Cervical spine clearance


  • US and Canada with more than 13 million trauma patients per year at risk for C-spine injury
  • Most blunt trauma patients will be placed in a cervical collar by EMS to protect the C-spine
  • C-spine can be clinically cleared by trained personnel

Decision Rules

NEXUS Cervical Spine Rule

Radiography is not necessary if the patient satisfies ALL of the following low risk criteria:

  • No midline cervical tenderness
  • No focal neuro deficits
  • Normal alertness
  • No intoxication
  • No painful distracting injury

C-spine imaging should be considered unless the patient meets all of the above low risk criteria[1] [2]

Canadian Cervical Spine Rule

Algorithm for evaluation of cervical spine injuries (Canadian C-spine Rule)

No High Risk Factors

  • Age >65
  • Dangerous mechanism (fall>3ft/5 stairs, high speed MVC (>60mph)/rollover/ejection, bicycle crash, RV, axial load injury)
  • Parasthesias in extremities

ANY Low Risk Factor

  • Simple rear end MVC
  • Delayed onset of pain
  • Sitting position in ED
  • Ambulatory at any time
  • Absence of midline C-spine tenderness


  • Rotates neck 45 degrees to left and right

C-spine can be cleared clinically if above criteria met[3] [4]

Canadian rule vs. Nexus

A single trial showed Canadian rule would pick up 312 or 313 clinically important cases, while NEXUS would miss 1 one in 10 cases[5]


Canadian 99.4% vs Nexus 90.7%


Canadian 45.1% vs. Nexus 36.8%


Criteria Met

  • If CCSR or NEXUS criteria is met, patient can be cleared clinically

Criteria Not Met

  • If unable to be cleared by CCSR or NEXUS then imaging is indicated with CT C-spine is indicated
    • CT recommended over xray
    • For significant injury CT has a sensitivity of 100% while xray has a sensitivity 36%[6]
  • If negative CT may clear spine unless: 1) high-risk patient, 2) with severe mid-line pain, AND 3) refusal to range neck after adequate pain control
    • CTs may miss ligamentous instability
    • Keep on C-collar and obtain MRI (potentially as outpatient) vs. flexion-extension films
    • For obtunded patients, see below

Obtunded Patient

  • EAST (Eastern Association for the Surgery of Trauma) performed systematic review in 2015[7]
    • Review included 1800 obtunded patients generally defined as GCS<13 with negative CT c-spine using <3mm axial cuts
    • Of 1800 patients, 176 patients with abnormal MRI
    • None (or 0/176) had unstable C-spine injury
    • EAST guideline notes: We conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone[8]
  • C-spine clearance with CT was highly accurate and reliable for identifying clinically significant spine injuries, and had a 100% NPV for identifying unstable injuries. [9]
    • 10,191 patient multicenter prospective study
    • Supplement to EAST recommendations
    • 99.9% NPV for clinically significant C-spine injuries
    • The practice of continuing spine precautions due to concerns about intoxication despite a negative CT scan only result in significantly prolonged immobilization and c-collar wear, with no benefit in identifying additional injuries
  • Prolonged C-spine immobilization is still at times selectively used in both sober or intoxicated patients based on evaluation, individual threshold and practice

See Also

Neck Trauma

External Links


  1. 27. Hoffman JR, et al. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med 1992;21:1454-60.
  2. Mahadevan, et al. Interrater reliability of cervical spine injury criteria inpatients with blunt trauma. Ann Emerg Med1998;31:197-201
  3. Stiell IG,et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17;286(15):1841-8. EBQ:Canadian C-spine Rule Study
  4. Stiell IG, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-8.
  5. Stiell IG, Clement CM, and McKnight DR, et al. The Canadian c-spine rule versus the NEXUS low-risk criteria in patients with trauma. NEJM. 2003; 349:2510-2518.
  6. Bailitz J, Starr F, Beecroft M, et al. CT should replace three view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: a prospective comparison. J Trauma. 2009;66:1605e1609.
  7. Patel MB, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015 Feb;78(2):430-41
  8. https://www.east.org/education/practice-management-guidelines/cervical-spine-collar-clearance-in-the-obtunded-adult-blunt-trauma-patient
  9. Martin MJ, Bush LD, et al. J Trauma Acute Care Surg. 2017 Jul 19. doi: 10.1097/TA.0000000000001650.