Canadian C-Spine Rule

This algorithmic approach to assessment of patients with suspected cervical spine injury is widely used across the world. It´s is primarily designed for evaluation of low-risk patients and follows three steps:

Step 1

Presence of high-risk factor requiring radiological evaluation?

  • Age older than 65 years
  • Mechanism of injury considered dangerous
  • Numbness or tingling present in the extremities

Mechanisms of injury considered potentially dangerous: a fall from a height 1 meter or higher, a bicycle collision, an axial load to the head or a motor vehicle collision involving high speed, rollover, or ejection.

If Yes to any of the above, radiological examination is mandated. Otherwise, proceed to step 2.

Step 2

Presence of low-risk factors preventing safe assessment of range of motion?

  • Simple rear-end motor vehicle collision
  • Patient ambulatory at any time since injury
  • Delayed onset of neck pain
  • Patient in sitting position in emergency department
  • Absence of midline cervical spine tenderness

If none of these low-risk factors is present, cervical spine radiological evaluation is indicated. If present go to Step 3.

Step 3

Ask patient to actively rotate his or her neck 45° left and right?

If the patient is unable to comply, radiological evaluation should be performed. If yes, radiography is not indicated.

Source:  The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001, Stiell et al.

This approach is often compared to the NEXUS Criteria, which also provide an evaluation tool for low-risk patients. This study (abstract), published in the NEJM in 2003, concludes with the CCR being superior to the NEXUS Criteria in this patient group. Likewise, a review from 2012 conducted by Michaleff et al, also finds the CCR superior in accuracy. However, the majority of studies included in their review were of low methodological quality.