View source for Cervical spine clearance

==Background==
*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==

{{Template:C-spine NEXUS}}

{{Template:C-spine Canadian}}

==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<ref>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.</ref>

===Sensitivity===
Canadian 99.4% vs Nexus 90.7% 

===Specificity===
Canadian 45.1% vs. Nexus 36.8%

==Management==
===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%<ref> 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.</ref>
*If negative CT for boney injury may clear spine unless<ref>Inaba, K et al.Cervical spinal clearance: a prospective Western Trauma Association multi-institutional trial.J Trauma Acute Care Surg. 2016 Dec; 81(6):1122-1130.</ref>
**'''Patient Altered''' ([[Cervical_spine_clearance#Altered_Patient|see below]])<ref>Martin MJ, Bush LD, Inaba K, et al. Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey.J Trauma Acute Care Surg. 2017;83(6):1032-1040.</ref>
**'''Neurologic abnormalities'''<ref>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 A cute Care Surg. 2015 Feb;78(2):430-41.</ref>

===Altered Patient===
*EAST (Eastern Association for the Surgery of Trauma) performed systematic review in 2015<ref>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</ref>
**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'''<ref>https://www.east.org/education/practice-management-guidelines/cervical-spine-collar-clearance-in-the-obtunded-adult-blunt-trauma-patient</ref>
*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. <ref>Martin MJ, Bush LD, et al. J Trauma Acute Care Surg. 2017 Jul 19. doi: 10.1097/TA.0000000000001650.</ref>
**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==
*[[Canadian cervical spine rule]]
*[[EBQ:Canadian C-spine Rule Study]]
*[[NEXUS cervical spine rule]]
*[[EBQ:NEXUS]]
*[[C-Spine X-Ray]]

{{Blunt neck trauma DDX}}

==External Links==
*[http://www.mdcalc.com/canadian-c-spine-rule/ MDCalc Canadian C-Spine Rule]
*[http://www.mdcalc.com/nexus-criteria-for-c-spine-imaging/ MDCalc NEXUS]

==References==
<references/>

[[Category:Trauma]][[Category:Orthopedics]]