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The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients
Ian G. Stiell, MD,MSc,FRCPC;
George A. Wells, PhD;
Katherine L. Vandemheen, BScN;
Catherine M. Clement, RN;
Howard Lesiuk, MD;
Valerie J. De Maio, MD,MSc;
Andreas Laupacis, MD,MSc;
Michael Schull, MD,MSc;
R. Douglas McKnight, MD;
Richard Verbeek, MD;
Robert Brison, MD,MPH;
Daniel Cass, MD;
Jonathan Dreyer, MD;
Mary A. Eisenhauer, MD;
Gary H. Greenberg, MD;
Iain MacPhail, MD,MHSc;
Laurie Morrison, MD,MSc;
Mark Reardon, MD;
James Worthington, MBBS
JAMA. 2001;286:1841-1848.
Context 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.
Design 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.
Setting Ten EDs in large Canadian community and university hospitals.
Patients 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.
Main Outcome Measure 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  coefficient, logistic regression analysis, and  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° 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%.
Conclusion 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.
Author Affiliations: Division of Emergency Medicine (Drs Stiell, Greenberg, Reardon, and Worthington), Department of Medicine (Drs Stiell, Wells, and Laupacis), Department of Epidemiology and Community Medicine (Drs Stiell and Wells), Division of Neurosurgery (Dr Lesiuk), and Clinical Epidemiology Unit (Drs Stiell and De Maio, and Mss Vandemheen and Clement), University of Ottawa, Ottawa, Ontario; Department of Emergency Medicine, Queen's University, Kingston, Ontario (Dr Brison); Division of Emergency Medicine, University of Toronto, Toronto, Ontario (Drs Schull, Verbeek, Cass, and Morrison); Division of Emergency Medicine, University of Western Ontario, London (Drs Dreyer and Eisenhauer); Division of Emergency Medicine, University of British Columbia, Vancouver (Drs McKnight and MacPhail).
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