Last Updated on February 27, 2025
The Canadian C-Spine Rule is an assessment tool that is used to rule out the presence of traumatic cervical spine injury in patients who are not high risk for the injury and are alert and awake. This is done to remove the need for cervical spine radiography.
What is the need for Canadian C-Spine rule?
Canadian C-spine rule is for the use of radiography in cervical spine injuries. Cervical spine injury is critical. This is due to the risk of neurological injury.
Various protocols have been developed to protect the C-spine from field to hospital emergency care. These protective measures like a backboard, collar, and sandbags are used in all trauma patients with or without neck symptoms.
To rule out cervical injury, cervical imaging is done in patients with trauma. The majority of trauma patients are subjected to cervical x-ray to rule out cervical injury. However, less than 3% of the trauma series have any positive findings as per reports.
Thus universal cervical spine radiography is inefficient and not cost effective.
Canadian C-spine rule is a set of guidelines that aim to reduce unnecessary cervical spine radiography and reduce health care costs.
Moreover, due to different existing guidelines, there is controversy and confusion among physicians regarding indications of cervical spine x-rays.
The recommendations vary from everybody to selected groups depending on the protocol and the trauma center. Some trauma centers just rely on the clinician’s decision whether to get an X-ray or not. This takes out objectivity from the caregiving.
In this scenario, the Canadian C-spine rule provides a universal protocol for cervical imaging in alert and stable patients. It is safe and reliable and obviates the need for unnecessary imaging in low-risk patients. That amounts to a reduction of burden on emergency imaging and lesser waiting time.
Where Can Be Canadian C-spine Rule Applied?
Candian C-spine rule is applied in trauma patients where there is a concern for the presence of cervical injury and we want to determine if the patient requires cervical x-ray. This tool is dependent on the history and examination of the patient. Hence the Canadian cervical spine rule can only be applied to applies to alert trauma patients (Glasgow coma scale of 15) and stable.
Thus the rule cannot be used in
- Nontrauma cases
- GCS<15
- Unstable vital signs
- Age<16 years
- Acute paralysis
- Known disease of the vertebra
- Any previous cervical spine injury
For assessing a patient with cervical spine injury for the need of x-ray, first look for high-risk factors
Stepwise Application of Canadian C-spine Rules
Step I- Find if there are any high-risk factors.
The presence of high-risk factors makes cervical spine x-rays necessary
High-Risk Factors
- Age 65 years or over.
- Paraesthesia in extremities.
- Dangerous mechanism of injury
The dangerous mechanisms of injury described are
- A fall from a height of at least a meter or five stairs.
- An axial load to the head – eg, during diving.
- A motor vehicle collision at high speed (>100 km/h) or with rollover or ejection.
- A collision involving a motorized recreational vehicle.
- A bicycle collision.
If a high-risk factor is present, radiography is required.
Step 2- Any Low-risk Factors That Indicate Safe Assessment?
If high-risk factors are absent, the next step is to look for the presence of low-risk factors. If low-risk factors are present, these indicate that the patient can be assessed further by physical examination.
The following factors are considered low-risk factors in the Canadian C-spine rule.
- Simple rear-end motor vehicle collision (excludes being pushed into oncoming traffic, being hit by a bus or a large truck, a rollover, and being hit by a high-speed vehicle).
- The patient can sit or is sitting in the emergency department.
- The patient is ambulatory at any time.
- The onset of neck pain is delayed [The pain did not occur immediately after the injury after some time]
- An absence of midline cervical spine tenderness.
If none of these low-risk factors is present, the patient is at risk of having a cervical spine injury, and neck radiography should be done.
However, if low-risk factors are present, proceed to step 3.
Step 3- Able to Rotate Neck?
The patient is asked to rotate the neck to 45 degrees.
If the patient can rotate the neck, 45 degrees on either side [left and right], then no radiography is required.
If the patient is not able to rotate 45 degrees on either side [left and right]then radiography is required.
References
Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17. 286(15):1841-8. [Pubmed].
