The need for cervical spine imaging
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.
Emergency Medicine Physician
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.
- 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.
This decision rule can only be used in alert and stable trauma patients.
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.
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.
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.
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.
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.