The Canadian C-spine rule for radiography in alert and stable trauma patients.
BACKGROUND
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.


METHODS
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.


METHODS
Ten EDs in large Canadian community and university hospitals.


METHODS
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.


METHODS
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 kappa coefficient, logistic regression analysis, and chi(2) 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 degrees 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%.


CONCLUSIONS
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.
Stiell
I G
IG
Clinical Epidemiology Unit, F6, Ottawa Health Research Institute, 1053 Carling Ave, Ottawa, Ontario, Canada K1Y 4E9. istiell@ohri.ca
Wells
G A
GA
Vandemheen
K L
KL
Clement
C M
CM
Lesiuk
H
H
De Maio
V J
VJ
Laupacis
A
A
Schull
M
M
McKnight
R D
RD
Verbeek
R
R
Brison
R
R
Cass
D
D
Dreyer
J
J
Eisenhauer
M A
MA
Greenberg
G H
GH
MacPhail
I
I
Morrison
L
L
Reardon
M
M
Worthington
J
J
D000328:Adult; D000368:Aged; D002170:Canada; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging; D006259:Craniocerebral Trauma / Q000000981:diagnostic imaging*; D003661:Decision Support Techniques; D004632:Emergency Medical Services / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019838:Neck Injuries / Q000000981:diagnostic imaging*; D010043:Outcome and Process Assessment, Health Care; D011446:Prospective Studies; D011859:Radiography / Q000592:standards; D012044:Regression Analysis; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed; D014194:Traumatology / Q000592:standards*; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging*