The American College of Radiology has published the 2026 update of its appropriateness criteria for myelopathy, covering acute, chronic and vascular causes. The document is built the way the series always is: systematic review of peer-reviewed literature, GRADE-adapted appraisal, and the RAND/UCLA appropriateness method to rate imaging for each defined clinical scenario, with expert consensus filling gaps where the literature is thin or equivocal.

The value of these documents to a radiologist is not the recommendation you already follow — it is the scenario you meet rarely. Myelopathy is a clinical diagnosis, and the imaging question is really a triage question: is this cord dysfunction extrinsic, from compression that a surgeon can decompress, or intrinsic, from inflammation, infection, infarction or a metabolic cause that imaging characterises rather than solves. Those two paths diverge in urgency and in protocol, and the criteria are organised around separating them.

That matters most in a service where requests arrive as 'MRI spine — myelopathy' without a level, a time course, or a statement of what is being asked. A vascular presentation needs a different acquisition from a chronic compressive one, and an acute cord syndrome needs it today. Having the framework to hand is what lets the protocolling radiologist ask the right question back.

It is worth being plain about what a document like this is: a framework for choosing imaging, reviewed annually, not new evidence. Where the literature was equivocal, experts decided. Local availability — how quickly magnetic resonance imaging can actually be obtained out of hours — will often dominate the choice in Indian practice, and the criteria do not change that.

Ask for time course and a suspected level before protocolling a myelopathy request; the answer changes the sequences
Separate the extrinsic from intrinsic question explicitly in your report — that is what determines who acts next
Keep a vascular myelopathy protocol ready; it is not the same acquisition as degenerative compression
Use the criteria for the uncommon scenario rather than the routine one; that is where they add most
Say in the report what should be imaged next and when, rather than closing with a generic advisory line

Why it matters

Myelopathy requests arrive without the information that determines the protocol, and an acute cord syndrome cannot wait for the detail to emerge.

Don't overread it

Appropriateness criteria are a consensus framework for selecting imaging, not new evidence, and expert opinion fills the gaps where literature is equivocal.