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    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

    From the Creator

    Why did you develop the Canadian C-Spine Rule?
    My interest was piqued through a paper that demonstrated there is a gross inefficiency and amazing variation in image ordering between teaching hospitals and hospitals alike. My intent was the provide sensible decision rules developed by emergency physicians, for use by emergency personnel.
    Any Pearls/Pitfalls/Tips?
    The CCR is only intended for use with alert and stable trauma patients with neck pain; therefore, patients over the age of 65 with neck pain do not necessarily require imaging.

    About the Creator

    Ian Stiell, MD, MSc, FRCPC, is Professor and Chair, Department of Emergency Medicine, University of Ottawa; Distinguished Professor and University Health Research Chair, University of Ottawa; Senior Scientist, Ottawa Hospital Research Institute; and Emergency Physician, The Ottawa Hospital. He is internationally recognized for his research in emergency medicine with a focus on the development of clinical decision rules and the conduct of clinical trials involving acutely ill and injured patients treated by prehospital services and in emergency departments. He is best known for the development of the Ottawa Ankle Rule, the Canadian C-Spine Rule, and Canadian CT Head Rule and as the Principal Investigator for the landmark OPALS Studies for prehospital care. Dr. Stiell is the Principal Investigator for 1 of 3 Canadian sites in the Resuscitation Outcomes Consortium (ROC) which is funded by CIHR, NIH, HSFC, AHA, and National Defence Canada. Dr. Stiell is a Member of the Institute of Medicine of the U.S. National Academies of Science.

    To read more about Dr. Stiell's work, visit his website.

    To view Dr. Ian Stiell's publications, visit PubMed

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