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Canadian C-Spine Rule

Calculators  Musculoskeletal
The Canadian C-Spine Rule determines if cervical spine injury can be ruled out without imaging in alert and stable trauma patients.
Age ≥ 65 years extremity paresthesias or dangerous mechanism
Fall from ≥ 3ft / 5 stairs, axial load injury, high speed MVC/rollover/ejection, bicycle collision, motorized recreational vehicle
No 100
Yes 200
Low risk factor present
Sitting position in the ED, ambulatory at any time, delayed (not immediate onset) neck pain, no midline tenderness. Simple rearend motor vehicle collision (MVC) not simple if: pushed into traffic, hit by bus/large truck, rollover, hit by high-speed vehicle.
No 10
Yes 20
Able to actively rotate neck 45° left and right
No 1
Yes 2
Result:

Background

Measured Factor
The need for cervical spine imaging
Measured Factor Disease
  • Cervical spine injury
Measured Factor Detail
The Canadian C-Spine (cervical spine) Rule determines if cervical spine injury can be ruled out without imaging in alert and stable trauma patients. It helps emergency physicians to assess the need for cervical spine imaging. Imaging is required for correct diagnosis of cervical spine injury in the following cases: 1) the patient has high risk factors (e.g., age older than 65 year old, a defined dangerous mechanism, or extremity paresthesias), 2) the patient has no high risk factors AND no low risk factors (low risks factor can be simple rear-end motor vehicle collision, ambulatory at any time since injury, sitting position in the emergency department, ambulatory at any time, delayed onset of neck pain, no midline cervical spine tenderness, etc.), 3) the patient has no high risk factor but has one low risk factor and is not able to rotate his neck 45 degrees left and right.
Speciality
Emergency Medicine Physician
Body System
Musculoskeletal
Measured Factor Low Impact
  • Patient has low risk. Cervical spine injury is ruled out. No imaging is required.
Measured Factor High Impact
  • High risk for cervical spine injury and imaging is recommended.

Result Interpretation

Ranges Ranges
  • Critical High: High risk for cervical spine injury and imaging is recommended.
  • Normal: Patient has low risk. Cervical spine injury is ruled out. No imaging is required.
  • Normal Adult Male: Patient has low risk. Cervical spine injury is ruled out. No imaging is required.
  • Normal Adult Female: Patient has low risk. Cervical spine injury is ruled out. No imaging is required.
  • Normal Geriatric Male: Patient has low risk. Cervical spine injury is ruled out. No imaging is required.
  • Normal Geriatric Female: Patient has low risk. Cervical spine injury is ruled out. No imaging is required.
Result High Conditions
  • Cervical spine injury
Test Limitations
This decision rule can only be used in alert and stable trauma patients.
References: 1

Studies

Study Validation 1
This three-year prospective cohort study in six Canadian emergency departments evaluated the accuracy, reliability and acceptability of the Canadian C-Spine Rule when used by nurses. A total of 3633 study patients were assessed by 191 triage nurses using the Canadian C-Spine Rule. The nurses classified patients with a sensitivity of 90.2% (95% confidence interval (CI) 76.0%-95.0%) and a specificity of 43.9% (95% CI 42.0%-46.0%). Nurses failed to identify four high risk cases; however, after retraining, these cases were all identified. The study concluded that nurses might be able to use the Canadian C-Spine Rule accurately and reliably.
References: 2
Study Validation 2
This systematic review of 15 studies evaluated the diagnostic accuracy of the Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) criteria. The Canadian C-spine rule was found to have a sensitivity ranged from 0.90 to 1.00 and a specificity ranged from 0.01 to 0.77. The  NEXUS criteria was found to have a sensitivity ranged from 0.83 to 1.00 and a specificity ranged from 0.02 to 0.46. One study directly compared the accuracy of these 2 rules using the same cohort and found that the Canadian C-spine rule had better accuracy. The authors concluded that the Canadian C-spine rule may have better diagnostic accuracy than the NEXUS criteria.
References: 3
Study Validation 3
This matched pair cluster randomised trial evaluated the effectiveness of active strategies to implement the Canadian C-Spine Rule at 6 control and 6 intervention sites. At the intervention sites, active strategies were education, policy, and real time reminders on radiology requisitions. Main outcome was the diagnostic imaging rate of the cervical spine during two 12 month before and after active strategies were implemented. The imaging rate were significantly different between two groups (P<0.001). While the intervention group showed a reduction in cervical spine imaging of 12.8% (95% confidence interval 9% to 16%; 61.7% v 53.3%; P=0.01), the control group showed an increase in cervical spine imaging of 12.5% (7% to 18%; 52.8% v 58.9%; P=0.03). No fractures were missed and no adverse outcomes occurred. The study concluded that active strategies to implement the Canadian C-Spine Rule reduce unnecessary imaging without missing fractures.
References: 4
Study Additional 1
This study evaluated if paramedics could assess very low-risk trauma patients using the Canadian C-Spine Rule to determine the need for immobilization during transport to the emergency department. Three thousand alert and stable adult trauma patients with a potential c-spine injury were enrolled in the study. The study found that when paramedics used the Canadian C-Spine Rule, about 40% of very low-risk trauma patients could be transported safely without c-spine immobilization. Further studies at multiple centers might be warranted to confirm the results of this study.
References: 5
Study Additional 2
This publication summarizes diagnostic and treatment recommendations for subaxial cervical spine injuries from the Spine Section of the German Society for Orthopaedics and Trauma. The Canadian C-Spine Rule is recommended to decide on the need for imaging. While computed tomography is the preferred method, conventional x-ray is recommended for mild cases, and magnetic resonance imaging is recommended in cases of unexplained neurologic deficit. Computed tomography angiography is preserved for high-grade facet joint injuries or in the presence of vertebra-basilar symptoms. A0-, A1- and A2-injuries are treated conservatively, but have to be monitored for progressive kyphosis. A3 injuries are mostly operated. A4- and B- and C-injuries are treated surgically.
References: 6

Authors

Ian Stiell, MD, MSc, FRCPC, is a senior scientist and a distinguished professor in the Department of Emergency Medicine at the University of Ottawa, Canada. He is also the editor-in-chief of the Canadian Journal of Emergency Medicine. His research focuses on clinical decision rules, acute heart failure, and atrial fibrillation.
https://med.uottawa.ca/emergency/people/stiell-ian

References

  1. Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17;286(15):1841-8.
  2. Stiell IG, Clement CM, O'Connor A, Davies B, Leclair C, Sheehan P, et al. Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department. CMAJ. 2010 Aug 10;182(11):1173-9.
  3. Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CW. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ. 2012 Nov 6;184(16):E867-76.
  4. Stiell IG, Clement CM, Grimshaw J, Brison RJ, Rowe BH, Schull MJ, et al. Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial. BMJ. 2009 Oct 29;339:b4146.
  5. Vaillancourt C, Charette M, Kasaboski A, Maloney J, Wells GA, Stiell IG. Evaluation of the safety of C-spine clearance by paramedics: design and methodology. BMC Emerg Med. 2011 Feb 1;11:1.
  6. Schleicher P, Kobbe P, Kandziora F, Scholz M, Badke A, Brakopp F, et al. Treatment of Injuries to the Subaxial Cervical Spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J. 2018 Sep;8(2 Suppl):25S-33S.