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      Calc Function

    • Calcs that help predict probability of a diseaseDiagnosis
    • Subcategory of 'Diagnosis' designed to be very sensitiveRule Out
    • Disease is diagnosed: prognosticate to guide treatmentPrognosis
    • Numerical inputs and outputsFormula
    • Med treatment and moreTreatment
    • Suggested protocolsAlgorithm





    Chief Complaint


    Organ System


    Patent Pending

    Canadian C-Spine Rule

    Clinically clears cervical spine fracture without imaging.
    When to Use
    Why Use

    The Canadian C-Spine Rule is a well-validated decision rule that can be used to safely rule out cervical spine injury (CSI) in alert, stable trauma patients without the need to obtain radiographic images.

    The Canadian C-spine Rule (CCR) was developed to help physicians determine which trauma patients need c-spine imaging.

    • CCR is highly sensitive for CSI, with the majority of studies finding it catches 99-100% of these types of injuries.
    • Applying the Canadian C-Spine Rule would allow healthcare providers to safely decrease the need for imaging among this patient population by over 40%.
    • Subsequent studies have found a sensitivity of 90-100% for CSI with majority finding 99-100% sensitivity.

    Points to keep in mind:

    • Not all patients in the validation study underwent imaging if the treating physician felt the patient was at very low risk of injury.
    • Most common criticism is that the CCR is difficult to memorize due to its multiple criteria; use of a smartphone app or digital reference (like MDCalc) is recommended.
    • The rule can be used in patients who are intoxicated; if the patients are alert and cooperative, the rule can be used regardless of blood alcohol content.
    • The quoted sensitivities are all for CSI. Some practice environments might be concerned with identifying any cervical spine injury (CCR is highly sensitive for clinically important c-spine imaging.)
    • The lone trial with a sensitivity of 90% was in a study where nurses were trained to apply the rule (retrospective review by investigators in this study found the rule was misapplied in 4 cases with obvious high-risk features); it has also been successfully evaluated in paramedics.

    Exclusion Criteria:

    • Non-trauma patients
    • GCS <15
    • Unstable vital signs
    • Age <16 years
    • Acute paralysis
    • Known vertebral disease
    • Previous c-spine surgery
    • There are over 1 million visits to US Emergency Departments annually for blunt trauma patients who present with a concern for possible cervical spine imaging. Many of these patients undergo imaging of their c-spine, with the overwhelming majority (98%) of the studies coming back negative for a fracture. Applying the Canadian C-spine Rule would allow healthcare providers to safely decrease the need for imaging among this patient population by over 40%.
    • While the Canadian C-Spine Rule is more complex than other c-spine clinical decision rules (NEXUS), it is a more sensitive rule and can potentially be used on patients who cannot be cleared using other rules.


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    Creator Insights
    Dr. Ian Stiell