12-3-01 Canadian C-Spine Rule Could Safely Reduce Radiography Use Submitted by: Warren Jahn, DC - drwjahn@ix.netcom.com LeAnne Cupon, DC - drlcoupon@enter.net WESTPORT, CT (Reuters Health) Oct 16 - A newly derived clinical decision rule is highly sensitive in determining the need for cervical (C)-spine radiography in alert and stable trauma patients, Canadian investigators report in The Journal of the American Medical Association for October 17. "A physician can clear a patient's C-spine in about a minute" using the rule, Dr. Ian G. Stiell told Reuters Health. "Not only would it save the X-ray, but it would get the patient out from the immobilization restrains. Sometimes patients are stuck on the backboard for hours, even though they're pretty stable, just because they're waiting for an X-ray they don't even need." In their prospective cohort study, Dr. Stiell, of the Ottawa Health Research Institute, and colleagues collected data on 8924 adult patients from 10 large Canadian hospitals. All of the patients presented to the ED after sustaining acute blunt trauma to the head or neck. The researchers evaluated the accuracy and reliability of 25 clinical variables in predicting a clinically important C-spine injury. Statistical analysis yielded a three-question decision rule for detecting acute C-spine injury. The first question determines whether a patient has high-risk factors, such as age >65, paresthesias or a particularly dangerous mechanism of injury, which would mandate radiography. The second question asks if there are any low-risk factors that would allow safe assessment of range of motion. For example, has the patient been ambulatory at any time since the accident or able to sit upright? The third question determines whether the patient is able to actively rotate his neck 45 degrees to the left and right. If the answers to the second and third questions are positive, no radiography would be required. This rule identified all of the 151 patients who had sustained an important C-spine injury. The rule had a specificity of 42.5%. The investigators conclude that the Canadian Rule is clinically sensible, highly sensitive, and relatively specific. They estimate that its implementation could safely reduce the use of C-spine radiography between 25% and 50%. The authors point out that the National Emergency X-Radiography Utilization Study (NEXUS) criteria, used in the US, increases the use of radiography. "The Rule has quite different criteria from the NEXUS criteria," Dr. Stiell pointed out. "For example, NEXUS doesn't address patient age, the mechanism of injury, paresthesias, or the patient's ability to rotate the neck." "Validation of the Canadian C-spine Rule in other patient populations is the next step for improving the efficacy of C-spine imaging for patients with trauma," Dr. Richard H. Daffner, of Allegheny General Hospital in Pittsburgh, Pennsylvania, remarks in an accompanying editorial. At that point, physicians will have "a workable system" to evaluate patients thoroughly and safely, he concludes. Dr. Stiell agrees. "We are doing a concurrent prospective validation comparing the Canadian C-spine Rule to the NEXUS criteria in multiple sites. We think it should be done in as many places as possible." He noted that his group hopes to include 10,000 patients from nine study sites across Canada. JAMA 2001;286:1841-1848,1893-1894.