Article Citation: Stiell IG, Wells GA, Vandemheen KL, Clement CM, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17;286(15):1841-8.

What we already know about the topic: More than a million patients treated annually in EDs around the country for blunt trauma and possible c-spine injury and prior to this study there was no clinical tool to identify low risk patients that do not require imaging for their c-spine trauma.

Why this study is important: reduce unnecessary c-spine imaging in alert blunt trauma patients.

Brief overview of the study: This was a prospective cohort study from Oct 1996 to April 1999 in 10 EDs in large Canadian community and university hospitals. 8924 adults who presented to the ED with blunt head/neck trauma with stable vitals and GCS 15 were included in
this study. Physicians evaluated patients for 20 standardized clinical findings prior to radiography. Clinically important c-spine injury was evaluated by X-ray, CT, and a structured follow-up telephone interview.

Results: 151/8924 (1.7%) patients had clinically significant c-spine injury.

Canadian c-spine rule:
1. Is there a high-risk factor in the patient that mandates imaging (age >= 65,
dangerous mechanism, paresthesias in extremities)
2. Is there any low-risk factor that allows safe assessment of range of motion
3. Is patient able to actively rotate neck 45 degrees to left and right

The Canadian C-spine rule is 100% sensitive for ruling out clinically significant injury (fracture, dislocation, ligamentous injury). This rule also detects 96.4% clinically insignificant c-spine injuries.

Limitations: Not all patients in the study underwent c-spine imaging

Take home points:
Age >= 65, extremity paresthesias, dangerous mechanism (fall >=3ft/5 stairs, axial loading injury, high speed MVC/rollover/ejection, bicycle collision, motorized recreational vehicle) NO
Low risk factor present (sitting position in the ED, ambulatory at any time, delayed neck pain, no midline tenderness, simple rear-end MVC) YES
Able to actively rotate neck 45 degrees left and right YES

If the above criteria is met, c-spine can be cleared clinically and no further imaging is required.