Canadian C-Spine Rules | Cervical Fracture Screening

After blunt trauma to the head, it is essential to screen for fractures, dislocation, or ligamentous instability in the cervical spine, which would require specialist follow-up with possible surgical intervention as these injuries can have fatal consequences ranging from spinal cord injury to death if they are not detected. 

The Canadian C-Spine rules are a clinical decision rule that’s used to safely rule out cervical spine fractures in alert, stable patients without the need for radiographic imagery.

A review by Michaleff et al. (2012) found values of sensitivity ranging from  90-100% and specificity ranging from  1-77%.

So first you want to clear any high-risk factors which would mandate radiography

Radiography is indicated for patients who are 65 or older, patients who have paresthesias in the extremities, or if the trauma had a dangerous mechanism which are:

1. falls from more than 3 feet of height or 5 stairs,
2. axial load on the head such as during diving
3. a motor vehicle accident at high speeds (more than 100km/h or 60mph), rollover accidents, or being ejected from the vehicle
4. an accident using motorized recreational vehicles
5. or a bicycle accident

If these factors are not present, check if the following low-risk factors apply, allowing safe assessment of range of motion. These are:

1. The accident was a simple rear-end collision (these exclude being pushed into oncoming traffic or when being hit by a truck or bus or at high speeds as well as rollover accidents)
2. the patient is able to sit in the emergency department
3. the patient is ambulatory at any time
4. there was a delayed onset of neck pain (meaning no immediate neck pain after the trauma)
5. there is no tenderness over the midline at the cervical spine

If these do not apply, refer out for radiographs. Otherwise, continue by asking the patient to actively rotate the neck. 

If they are not able to rotate 45° left and right, refer out for radiographs.  If they are able to do so, then no radiographs are needed.

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Another common screening tool for cervical fractures are the NEXUS criteria. If you want to screen for fractures in other body parts, check out the list below:

• Elbow Extension Test (Elbow)
• Caradeniz Wrist Rules (Wrist)
• Supine Sign (Thoracic Spine)
• Closed-Fist Percussion Test
• Patellar Pubic Percussion Test (Hip)
• Fulcrum Test (Femur)
• Ottawa Knee Rules (Knee)
• Ottawa Ankle Rules (Ankle & Foot)

References

Michaleff, Z. A., Maher, C. G., Verhagen, A. P., Rebbeck, T., & Lin, C. W. C. (2012). 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, 184(16), E867-E876.