title: The Canadian C-spine rule performs better than unstructured physician judgment.
abstract: OBJECTIVE
  We compare the predictive accuracy of emergency physicians' unstructured clinical judgment to the Canadian C-Spine rule.
  
  
  METHODS
  This prospective multicenter cohort study was conducted at 10 Canadian urban academic emergency departments. Included in the study were alert, stable, adult patients with a Glasgow Coma Scale score of 15 and trauma to the head or neck. This was a substudy of the Canadian C-Spine and CT Head Study. Eligible patients were prospectively evaluated before radiography. Physicians estimated the probability of unstable cervical spine injury from 0% to 100% according to clinical judgment alone and filled out a data form. Interobserver assessments were done when feasible. Patients underwent cervical spine radiography or follow-up to determine clinically important cervical spine injuries. Analyses included comparison of areas under the receiver operating characteristic (ROC) curve with 95% confidence intervals (CIs) and the kappa coefficient.
  
  
  RESULTS
  During 18 months, 6265 patients were enrolled. The mean age was 36.6 years (range 16 to 97 years), and 50.1% were men. Sixty-four (1%) patients had a clinically important injury. The physicians' kappa for a 0% predicted probability of injury was 0.46 (95% CI 0.28 to 0.65). The respective areas under the ROC curve for predicting cervical spine injury were 0.85 (95% CI 0.80 to 0.89) for physician judgment and 0.91 (95% CI 0.89 to 0.92) for the Canadian C-Spine rule (P <.05). With a threshold of 0% predicted probability of injury, the respective indices of accuracy for physicians and the Canadian C-Spine rule were sensitivity 92.2% versus 100% (P <.001) and specificity 53.9% versus 44.0% (P <.001).
  
  
  CONCLUSIONS
  Interobserver agreement of unstructured clinical judgment for predicting clinically important cervical spine injury is only fair, and the sensitivity is unacceptably low. The Canadian C-Spine rule was better at detecting clinically important injuries with a sensitivity of 100%. Prospective validation has recently been completed and should permit widespread use of the Canadian C-Spine rule.
authors.affiliation: Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Glen
authors.initials: G
authors.lastname: Bandiera
authors.forename: Ian G
authors.initials: IG
authors.lastname: Stiell
authors.forename: George A
authors.initials: GA
authors.lastname: Wells
authors.forename: Catherine
authors.initials: C
authors.lastname: Clement
authors.forename: Valerie
authors.initials: V
authors.lastname: De Maio
authors.forename: Katherine L
authors.initials: KL
authors.lastname: Vandemheen
authors.forename: Gary H
authors.initials: GH
authors.lastname: Greenberg
authors.forename: Howard
authors.initials: H
authors.lastname: Lesiuk
authors.forename: Robert
authors.initials: R
authors.lastname: Brison
authors.forename: Daniel
authors.initials: D
authors.lastname: Cass
authors.forename: Jonathan
authors.initials: J
authors.lastname: Dreyer
authors.forename: Mary A
authors.initials: MA
authors.lastname: Eisenhauer
authors.forename: Iain
authors.initials: I
authors.lastname: Macphail
authors.forename: R Douglas
authors.initials: RD
authors.lastname: McKnight
authors.forename: Laurie
authors.initials: L
authors.lastname: Morrison
authors.forename: Mark
authors.initials: M
authors.lastname: Reardon
authors.forename: Michael
authors.initials: M
authors.lastname: Schull
authors.forename: James
authors.initials: J
authors.lastname: Worthington
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002170:Canada; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000293:injuries*; D002983:Clinical Competence; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D011859:Radiography; D012680:Sensitivity and Specificity; D013124:Spinal Injuries / Q000175:diagnosis* / Q000000981:diagnostic imaging