Canadian C-Spine Rule

The Canadian C-Spine Rule explained

This is a clinical decision rule that is highly sensitive for detecting acute C-spine injury and can help emergency department physicians with decisions regarding need for imaging in alert and stable patients.

The three criteria assessed as part of the Canadiac C-Spine Rule are:

1. Any high-risk factor which mandates radiography?*

• Age ≥65 years;
• OR Dangerous mechanism (fall from elevation >3 feet/5 stairs; axial load to the head; MVC high speed >100km/hr, rollover, ejection; motorized recreational vehicles; bicycle struck or collision);
• OR Paresthesias in extremities.

* If the patient has any high-risk factors then they require imaging.

2. Any low-risk factor which allows safe assessment of range of motion?*

• Simple rearend MVC (excludes pushed into oncoming traffic, hit by bus/large truck, rollover, hit by high speed vehicle);
• OR Sitting position in ED;
• OR Ambulatory at any time;
• OR Delayed onset of neck pain (not immediate);
• OR Absence of mudline c-spine tenderness.

* If the patient has multiple low-risk factors then they require imaging. If a patient has no high-risk factors, has neck pain, meets at least one low risk factor, then it is safe to proceed with assessing whether the patient is able to rotate their neck 45 degrees to the left and right. If they can do this, then need for further imaging is unlikely.

3. Able to actively rotate neck 45° left and right?

If criteria 1 is not present and criteria 2 and 3 are present then C-spine can be cleared clinically by these criteria. No imaging required. In every other combination, imaging is required.

It is important to keep in mind these CCR exclusion criteria examples:

• Age <16 years;
• Non-trauma patients;
• Unstable vital signs;
• GCS <15;
• Acute paralysis;
• Known vertebral disease;
• Previous c-spine surgery.

About the original study

The original study by Stiell et al. involved a sample of 8924 adults (mean age: 37) with blunt trauma to the head/neck, stable vital signs, and a Glasgow Coma Scale score of 15 at presentation.

Among the study sample, 151 (1.7%) had important C-spine injury. By cross-validation, this rule had:

• 100% sensitivity (95% confidence interval [CI], 98%-100%);
• 5% specificity (95% CI, 40%-44%).

for identifying 151 clinically important C-spine injuries whilst it showed that the potential radiography ordering rate would be 58.2%.

The CCR is deemed as a highly sensitive model for cervical spine injuries and helps emergency physicians decrease the need for imaging by over 40%.

References

Original reference

Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA, Greenberg GH, MacPhail I, Morrison L, Reardon M, Worthington J. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17;286(15):1841-8.

Validation

Stiell IG, Clement CM, Mcknight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-8.

Other references

Stiell IG, Wells GA, Vandemheen K, et al. Variation in emergency department use of cervical spine radiography for alert, stable trauma patients. CMAJ. 1997;156(11):1537-44.

Dickinson G, Stiell IG, Schull M, Brison R, Clement CM, Vandemheen KL, Cass D, McKnight D, Greenberg G, Worthington JR, Reardon M, Morrison L, Eisenhauer MA, Dreyer J, Wells GA. Retrospective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments. Ann Emerg Med. 2004;43(4):507-14.

Bandiera, G., Stiell, I. G., Wells, G. A., et. al. The Canadian C-spine rule performs better than unstructured physician judgment. Annals of emergency medicine, 2003;42(3):395-402.