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    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 should can 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


    The overwhelming majority of patients who are CCR negative do not warrant further imaging.

    • In the case of the inebriated but alert patient with a GCS of 15, one reasonable approach would be to leave the patient in a c-collar until they are clinically sober, however one recent 2015 systematic review calls this into question assuming a high-quality c-spine CT study and an attending-level radiologist interpretation.
    • The physician should order appropriate imaging when appropriate - XR vs CT - based on best clinical judgment.


    If a patient has a clinically significant c-spine injury identified on imaging:

    • Maintain cervical spine protection with an appropriate collar.
    • Consult neurosurgery.
    • Keep patient non-ambulatory and NPO until treatment plan is complete.
    • Patient may require emergent operative stabilization and/or admission to neurosurgical ICU.

    Critical Actions

    • If a patient has any high risk factors (age >65, a defined dangerous mechanism or paresthesias in the arms or legs) then they require c-spine imaging.
    • If a patient has no high risk factors but meets none of the defined low risk criteria (see list), they require c-spine imaging.
    • If a patient has no high risk factors, has neck pain, but meets even one low risk factor, then it is safe to assess whether the patient is able to rotate their neck 45 degrees to the left and right. If they can do this (even with some pain or discomfort), then they do not require further imaging. If they cannot rotate their neck 45 degrees in both directions then c-spine images are indicated.


    Algorithm of Yes/No questions from The Canadian C-spine Rule performs better than unstructured physician judgment.

    Facts & Figures

    canadian c spine work up algorithm

    Evidence Appraisal

    • Primary endpoint was clinically significant c-spine injuries.
    • Validation study included a convenience sample of 8,924 patients, aged 16 to 64, presenting to 10 Canadian trauma centers, with stable vital signs and a GCS of 15. 1.7% of those studied had clinically significant c-spine injuries (CSI). CCR found to be 100% sensitive for ruling out CSI (defined as any fracture, dislocation or ligamentous injury).
    • Also detected 96.4% (27/28) clinically insignificant c-spine injuries (injuries that don’t require stabilization, specialized treatment and are unlikely to cause any long-term problems).


    Other References

    Research PaperStiell IG, Clement CM, Grimshaw J, et al. Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial. BMJ. 2009;339:b4146.Research PaperBandiera, G., Stiell, I. G., Wells, G. A., et. al. The Canadian C-spine rule performs better than unstructured physician judgment. Annals of emergency medicine, 2003;42(3):395-402.Research PaperCoffey, F., Hewitt, S., et. al. Validation of the Canadian c-spine rule in the UK emergency department setting. Emergency Medicine Journal, 2011;28(10):873-876.Research PaperStiell IG, Clement CM, O'connor A, et al. Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department. CMAJ. 2010;182(11):1173-9.Research PaperVaillancourt, C., Stiell, I. G., et. al. The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Annals of emergency medicine, 2009;54(5):663-671.Research PaperStiell, I. G., Clement, C. M., et. al.Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department. Canadian Medical Association Journal, 2010;182(11):1173-1179,663-671.Research PaperDickinson G, Stiell IG, Schull M, Brison R, Clement CM, Vandemheen KL, Cass D, McKnight D, Greenberg G, Worthington JR, Reardon M, Morrison L, Eisenhauer MA, Dreyer J, Wells GA. Retrospective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments. Ann Emerg Med. 2004;43(4):507-14.Research PaperStiell IG, Wells GA, Vandemheen K, et al. Variation in emergency department use of cervical spine radiography for alert, stable trauma patients. CMAJ. 1997;156(11):1537-44.
    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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    Dr. Ian Stiell
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