Canadian C-Spine Rule
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.
- 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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