Clinical Assessment: Adults

For the purposes of clearing the cervical spine, patients can be divided into two groups:

  • Conscious cooperative patients: This is the most commonly encountered group of patients who present to the ED or pre-hospital practitioner. They have a low incidence (less than 3%) of cervical spine injury and are able to cooperate with clinical assessment. Therefore, a focussed history and examination can be used to clinically clear their necks – various clinical decision rules have been developed to be used in these patients:
    • NEXUS Low Risk Criteria
    • Canadian Cervical Spine Rules
  • Unconscious/uncooperative patients: These patients are not able to have their cervical spines cleared clinically as a reliable clinical assessment cannot be made. These patients require imaging to clear their spines

NEXUS Low Risk Criteria (NLC) [5]

This was developed from a prospective study of patients undergoing cervical spine radiography in 21 centres in the USA. The study looked at 5 criteria; if all were negative the patient was classified as having a low risk of injury.

Five NEXUS criteria:

  1. No midline cervical tenderness
  2. No focal neurological deficit
  3. Normal alertness
  4. No intoxication
  5. No painful distracting injury

A total of 34,069 patients underwent radiography, and all but 8 of 818 patients with cervical spine injury were identified by applying the NEXUS criteria (a sensitivity of 99%; 95% confidence intervals 98.0-99.6%). The negative predictive value was 99.8%, but the specificity was low (12.9%) which means that the majority of patients with positive NEXUS criteria still did not have actual cervical spine injury. Some authors have tried to refine the NEXUS Guidelines without success.

Canadian C-Spine Rule (CCR) [6]

It should be noted that, due to reduced radiation and increased availability, there is increasing utility of CT as first line imaging modality in the over 65yo population (due to difficulty in interpreting plain radiographs). Please review individual trusts local policy.

This prospective cohort study in 10 Canadian EDs evaluated 20 standardised clinical factors prior to radiography in 8924 patients. The study sample included 151 (1.7%) clinically significant cervical spine injuries. The decision rule resulting from this study asks three questions:

  1. Is there any high-risk factor present which mandates radiography?
  2. Is there any low-risk factor present that allows safe assessment of the range of neck motion?
  3. Is the patient able to actively rotate their neck 45ยบ to the left and right?

Subsequent validation of this rule revealed a sensitivity of 100% (95% confidence intervals 98-100%) and a specificity of 42.5% (95% confidence intervals 40-44%).

Unlike the NEXUS rule, this study excluded children <16 yrs of age, and all patients with a Glasgow Coma Scale (GCS) score of <15.

CCR or NLC?

There have been two studies which have compared the CCR with the NLC. Both these studies found that the CCR had a higher sensitivity and specificity than the NLC, however one study was a retrospective application of the NEXUS criteria to the CCR study raw data, and did not exactly follow the NEXUS criteria (No evidence of intoxication vs. unevaluable due to intoxication).

the most recent NICE guidance (2016) advises clinical assessment utilising the Canadian C-spine rules.

The CCR are used more in EDs in the UK at present (anecdotal), and the NLC are currently used in the pre-hospital setting being recommended by the current JRCALC (national ambulance service) Guidelines. However a number of ambulance services are now training their staff in the use of the CCR.

Learning bite

The cervical spine can reliably be ‘cleared’ if either the NEXUS low risk criteria or Canadian C-Spine rules are satisfied