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