Canadian C-spine rules

Last revised by João Ramos on 10 Feb 2020

Canadian C-spine rules are a set of guidelines that help a clinician decide if cervical spine imaging is not appropriate for a trauma patient in the emergency department. The patient must be alert and stable.

There are three rules:

  • is there any high-risk factor present that requires cervical spine imaging?
    • ≥65 years
    • a dangerous mechanism
      • fall from elevation >3 ft (or 5 stairs)
      • axial load to the head
      • high-speed motor vehicle collision (e.g. >100 km/hr or ~60 mph, rollover, ejection)
      • motorized recreational vehicles
      • bicycle collision
    • paresthesias in extremities

If any high-risk factor is present, then cervical spine imaging is warranted.

  • is there any low-risk factor present?
    • simple rear-end motor vehicle collision
      • excludes being hit by a high-speed vehicle, a large vehicle (e.g. bus), or rollover
    • sitting position in emergency department
    • ambulatory at any time since the injury
    • delayed onset of neck pain
    • absence of midline C-spine tenderness

If the patient does not meet the criteria of a low-risk injury, then cervical spine imaging is warranted. 

If the patient meets the criteria of a low-risk injury, then one should assess on physical exam whether the patient can rotate the neck 45°.

  • if low-risk injury and the patient can rotate the neck 45°
    • no cervical spine imaging required
  • if low-risk injury and the patient cannot rotate the neck 45°
    • then cervical spine imaging is warranted

The original study presented 100% sensitivity for identifying "clinically important C-spine injuries" (95 percent confidence interval 98%-100%).

See also

There is debate over whether the NEXUS criteria or the Canadian C-spine rules (CCR) are more reliable for excluding C-spine injury, though high-quality evidence points to better sensibility, better sensitivity, and a lower rate of imaging use when following the CCR criteria 3.

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