Five Things Physicians and Patients Should Question

Released April 2, 2014


Don’t do imaging for lower-back pain unless red flags are present.

Red flags include suspected epidural abscess or hematoma presenting with acute pain, but no neurological symptoms (urgent imaging is required); suspected cancer; suspected infection; cauda equina syndrome; severe or progressive neurologic deficit; and suspected compression fracture. In patients with suspected uncomplicated herniated disc or spinal stenosis, imaging is only indicated after at least a six-week trial of conservative management and if symptoms are severe enough that surgery is being considered.


Don’t do imaging for minor head trauma unless red flags are present.

Red flags include Glasgow Coma Scale (GCS) less than 13; GCS less than 15 at 2 hours post-injury; a patient aged 65 years or older; obvious open skull fracture; suspected open or depressed skull fracture; any sign of basilar skull fracture (e.g., hemotympanum, raccoon eyes, Battle’s Sign, CSF otorhinorrhea); retrograde amnesia to the event lasting 30 minutes or longer after the event; “dangerous” mechanism (e.g., pedestrian struck by motor vehicle, occupant ejected from motor vehicle, or fall from higher than 3 feet or down more than 5 stairs); and coumadin-use or bleeding disorder.


Don’t do imaging for uncomplicated headache unless red flags are present.

Red flags include recent onset, rapidly increasing frequency and severity of headache; headache causing the patient to wake from sleep; associated dizziness, lack of coordination, tingling or numbness, new neurologic deficit; and new onset of a headache in a patient with a history of cancer or immunodeficiency.


Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is nearly as good in experienced hands. Since ultrasound will reduce radiation exposure, ultrasound is the preferred initial imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94 percent.


Don’t do an ankle X-ray series in adults for minor injuries.

X-rays are only indicated if there is pain in the malleolar zone, bone tenderness at the posterior edge or tip of either malleolus, or inability to bear weight for four steps immediately after the trauma and in the emergency department.

How the list was created

The Canadian Association of Radiologists (CAR) established its Choosing Wisely Canada Top 5 recommendations by initially soliciting expert opinion from physician leaders within its Board of Directors. A working group was then formed to further identify common clinical scenarios in which imaging may be misused and should be reconsidered. The working group included CAR leaders in the areas of medical imaging appropriateness and access. The list was narrowed down based on the highest potential for improvement, representing a broad range of tests and the availability of strong guidelines. The first three recommendations had previously been researched, submitted and adopted for another appropriateness initiative underway in Canada in 2013. That process included obtaining stakeholder support from a range of colleagues including technologists, sonographers, nuclear medicine physicians, family physicians and physicists. Two additional recommendations were added using similar criteria, including a comprehensive literature search undertaken through the Canadian Agency for Drugs and Technologies in Health. The full list of proposed recommendations was then vetted by stakeholder organizations, such as provincial radiology organizations and the full CAR membership. Item 4 was adapted with permission from the Five Things Physicians and Patients Should Question. © 2012 American College of Radiology



American Academy of Family Physicians (AAFP). Fifteen things physicians and patients should question [Internet]. 2012 [cited 2014 Mar 12]. Available from: URL.

American College of Radiology. ACR appropriateness criteria® low back pain [Internet]. 2011 [cited 2014 Feb 23]. Available from: URL.

Bach SM, Holten KB. Guideline update: What’s the best approach to acute low back pain? J Fam Pract. 2009 Dec;58(12):E1.

Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: Systematic review and meta-analysis. Lancet. 2009 Feb 7;373(9662):463-72.

Chou R, Qaseem A, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: Advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011 Feb 1;154(3):181-9.

Goertz M, Thorson D, Bonsell J, Bonte B, Campbell R, Haake B, et al. Adult acute and subacute low back pain [Internet]. 2012 Nov [cited 2014 Feb 23]. Available from: URL.

Michigan Quality Improvement Consortium. Management of acute low back pain [Internet]. 2012 Sep [cited 2014 Feb 23]. Available from: URL.

National Institute for Health and Clinical Excellence (NICE). Low back pain: Early management of persistent non-specific low back pain [Internet]. 2009 May [cited 2014 Feb 23]. Available from: URL.

Toward Optimized Practice. Guideline for the evidence-informed primary care management of low back pain [Internet]. 2011 Nov [cited 2014 Feb 23]. Available from: URL.

University of Michigan Health System. Acute low back pain [Internet]. 2010 Jan [cited 2014 Feb 23]. Available from: URL.

van Rijn RM, Wassenaar M, Verhagen AP, Ostelo RW, Ginai AZ, de Boer MR, et al. Computed tomography for the diagnosis of lumbar spinal pathology in adult patients with low back pain or sciatica: A diagnostic systematic review. Eur Spine J. 2012 Feb;21(2):228-39.

Wassenaar M, van Rijn RM, van Tulder MW, Verhagen AP, van der Windt DA, Koes BW, et al. Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: A diagnostic systematic review. Eur Spine J. 2012 Feb;21(2):220-7.


Davis PC, Wippold FJ II, Cornelius RS, Aiken AH, Angtuaco EJ, Berger KL, et al. ACR appropriateness criteria® head trauma [Internet]. 2012 [cited 2014 Feb 23]. Available from: URL.

Holmes MW, Goodacre S, Stevenson MD, Pandor A, Pickering A. The cost-effectiveness of diagnostic management strategies for adults with minor head injury. Injury. 2012 Sep;43(9):1423-31.

Jagoda AS, Bazarian JJ, Bruns JJ,Jr, Cantrill SV, Gean AD, Howard PK, et al. Clinical policy: Neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2008 Dec;52(6):714-48.

Management of Concussion/mTBI Working Group. VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury (mTBI) [Internet]. 2009 Apr [cited 2014 Feb 23]. Available from: URL.

Marshall S, Bayley M, McCullagh S, Velikonja D, Berrigan L. Clinical practice guidelines for mild traumatic brain injury and persistent symptoms. Can Fam Physician. 2012 Mar;58(3):257,67, e128-40.

Motor Accidents Authority NSW (MAA). Guidelines for mild traumatic brain injury following closed head injury: Acute/post-acute assessment and management [Internet]. 2008 [cited 2014 Feb 23]. Available from: URL.

MTBI Guidelines Development Team. Guidelines for mild traumatic brain injury and persistent symptoms [Internet]. 2011 [cited 2014 Feb 23]. Available from: URL.

Pandor A, Goodacre S, Harnan S, Holmes M, Pickering A, Fitzgerald P, et al. Diagnostic management strategies for adults and children with minor head injury: A systematic review and an economic evaluation. Health Technol Assess. 2011 Aug;15(27):1-202.

Pandor A, Harnan S, Goodacre S, Pickering A, Fitzgerald P, Rees A. Diagnostic accuracy of clinical characteristics for identifying CT abnormality after minor brain injury: A systematic review and meta-analysis. J Neurotrauma. 2012 Mar 20;29(5):707-18.

Reed D. Adult trauma clinical practice guidelines: Initial management of closed head injury in adults [Internet]. 2011 [cited 2014 Feb 23]. Available from: URL.

Scottish Intercollegiate Guidelines Network (SIGN). Early management of patients with a head injury: A national clinical guideline [Internet]. 2009 May [cited 2014 Feb 23]. Available from: URL.

Smits M, Dippel DW, Nederkoorn PJ, Dekker HM, Vos PE, Kool DR, et al. Minor head injury: CT-based strategies for management–a cost-effectiveness analysis. Radiology. 2010 Feb;254(2):532-40.

West TA, Bergman K, Biggins MS, French B, Galletly J, Hinkle JL, et al. Care of the patient with mild traumatic brain injury [Internet]. 2011 [cited 2014 Feb 23]. Available from: URL.

Work Loss Data Institute. Head (trauma, headaches, etc., not including stress & mental disorders) [Internet]. 2011 [cited 2014 Feb 23]. Available from: URL.


American College of Radiology. Five things physicians and patients should question [Internet]. 2013 [cited 2014 Mar 12]. Available from: URL.

Beithon J, Gallenberg M, Johnson K, Kildahl P, Krenik J, Liebow M, et al. Institute for clinical systems improvement. Diagnosis and treatment of headache [Internet]. 2013 Jan [cited 2014 Feb 23]. Available from: URL.

Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW, American College of Emergency Physicians. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2008 Oct;52(4):407-36.

Hayes LL, Coley BD, Karmazyn B, Dempsey-Robertson ME, Dillman JR, Dory CE, et al. ACR appropriateness criteria®: Headache – child [Internet]. 2012 [cited 2014 Feb 23]. Available from: URL.

Health Quality Ontario. Neuroimaging for the evaluation of chronic headaches: An evidence-based analysis. Ont Health Technol Assess Ser. 2010;10(26):1-57.

Jordan YJ, Lightfoote JB, Jordan JE. Computed tomography imaging in the management of headache in the emergency department: Cost efficacy and policy implications. J Natl Med Assoc. 2009 Apr;101(4):331-5.

National Institute for Health and Clinical Excellence (NICE). Headaches: Diagnosis and management of headaches in young people and adults [Internet]. 2012 Sep [2014 Feb 23]. Available from: URL.

Sandrini G, Friberg L, Coppola G, Janig W, Jensen R, Kruit M, et al. Neurophysiological tests and neuroimaging procedures in non-acute headache (2nd edition). Eur J Neurol. 2011 Mar;18(3):373-81.

Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of headache in adults: A national clinical guideline [Internet]. 2008 Nov [2014 Feb 23]. Available from: URL.

Toward Optimized Practice. Guideline for primary care management of headache in adults [Internet]. 2012 Jul [2014 Feb 23]. Available from: URL.


Adibe OO, Amin SR, Hansen EN, Chong AJ, Perger L, Keijzer R, et al. An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed tomography in children. J Pediatr Surg. 2011 Jan;46(1):192-6.

American College of Radiology. Five things physicians and patients should question [Internet]. 2013 [cited 2014 Mar 12]. Available from: URL.

Bachur RG, Dayan PS, Bajaj L, Macias CG, Mittal MK, Stevenson MD, et al. The effect of abdominal pain duration on the accuracy of diagnostic imaging for pediatric appendicitis. Ann Emerg Med. 2012 Nov;60(5):582,590.e3.

Bachur RG, Hennelly K, Callahan MJ, Chen C, Monuteaux MC. Diagnostic imaging and negative appendectomy rates in children: Effects of age and gender. Pediatrics. 2012 May;129(5):877-84.

Bachur RG, Hennelly K, Callahan MJ, Monuteaux MC. Advanced radiologic imaging for pediatric appendicitis, 2005-2009: Trends and outcomes. J Pediatr. 2012 Jun;160(6):1034-8.

Burr A, Renaud EJ, Manno M, Makris J, Cooley E, DeRoss A, et al. Glowing in the dark: Time of day as a determinant of radiographic imaging in the evaluation of abdominal pain in children. J Pediatr Surg. 2011 Jan;46(1):188-91.

Krishnamoorthi R, Ramarajan N, Wang NE, Newman B, Rubesova E, Mueller CM, et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: Reducing radiation exposure in the age of ALARA. Radiology. 2011 Apr;259(1):231-9.

Park JS, Jeong JH, Lee JI, Lee JH, Park JK, Moon HJ. Accuracies of diagnostic methods for acute appendicitis. Am Surg. 2013 Jan;79(1):101-6.

Ramarajan N, Krishnamoorthi R, Barth R, Ghanouni P, Mueller C, Dannenburg B, et al. An interdisciplinary initiative to reduce radiation exposure: Evaluation of appendicitis in a pediatric emergency department with clinical assessment supported by a staged ultrasound and computed tomography pathway. Acad Emerg Med. 2009 Nov;16(11):1258-65.

Santillanes G, Simms S, Gausche-Hill M, Diament M, Putnam B, Renslo R, et al. Prospective evaluation of a clinical practice guideline for diagnosis of appendicitis in children. Acad Emerg Med. 2012 Aug;19(8):886-93.

Thirumoorthi AS, Fefferman NR, Ginsburg HB, Kuenzler KA, Tomita SS. Managing radiation exposure in children–reexamining the role of ultrasound in the diagnosis of appendicitis. J Pediatr Surg. 2012 Dec;47(12):2268-72.

Wan MJ, Krahn M, Ungar WJ, Caku E, Sung L, Medina LS, et al. Acute appendicitis in young children: Cost-effectiveness of US versus CT in diagnosis–a markov decision analytic model. Radiology. 2009 Feb;250(2):378-86.


Bennett DL, Daffner RH, Weissman BN, Bancroft L, Blebea JS, Bruno MA, et al. ACR appropriateness criteria® acute trauma to the foot [Internet]. 2010 [cited 2014 Feb 23]. Available from: URL.

Blackham JE, Claridge T, Benger JR. Can patients apply the ottawa ankle rules to themselves? Emerg Med J. 2008 Nov;25(11):750-1.

Can U, Ruckert R, Held U, Buchmann P, Platz A, Bachmann LM. Safety and efficiency of the ottawa ankle rule in a swiss population with ankle sprains. Swiss Med Wkly. 2008 May 3;138(19-20):292-6.

Dowling S, Spooner CH, Liang Y, Dryden DM, Friesen C, Klassen TP, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. 2009 Apr;16(4):277-87.

Gravel J, Hedrei P, Grimard G, Gouin S. Prospective validation and head-to-head comparison of 3 ankle rules in a pediatric population. Ann Emerg Med. 2009 Oct;54(4):534,540.e1.

Jenkin M, Sitler MR, Kelly JD. Clinical usefulness of the ottawa ankle rules for detecting fractures of the ankle and midfoot. J Athl Train. 2010 Sep-Oct;45(5):480-2.

Knudsen R, Vijdea R, Damborg F. Validation of the ottawa ankle rules in a danish emergency department. Dan Med Bull. 2010 May;57(5):A4142.

Lin CW, Uegaki K, Coupe VM, Kerkhoffs GM, van Tulder MW. Economic evaluations of diagnostic tests, treatment and prevention for lateral ankle sprains: A systematic review. Br J Sports Med. 2013 Dec;47(18):1144-9.

National Guideline Clearinghouse. Guideline summary: Ankle and foot disorders [Internet]. 2013 Oct 28 [cited 2014 Feb 23]. Available from: URL.

Petscavage J, Baker SR, Clarkin K, Luk L. Overuse of concomitant foot radiographic series in patients sustaining minor ankle injuries. Emerg Radiol. 2010 Jul;17(4):261-5.

Polzer H, Kanz KG, Prall WC, Haasters F, Ockert B, Mutschler W, et al. Diagnosis and treatment of acute ankle injuries: Development of an evidence-based algorithm. Orthop Rev (Pavia). 2012 Jan 2;4(1):e5.

Seah R, Mani-Babu S. Managing ankle sprains in primary care: What is best practice? A systematic review of the last 10 years of evidence. Br Med Bull. 2011;97:105-35.

Wang X, Chang SM, Yu GR, Rao ZT. Clinical value of the ottawa ankle rules for diagnosis of fractures in acute ankle injuries. PLoS One. 2013 Apr 30;8(4):e63228.

Work Loss Data Institute. Guideline summary: Ankle & foot (acute & chronic) [Internet]. 2013 Oct 28 [2014 Feb 23]. Available from: URL.