The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma

For paramedics around the world one question rings out repeatedly: “To collar or not to collar?”

Seeing as how paramedics are at the bottom of the hill, many patients end up boarded  when they need not.  Liability is always on the mind of the paramedic.  Our job is quite often a delicate balancing act between the patient’s best interests and liability.  Unfortunately sometimes these two issues collide.  Quite often patients are boarded because it is expected of us (because of liability).  The Canadian C Spine Rules have been in effect for quite some time now with great success.  Below is a recent study comparing the Canadian C Spine Rules with NLC.  The study was completed by Ian G. Stiell, M.D., M.Sc., Catherine M. Clement, R.N., R. Douglas McKnight, M.D., Robert Brison, M.D., M.P.H., Michael J. Schull, M.D., M.Sc., Brian H. Rowe, M.D., M.Sc., James R. Worthington, M.B., B.S., Mary A. Eisenhauer, M.D., Daniel Cass, M.D., Gary Greenberg, M.D., Iain MacPhail, M.D., M.H.Sc., Jonathan Dreyer, M.D., Jacques S. Lee, M.D., Glen Bandiera, M.D., Mark Reardon, M.D., Brian Holroyd, M.D., Howard Lesiuk, M.D., and George A. Wells, Ph.D.

Below is the abstract, the full study was published by The NEW ENGLAND JOURNAL of MEDICINE.

Background

The Canadian C-Spine (cervical-spine) Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC) are decision rules to guide the use of cervical-spine radiography in patients with trauma. It is unclear how the two decision rules compare in terms of clinical performance.

Method

We conducted a prospective cohort study in nine Canadian emergency departments comparing the CCR and NLC as applied to alert patients with trauma who were in stable condition. The CCR and NLC were interpreted by 394 physicians for patients before radiography.

Results

Among the 8283 patients, 169 (2.0 percent) had clinically important cervical-spine injuries. In 845 (10.2 percent) of the patients, physicians did not evaluate range of motion as required by the CCR algorithm. In analyses that excluded these indeterminate cases, the CCR was more sensitive than the NLC (99.4 percent vs. 90.7 percent, P<0.001) and more specific (45.1 percent vs. 36.8 percent, P<0.001) for injury, and its use would have resulted in lower radiography rates (55.9 percent vs. 66.6 percent, P<0.001). In secondary analyses that included all patients, the sensitivity and specificity of CCR, assuming that the indeterminate cases were all positive, were 99.4 percent and 40.4 percent, respectively (P<0.001 for both comparisons with the NLC). Assuming that the CCR was negative for all indeterminate cases, these rates were 95.3 percent (P=0.09 for the comparison with the NLC) and 50.7 percent (P=0.001). The CCR would have missed 1 patient and the NLC would have missed 16 patients with important injuries.

Conclusions

For alert patients with trauma who are in stable condition, the CCR is superior to the NLC with respect to sensitivity and specificity for cervical-spine injury, and its use would result in reduced rates of radiography.