Canadian C-spine Rule

Canadian C-Spine Spine Rule For Risk of Skeletal Injury

Canadian C-spine rule is for use of radiography in cervical spine injuries. Cervical spine injury has the potential for neurological injury and 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 of trauma. 97% trauma centers in US were found to order cervical spine radiography for all trauma patients and the rate of imaging varies in hospitals.

It is reported that less than 3% of the trauma series have any positive finding. Therefore universal cervical spine radiography is considered inefficient and not cost effective.

Canadian C-spine rule is a set of guidelines that aim to reduce unnecessary cervical spine imaging and reduce health care costs.
Canadian C-spine rule was developed because there is a controversy among emergency physicians, neurosurgeons and trauma surgeons regarding the indications for C-spine radiography.

The different existing guidelines are confusing. Some say that all trauma patients should undergo imaging. Advanced Trauma Life Support course recommends that cervical spine films be obtained on all patients with injuries above the clavicle.

Some centers have a physician based selective approach where the decision to get an x-ray or not lies with a clinician.
Canadian C-spine rule for risk of skeletal injury aims to provide a universal protocol for cervical imaging in alert and stable patients. Canadian C-spine rule has been reported to be safe and reliable though there is a report of missing one unstable injury.

Here is an image showing Canadian C-spine rule.

How to Apply Canadian C-spine Rule

The Canadian cervical spine rule applies to trauma patients who are alert (Glasgow coma scale of 15) and stable.

The rule is not applicable 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

High-Risk Factors

• Age 65 years or over.
• Paraesthesia in extremities.
• Dangerous mechanism of injury, which is considered to be
  • 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 motorised recreational vehicle.
  • A bicycle collision.

If a high-risk factor is present, radiography is required.

If there are no high-risk factors, look for low-risk factors

Low Risk Factors

• 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 is able to 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 any low-risk factor is present, the patient is asked to rotate the neck to 45 degrees.

Able to Rotate Neck

If the patient is able to 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.