2++ 2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal 2++ High-quality systematic reviews of case–control

or cohort studies or High quality case–control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal

Recommendation
MRI has a role where other imaging is contraindicated/inconclusive or where clinical or imaging findings suggest ligamentous injury, spinal cord injury and/or arterial injury

  1. Daffner RH, Weissman BN, Angtuaco EJ, et al. ACR appropriateness criteria® – suspected spine trauma Reston, VA: American College of Radiology, 2012. [Online publication].
  2. Blackmore CC. Evidence-based imaging evaluation of the cervical spine in trauma. Neuroimaging Clinics of North America 2003;13(2):283–91.

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Explanation
The recommendation is supported by fair evidence (consistent results from multiple studies, but with some risk of bias).

Recommendation
MRI is indicated in the assessment of ACL injuries, but is not always necessary if the clinical diagnosis is clear

  1. Ryzewicz M, Peterson B, Siparsky PN, Bartz RL. The diagnosis of meniscus tears: the role of MRI and clinical examination. Clin Orthop Relat Res 2007;455:123–33.
Explanation
The recommendation is supported by fair evidence (consistent results from multiple studies, but with some risk of bias).

Recommendation
MRI is indicated for assessment of meniscal tears, but is not always necessary if a clear clinical diagnosis of meniscal tear has been made

  1. Ryzewicz M, Peterson B, Siparsky PN, Bartz RL. The diagnosis of meniscus tears: the role of MRI and clinical examination. Clin Orthop Relat Res 2007;455:123–33.
Explanation
The recommendation is supported by fair evidence (consistent results from multiple studies, but with some risk of bias).

Recommendation
Use MRI particularly in situations where there is doubt about diagnosis or patient management

Level II
  1. Ryzewicz M, Peterson B, Siparsky PN, Bartz RL. The diagnosis of meniscus tears: the role of MRI and clinical examination. Clin Orthop Relat Res 2007;455:123–33.
  2. Tuite MJ, Daffner RH, Weissman BN, et al. ACR appropriateness criteria® – acute trauma to the knee. J Am Coll Radiol 2012;9(2):96–103.

Explanation
The recommendation is supported by expert opinion only, based on level 4 evidence in the text, and the expertise within the multidisciplinary team.

Recommendation
Do not use MRI for the diagnosis of isolated medial collateral ligament injuries, except where there is concern about alternative pathology or if symptoms fail to settle after 6–8 weeks

  1. Ryzewicz M, Peterson B, Siparsky PN, Bartz RL. The diagnosis of meniscus tears: the role of MRI and clinical examination. Clin Orthop Relat Res 2007;455:123–33.

Grade: None given

Recommendation
Further testing is not immediately needed in patients with knee injury who have negative physical examination findings, although close follow-up is required

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