Summary
Usage Many blunt trauma patients undergo imaging of their cervical spine but most (98%) imaging studies come back negative for fracture. The Canadian C-Spine Rule (CCR) is a well-validated clinical decision aid that can be used to determine whether cervical imagining could be safely avoided in alert, stable trauma patients with concerns of possible cervical spine injury (CSI). CCR is highly sensitive for CSI with a sensitivity range of 90-100% depending on the study, but the majority of studies caught 99-100% of CSIs. The rule can be used in intoxicated patients regardless of blood alcohol content if the patients are alert and cooperative. Exclusion Criteria include:Non-trauma patientsGCS < 15Unstable vital signsAge < 16 yearsAcute paralysisKnown vertebral diseasePrevious c-spine injury The CCR is more complex than other c-spine clinical decision rules, such as the NEXUS Criteria. However, the CCR is a more sensitive rule than NEXUS and may be more appropriate for patients who cannot be cleared using other rules. In a head-to-head trial comparing NEXUS to CCR, CCR had a higher sensitivity (99.4%) than NEXUS (90.7%). However, there are some concerns about the generalizability of the findings. In some cases, providers will use both the Nexus Criteria and the CCR to assist in decision-making. The NEXUS Criteria does not have age cut-offs (unlike the Canadian C-spine Rule (CCR). However, caution is advised in applying NEXUS to patients > 65 years old, as the sensitivity may be as low as 66-84%. Additionally, there is controversy over x-rays versus CT as the most appropriate imaging modality. The question is, are X-rays of the c-spine sufficiently sensitive to rule out c-spine injuries in trauma patients or is CT more appropriate in this population (i.e. hospitals). Concern has been raised that NEXUS was derived and validated in an era when plain films were much more commonly ordered. CT imaging is more common now, and evidence suggests that CT may identify CSIs that would be missed by NEXUS and the CCR. Often providers will use both the NEXUS Criteria and the CCR to assist in decision-making.. Summary The Canadian C-Spine Rule (CCR) is a well-validated clinical decision aid that can be used to determine whether cervical imagining could be safely avoided in alert, stable trauma patients with concerns of possible cervical spine injury (CSI). Recommendations and Criteria RecommendationsCriteriaHigh Risk: C-spine imaging is recommendedAny high-risk factor¹ which mandates radiography? Yes - OR- Any high-risk factor which mandates radiography? No-AND-Any low risk factor² which allows safe assessment of range of motion? No -OR- Any high-risk factor which mandates radiography? No-AND-Any low risk factor which allows safe assessment of range of motion? Yes-AND-Able to actively rotate neck 45° left and right? NoLow Risk: No C-spine imaging is requiredAny high-risk factor which mandates radiography? No-AND-Any low risk factor which allows safe assessment of range of motion? Yes-AND-Able to actively rotate neck 45° left and right? Yes ¹High-risk FactorsAge ≥ 65 yearsExtremity paresthesiasDangerous mechanismFall from ≥ 3 ft (0.9 m) or 5 stairsAxial load to headHigh speed MVC or rollover or ejectionBicycle collisionMotorized recreational vehicles ²Low-risk FactorsSitting position in the Emergency DepartmentAmbulatory at any timeDelayed (not immediate onset) neck painNo midline c-spine tendernessSimple rearend motor vehicle accident Not simple if pushed into oncoming traffic, hit by bus or large truck, rollover, hit by high-speed vehicle. ConsiderationsClinicians ought to use clinical judgement when to order appropriate imaging and what study to order (i.e. X-ray versus CT).Additional risk factors, such as co-morbidities, intoxication and historical reliability of the event, may impact decision-making. Often providers will use both the NEXUS Criteria and the Canadian C-Spine Rule to assist in decision-making ManagementIf a c-spine injury is identified on imaging consider:Maintain cervical spine protection with appropriate collar.Consult neurosurgery.Keep patient NPO and non-ambulatory until treatment plan is complete.Patient may require emergent operative stabilization or admission to neurosurgical ICU..