The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients

Stiell, Ian G. MD, MSc, FRCPC
Wells, George A. PhD
Vandemheen, Katherine L. BScN
Clement, Catherine M. RN
Lesiuk, Howard MD
De Maio, Valerie J. MD, MSc
Laupacis, Andreas MD, MSc
Schull, Michael MD, MSc
McKnight, R. Douglas MD
Verbeek, Richard MD
Brison, Robert MD, MPH
Cass, Daniel MD
Dreyer, Jonathan MD
Eisenhauer, Mary A. MD
Greenberg, Gary H. MD
MacPhail, Iain MD, MHSc
Morrison, Laurie MD, MSc
Reardon, Mark MD
Worthington, James MBBS

Author Affiliations: Division of Emergency Medicine (Drs Stiell, Greenberg, Reardon, and Worthington), Department of Medicine (Drs Stiell, Wells, and Laupacis), Department of Epidemiology and Community Medicine (Drs Stiell and Wells), Division of Neurosurgery (Dr Lesiuk), and Clinical Epidemiology Unit (Drs Stiell and De Maio, and Mss Vandemheen and Clement), University of Ottawa, Ottawa, Ontario; Department of Emergency Medicine, Queen's University, Kingston, Ontario (Dr Brison); Division of Emergency Medicine, University of Toronto, Toronto, Ontario (Drs Schull, Verbeek, Cass, and Morrison); Division of Emergency Medicine, University of Western Ontario, London (Drs Dreyer and Eisenhauer); Division of Emergency Medicine, University of British Columbia, Vancouver (Drs McKnight and MacPhail).

Corresponding Author: Ian G. Stiell, MD, MSc, FRCPC, Clinical Epidemiology Unit, F6, Ottawa Health Research Institute, 1053 Carling Ave, Ottawa, Ontario, Canada K1Y 4E9 (e-mail: [email protected]).

JAMA: The Journal of the American Medical Association 286(15):p 1841-1848, October 17, 2001.

Context

High levels of variation and inefficiency exist in current clinical practice regarding use of cervical spine (C-spine) radiography in alert and stable trauma patients.

Objective

To derive a clinical decision rule that is highly sensitive for detecting acute C-spine injury and will allow emergency department (ED) physicians to be more selective in use of radiography in alert and stable trauma patients.

Design

Prospective cohort study conducted from October 1996 to April 1999, in which physicians evaluated patients for 20 standardized clinical findings prior to radiography. In some cases, a second physician performed independent interobserver assessments.

Setting

Ten EDs in large Canadian community and university hospitals.

Patients

Convenience sample of 8924 adults (mean age, 37 years) who presented to the ED with blunt trauma to the head/neck, stable vital signs, and a Glasgow Coma Scale score of 15.

Main Outcome Measure

Clinically important C-spine injury, evaluated by plain radiography, computed tomography, and a structured follow-up telephone interview. The clinical decision rule was derived using the κ coefficient, logistic regression analysis, and χ² recursive partitioning techniques.

Results

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 paresthesias 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° to the left and right? By cross-validation, this rule had 100% sensitivity (95% confidence interval [CI], 98%-100%) and 42.5% specificity (95% CI, 40%-44%) for identifying 151 clinically important C-spine injuries. The potential radiography ordering rate would be 58.2%.

Conclusion

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.

JAMA.2001;286:1841-1848