Canadian C-Spine Rule Criteria for Cervical Spine Imaging in Trauma Patients
The Canadian C-Spine Rule provides a highly sensitive algorithm for determining the need for cervical spine imaging in alert and stable trauma patients, with 100% sensitivity for detecting clinically significant cervical spine injuries while reducing unnecessary radiography by approximately 42%. 1
High-Risk Criteria (Imaging Mandatory)
If ANY of these factors are present, cervical spine imaging is required:
- Age ≥65 years
- Dangerous mechanism of injury:
- Fall from height >3 feet/5 stairs
- Axial load to head (e.g., diving)
- High-speed motor vehicle collision (>100 km/h), rollover, or ejection
- Motorized recreational vehicle accident
- Bicycle collision
- Paresthesias in extremities
Low-Risk Factors (Allow Range of Motion Assessment)
If ANY of these factors are present AND no high-risk factors exist, the patient can undergo range of motion assessment:
- Simple rear-end motor vehicle collision
- Sitting position in emergency department
- Ambulatory at any time since injury
- Delayed onset of neck pain
- Absence of midline cervical spine tenderness
Range of Motion Assessment
If the patient has at least one low-risk factor and no high-risk factors:
- Ask the patient to actively rotate their neck 45 degrees to the left and right
- If the patient can perform this movement, no imaging is needed
- If the patient cannot perform this movement, imaging is required
Implementation Considerations
- The Canadian C-Spine Rule has demonstrated superior performance compared to the NEXUS criteria, with higher sensitivity (98.7% vs 89.9%) and better diagnostic odds ratio (14.6 vs 5.9) 2
- Application of this rule could reduce cervical spine radiography by approximately 38-75% without missing significant injuries 3, 4
- CT is now preferred over plain radiographs for suspected cervical spine injuries due to significantly higher sensitivity 1
- For patients ≥65 years, imaging should be strongly considered regardless of other factors due to decreased sensitivity of clinical assessment in this population 1
Common Pitfalls to Avoid
- Failure to recognize dangerous mechanisms of injury that mandate imaging
- Incomplete assessment of range of motion (must be active rotation of 45 degrees in both directions)
- Applying the rule to patients who are not alert (GCS <15) or stable
- Using the rule in pediatric patients (under 16 years) - different criteria apply 5
- Overlooking paresthesias, which is a critical high-risk factor requiring immediate imaging
By systematically applying the Canadian C-Spine Rule, clinicians can reduce unnecessary imaging while maintaining high sensitivity for detecting clinically important cervical spine injuries, ultimately improving patient care and resource utilization.