Canadian C-Spine Rule

id

696

full_title

Canadian C-Spine Rule

short_title

Canadian C-Spine Rule

med_description

Clinically clears cervical spine fracture without imaging in alert, stable trauma patients.

description

The Canadian C-spine Rule Clinically clears cervical spine fracture without imaging.

keywords

CT neck rule, neck injury rule, neck trauma rule, canadian CT rule, canadian neck injury, neck injury scan, Canadian imaging rule, C spine rule, canadian C-spine, canadian neck imaging, canadian neck imaging rule, canadian c-spine imaging, canadian c-spine imaging rule, canadian c-spine calc, canadian C-spine score, canadian neck trauma trule, neck scan s/p trauma, r/o neck fx, r/o c-spine fx, r/o c-spine fracture, r/o neck fracture, rule out neck fracture, rule out c-spine fracture, rule out CT need, neck injury CT need, clears neck injury, cervical spine fracture, cervical spine fx rule, cervical spine fracture rule out, cervical spine clear, cervical spine rule

complaint

[ "Injury/Trauma" ]

formula

Algorithm of Yes/No questions fromThe Canadian C-spine Ruleperforms better than unstructured physician judgment.

evidence

• 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).

measurements

[]

information

The Canadian C-Spine Rule

For alert (GCS=15) and stable trauma patients where cervical spine injury is a concern.

refrences

{ "Clinical Practice Guidelines": [], "Manufacturer Website": [], "Original/Primary Reference": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/11597285", "text": "Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA, Greenberg GH, MacPhail I, Morrison L, Reardon M, Worthington J. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17;286(15):1841-8." } ], "Other References": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/9176419", "text": "Stiell 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." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/12944893", "text": "Bandiera, 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." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/15039695", "text": "Dickinson 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." }, { "href": "https://www.annemergmed.com/article/S0196-0644(09)00241-8/abstract", "text": "Vaillancourt, 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." }, { "href": "https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/19875425/", "text": "Stiell IG, Clement CM, Grimshaw J, et al. Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial. BMJ. 2009;339:b4146." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/20457772", "text": "Stiell 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." }, { "href": "https://emj.bmj.com/content/28/10/873.short", "text": "Coffey, 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." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/23048086", "text": "Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CW. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ. 2012;184(16):E867-76." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/23048086", "text": "Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CW. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ. 2012;184(16):E867-76." } ], "Outcomes": [], "Validation": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/14695411", "text": "Stiell IG, Clement CM, Mcknight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-8." } ], "Validations": [] }

pearls

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.

usecase

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.

reasons

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.

next_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.

next_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.

next_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.

diseases

[ "Trauma" ]

instructions

published

2022-04-21T20:29:45.885Z

purpose

[ "Algorithm", "Diagnosis", "Prognosis", "Rule Out" ]

search_terms

[ "trauma", "cspine", "neck", "c-spine" ]

seo

{ "keywords_en": "CT neck rule, neck injury rule, neck trauma rule, canadian CT rule, canadian neck injury, neck injury scan, Canadian imaging rule, C spine rule, canadian C-spine, canadian neck imaging, canadian neck imaging rule, canadian c-spine imaging, canadian c-spine imaging rule, canadian c-spine calc, canadian C-spine score, canadian neck trauma trule, neck scan s/p trauma, r/o neck fx, r/o c-spine fx, r/o c-spine fracture, r/o neck fracture, rule out neck fracture, rule out c-spine fracture, rule out CT need, neck injury CT need, clears neck injury, cervical spine fracture, cervical spine fx rule, cervical spine fracture rule out, cervical spine clear, cervical spine rule", "meta_description_en": "The Canadian C-spine Rule Clinically clears cervical spine fracture without imaging." }

specialty

[ "Emergency Medicine", "Internal Medicine", "Neurology", "Surgery (General)", "Surgery (Trauma)" ]

departments

[ "Musculoskeletal", "Neurologic", "Psychiatric" ]

tags

[]

version_number

1

versions

[]

related

[ { "calcId": 703, "short_title_en": "NEXUS C-Spine Rule", "slug": "nexus-criteria-c-spine-imaging" }, { "calcId": 10552, "short_title_en": "PECARN C-Spine Imaging Rule", "slug": "pecarn-cervical-spine-injury-prediction-rule" }, { "calcId": 10532, "short_title_en": "NDI", "slug": "neck-disability-index-ndi" } ]

ismed

true

section

[ "whenToUseViewed", "pearlsPitfallsViewed", "whyUseViewed", "nextStepsViewed", "evidenceViewed" ]

cleaned_departments

[ "orthopedics", "neurology", "psychiatry" ]

cleaned_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." ]

pub

true