The Canadian C-Spine Rule can be used in alert and stable trauma patients with possible injury to the cervical spine to determine if neck radiographs are necessary. This can hopefully reduce unnecessary X-rays without compromising patient care. The authors are from multiple Emergency Departments in Canada.


Patient selection: A trauma patient who

(1) is alert, with Glasgow coma score = 15

(2) is clinically stable

(3) may have a cervical spine injury based on clinical assessment


Step 1: Determine if the patient has a high risk factor that mandates radiography, with one or more of the following:

(1) age >= 65 years

(2) trauma involved a dangerous mechanism

(3) paresthesias are noted in the extremities


Dangerous mechanism includes:

(1) fall from >= 1 meter

(2) fall >= 5 stairs

(3) axial load to head (diving, etc.)

(4) high speed motor vehicle accident (> 100 km/h, or > 62 miles/h)

(5) motor vehicle accident with rollover or ejection

(6) motorcycle or recreational vehicle accident

(7) bicycle collision


Step 2: Determine if the patient has low risk factors that allow for safe assessment of the range of neck motion based on the following features:

(1) simple rear-end motor vehicle collision (MVC)

(2) sitting position in the ED

(3) ambulatory at any time

(4) delayed onset of neck pain

(5) absence of midline cervical spine tenderness


A simple rear-end motor vehicle accident is excluded (i.e, not considered low risk) if:

(1) the person is pushed into oncoming traffic

(2) the person has been hit by a bus or large truck

(3) rollover occurred

(4) hit by a high-speed vehicle


Step 3: If the patient is determined by Step 2 to be low risk, then can the patient actively rotate the neck 45 degrees to the left and right?


Radiographs are done if any of the following are present:

(1) step 1: One or more items indicate that radiography is mandatory.

(2) step 2: There is no evidence that the risk for neck rotation is low.

(3) step 3: The patient is unable to actively rotate the neck.


Else: No radiography is required.



• In 8,924 patients in the study, the sensitivity for detecting a clinical important injury was 100% and the specificity was 42.5%.



• By the time you answer all of these questions, the radiographs could be done and read.

• Step 2 is not as easy as it seems.


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