Background
Sensation of cervical nerve roots
Three column concept of spinal fracture stability
Numbering order of vertebrae.
Clinical Features
C-spine injuries may present with
- Rarely neurogenic shock (bradycardia, hypotension)
- Posterior neck pain
- Pain on palpation of spinous processes
- Limited neck ROM with pain
- Weakness, numbness, or paresthesias
Differential Diagnosis
Evaluation
Management
Disposition
Calculators
NEXUS Criteria
NEXUS Criteria for C-Spine Imaging
| Criteria (ALL must be absent to clear)
|
Absent
|
Present
|
| Posterior midline cervical tenderness
|
1
|
|
| Focal neurologic deficit
|
1
|
|
| Altered level of alertness
|
1
|
|
| Intoxication
|
1
|
|
| Distracting painful injury
|
1
|
|
| Criteria Present
|
/ 5
|
| Interpretation
|
| 0
|
C-spine can be cleared clinically — All 5 criteria absent. No imaging needed. Sensitivity 99.6% for clinically significant injury.
|
| ≥1
|
Cannot clear clinically — C-spine imaging indicated.
|
| References
|
- Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma (NEXUS). N Engl J Med. 2000;343(2):94-99. PMID 10891516.
|
Canadian C-Spine Rule
Canadian C-Spine Rule
| Step 1: Any High-Risk Factor? (mandates radiography)
|
| Criteria
|
No
|
Yes
|
| Age ≥65
|
1
|
|
| Dangerous mechanism (fall ≥1m/5 stairs, axial load to head, MVC >100km/h or rollover/ejection, motorized recreational vehicle, bicycle collision)
|
1
|
|
| Paresthesias in extremities
|
1
|
|
| Step 2: Any Low-Risk Factor? (allows safe ROM assessment)
|
| Simple rear-end MVC (excludes: pushed into traffic, hit by bus/large truck, rollover, hit by high-speed vehicle)
|
1
|
|
| Sitting position in ED
|
1
|
|
| Ambulatory at any time since injury
|
1
|
|
| Delayed onset of neck pain (not immediate)
|
1
|
|
| Absence of midline cervical tenderness
|
1
|
|
| Step 3: Able to actively rotate neck 45° left and right?
|
| Can rotate neck 45° L and R
|
1
|
|
| High Risk Factors
|
/ 3
|
| Low Risk Factors
|
/ 5
|
| Interpretation (stepwise)
|
| High risk ≥1
|
Radiography indicated — Do NOT assess ROM. Image the c-spine.
|
| Low risk = 0
|
Cannot assess ROM safely — No low-risk factor present to allow safe assessment. Image.
|
| Low risk ≥1 + ROM OK
|
C-spine can be cleared — At least one low-risk factor AND able to rotate neck 45°. No imaging needed.
|
| Low risk ≥1 + no ROM
|
Radiography indicated — Low-risk factor present but unable to rotate. Image.
|
| References
|
- Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-Spine Rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841-1848. PMID 11597285.
- Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine Rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-2518. PMID 14695411.
|
See Also
References
