2. The Art of Cervical Spine Clearance in the ED

Take Home: Every ED physician knows the theory of the clinical evaluation of a traumatic cervical spine injury. The details of the clinical decision rules, however, are important, but not well appreciated.  If you put together the two main rules, you can effectively clear most of your patients.

Cervical Spine Clearance – It’s not neurosurgery (it’s actually more complicated)

This was just reviewed in our Trauma conference, the review was a good baseline, resident level review of the basics of CCS rules.  I did some reading and listened to a few podcasts and wanted to go over some of the more attending level DETAILS that are really important for your day-to-day use.


Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study.

       – Annals of Emerg Med 1992

Click to access hoffman%20-%20Low-risk%20criteria%20for%20cervical-spine%20radiography%20in%20blunt%20trauma-%20A%20prospective%20study.pdf

NEXUS:  Know the foot notes… every step of this rule has them, and they are fairly restrictive.

  1.  No midline tenderness
  2.  No intoxication – this means not only are they acting sober, but if they smell of an alcoholic beverage, or even if someone gives you history that they have been using an intoxicating substance, even if they are NOT clinically intoxicated, it bumps them from the study.
  3.  Normal alertness – Must have GCS of 15, be A&O x3, and be ABLE TO RECALL 3 OBJECTS AT 5 MINUTES
  4.   NO neuro deficit – paresthesias of any type or duration remove from the study
  5.   No distracting injury – “No precise definition of a distracting injury is possible.”  These can include not just bad lacerations or fractures, but also “any injury that is thought to impair the patient’s ability to appreciate other injuries.”  SO, a patient that has a hangnail, but is “distraught” over it cannot be cleared.

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

     – JAMA 2001

Canadian C-Spine Rules: 


  1. Only applies to ages 16 – 65
  1. They must have ONE LOW RISK criterion and NO HIGH RISK criterion.


  1. Simple rear end accident (does not include getting hit by a bus or truck)
  2. Ambulatory at ANY time
  3. Sitting position in the ED
  4. Delayed onset of neck pain

HIGH RISK (Dangerous Mechanisms):

  1. Fall >3 feet or 5 stairs
  2. High Speed (>60 mph)
  3. No Axial Load to the head
  4. Rollover or Ejection MVC
  5. Recreational Vehicle or Bike Accident
  1. NECK ROTATION: Can the patient actively turn their head 45 degrees right and left.  This is a “can they do it” test.  It is WITHOUT regard to pain.  SO, if they CAN actively move their neck 45 degrees (even if it hurts) and they fit the other criterion, they may be cleared without imaging.

Use the Rules Together!

One GREAT suggestion on how to use these in clinical practice is from ED-Intensivist Scott Wiengard and his EMCRIT site (reference is below) is to use these two rules in SERIES for patients with midline CSPINE tenderness.

  1. Make sure they meet all NEXUS criterion except midline CS tenderness.
  2. Then plug into CCS rules, where they have to fit a low risk criterion and no high risk criterion.
  3. Range their neck 45 degrees, if they can move it, they are cleared.

May Cspine


Here is the entire EMCRIT podcast, which is awesome:

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