Canadian C-spine rules

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The Canadian C-Spine rule (Canadian cervical-spine rule, CCR)[1] is the best validated[2] and effective[3] rule for imaging the cervical spine after trauma in adults. It is not fully discriminatory in children 10 years old or less[4].

  1. For alert (Glasgow coma scale score = 15) and stable trauma patients where cervical spine injury is a concern
  2. Presence of any of following high-risk factors mandate radiography of cervical spine
    • Age ≥ 65 years
    • Dangerous mechanism:
      • Fall of 1 meter or more
      • Fall down 5 stairs or more
      • Axial load to head at trauma, as with diving
      • High speed road traffic accident (greater than 100 km/hr), rollover of car, ejection of car passenger
      • Motorized recreational vehicle
      • Bicycle collision
    • Paraesthesia in any extremity
  3. If not, assess if fit for cervical spine clinical examination of range of motion which means:
    • Simple rear-end road traffic accident. Exclude if:
      • Pushed into oncoming traffic
      • Hit by bus/large vehicle
      • Rollover
      • Hit by high speed (greater than 100 km/hr) vehicle
    • Sitting position possible
    • Patient ambulatory at any time after trauma
    • Delayed (not immediate) onset of neck pain after trauma
    • Absence of midline cervical spine tenderness
  4. If not able to actively rotate neck 45° left and right mandates radiography
  5. Otherwise no radiography is necessary.

In adults application of this set of rules not only prevents missed fractures, it also has a chance of missing a fracture that seems to be approaching zero with appropriate radiography and interpretation of this.