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Does the Canadian C-Spine Rule Miss Unstable Injuries?
Mandatory use of the Canadian C-Spine Rule at one Australian hospital reduced x-ray ordering but not the amount of time that patients wore hard collars.
Unstable cervical-spine injuries, while uncommon, are potentially devastating if missed; thus, c-spine x-rays are ordered frequently. Researchers at a community teaching hospital in Australia assessed whether mandated use of the Canadian C-Spine Rule (a clinical decision rule intended to reduce unnecessary orders for x-rays) affected x-ray ordering rates and length of time patients wore hard cervical collars.
Assessed patients had to be alert, to present within 48 hours of the injury, to have complete medical records, and to have had a cervical collar applied. These inclusion criteria were met by 98 of 522 patients (19%) who presented during a 3-month period before implementation of the rule and by 113 of 132 patients (86%) who presented during a 3-month period after implementation. Patients in the "before" cohort were identified retrospectively, and those in the "after" cohort were identified prospectively.
The authors defined significant injury as fracture, dislocation, or ligamentous instability of the c-spine identified on x-ray or computed tomography scan. Three significant injuries were detected in the before cohort, and one was identified in the after cohort. Although clinicians followed the rule only 78% of the time, implementation of the rule reduced the rate of x-ray ordering from 67% to 50% (a relative reduction of 25%). The length of time that patients wore hard cervical collars was not reduced significantly.
Comment: Unfortunately, this small, uncontrolled study lacked outcomes assessment beyond ED discharge for patients who did not have x-rays. Therefore, we cannot determine whether unstable c-spine injuries were missed. The Canadian C-Spine Rule and NEXUS guidelines have been studied previously in larger populations, and this trial’s findings add little information that can be generalized to other settings.
— Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine May 11, 2005
Citation(s):
Kerr D et al. Implementation of the Canadian C-spine rule reduces cervical spine x-ray rate for alert patients with potential neck injury. J Emerg Med 2005 Feb; 28:127-31.
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