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Canadian C-Spine Rule

Clinically clears cervical spine fracture without imaging.

Advice

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.

Management

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.