Stiell JAMA 2001 – Canadian C-spine Rule

Short Citation: JAMA 2001;286(15):1841-8.

PubMed PMID: 11597285

Full Citation: 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;286(15):1841-8.

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Study Size: 8924 (10 centres in Canada)

Primary Endpoint(s): Clinically important C-spine injury (evaluated by plain radiography, CT, and a structured follow-up telephone interview).

Findings: Among the study sample, 151 (1.7%) had important C-spine injury. The resultant model and final Canadian C-Spine Rule comprises 3 main questions:

  1. Is there any high-risk factor present that mandates radiography (ie, age >/=65 years, dangerous mechanism, or paraesthesias in extremities)?
  2. Is there any low-risk factor present that allows safe assessment of range of motion (ie, simple rear-end motor vehicle collision, sitting position in ED, ambulatory at any time since injury, delayed onset of neck pain, or absence of midline C-spine tenderness)? and
  3. Is the patient able to actively rotate neck 45 degrees to the left and right?

By cross-validation, this rule had 100% sensitivity and 42.5% specificity for identifying 151 clinically important C-spine injuries. The potential radiography ordering rate would be 58.2%.

Authors' Conclusions: We have derived the Canadian C-Spine Rule, a highly sensitive decision rule for use of C-spine radiography in alert and stable trauma patients. If prospectively validated in other cohorts, this rule has the potential to significantly reduce practice variation and inefficiency in ED use of C-spine radiography.

Additional comments from Journal Gems contributors: The CCR stipulates radiography (in alert GCS 15 and stable trauma patients) if:

  1. PRESENCE of high-risk factors (65+, dangerous mechanism, paraesthesia)
  2. ABSENCE of low-risk factors (simple rearend MVC, sitting position in ED, ambulatory at any time, delayed onset of neck pain, absence of midline c-spine tenderness)
  3. INABILITY to actively rotate neck 45 degrees
Similarly, it clears a C-spine if there is:
  1. ABSENCE of high-risk factors
  2. PRESENCE of low-risk factors
  3. ABILITY to actively rotate neck 45 degrees

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