Canadian C-Spine Rule

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 patients
• GCS < 15
• Unstable vital signs
• Age < 16 years
• Acute paralysis
• Known vertebral disease
• Previous 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.

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

¹High-risk Factors

• Age ≥ 65 years
• Extremity paresthesias
• Dangerous mechanism
  • Fall from ≥ 3 ft (0.9 m) or 5 stairs
  • Axial load to head
  • High speed MVC or rollover or ejection
  • Bicycle collision
  • Motorized recreational vehicles

²Low-risk Factors

• Sitting position in the Emergency Department
• Ambulatory at any time
• Delayed (not immediate onset) neck pain
• No midline c-spine tenderness
• Simple rearend motor vehicle accident  
  • Not simple if pushed into oncoming traffic, hit by bus or large truck, rollover, hit by high-speed vehicle.

Considerations

• Clinicians 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

Management

If 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.

The rule can be used in intoxicated patients regardless of blood alcohol content if the patients are alert and cooperative.

Exclusion Criteria

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