Clinical Decision Making Rule for Cervical Spine Radiography

WHEN TO SEND AN INJURED ATHLETE FOR A CERVICAL SPINE XRAY

Neck injuries, and the possibility of a spinal injury, in sport is a very serious issue. As sports physiotherapists we frequently assess neck injuries, and inappropriate diagnosis and subsequent management has the clear potential for catastrophic consequences. At times it can be difficult to differentiate the serious from the benign, and hence make appropriate decisions. However, it is fortunate that there is a sound evidence basis for when patients with traumatic neck injuries should be sent for further investigations.

Let me give you the clinical situation. An athlete comes to you complaining of neck pain following a sports-related trauma. It should be noted that this article is not about on-field evaluation or management of a suspected spinal injury – if given this case normal spinal precautions will obviously apply. Rather, this is an athlete who has walked off the field complaining of neck pain following a traumatic incident, such as in a tackle. In this instance you primarily want to answer one question:

Do I need to refer this athlete for an X-ray?

The Canadian C-Spine Rules (CCR) can quickly and effectively guide your decision making. This rule, in the same vein as the more familiar Ottowa Ankle Rules, has been shown to safely reduce inappropriate diagnostic imaging in cervical spine injuries (Stiell et al. 2009). Diagnostic accuracy studies have shown the Canadian C-Spine Rules to have a sensitivity of 99.4% and specificity of 45.1% (Stiell et al. 2003), which also clearly displays the very low occurrence of a false negative.

WHO IS THE CCR APPLICABLE TO?
For the rule to be applicable the athlete must satisfy these criteria (which fits the clinical scenario above)

• Adult (over 16)
• Alert (GCS = 15)
• Stable vital signs
• Traumatic Injury
• No – acute paralysis, vertebral disease, previous C-Spine surgery

Given the athlete satisfies these criteria you can apply the following decision-making framework.

1. ANY HIGH RISK FACTORS THAT MANDATE RADIOGRAPHY?

Over 65 years (less common in an athlete population)

Parasthesia in the extremities

Dangerous Mechanism: including

• fall from elevation ≥ 3 feet / 5 stairs
• axial load to head, e.g. when tackling
• MotorSport Relevant: MVC high speed (>100km/hr), rollover, ejection, motorized recreational vehicles.
• Cycling Relevant: bicycle struck or collision

If the answer is yes to any of these high risk factors – radiography is mandatory. If no, you continue your assessment to stage 2.

2. ANY LOW RISK FACTOR WHICH ALLOWS SAFE ASSESSMENT OF RANGE OF MOTION

• Simple rearend MVC
• Sitting position in ED (or in our clinical scenario – has walked up to you)
• Ambulatory at any time (as above)
• Delayed onset of neck pain
• Absence of midline c-spine tenderness (you must examine this)

Given that the athlete passes these criteria, you may safely assess range of motion.

3. RANGE OF MOTION ASSESSMENT
Is the athlete able to rotate their head left and right > 45 degrees? If so, then radiography is not required.

AND THAT’S IT?

At the end of this, it is pretty simple stuff. This framework indicates that many sports-related neck pain presentations do not require radiography. This can make answering the question “Do I need to go to hospital?” much easier, and better yet, evidence backed.

But your job is not over. Now you have assess, diagnoses and treat the athlete’s neck pain! Good luck.

It should be noted that the research for this rule had taken place in hospital emergency departments and the assessments/implementation of the rule was not by physiotherapists (or physical therapists). Therefore, validation has not specifically taken place in this setting. However, from my perspective (which is arguably more logical than scientific) if you travelled to the emergency department with the athlete and watched the Emergency Physician perform the assessment wouldn’t they come to the same conclusion?

What are your thoughts on the use of the Canadian C Spine Rules? Do you have any neck injury horror stories? Let me know in the comments below or on Twitter or Facebook.

REFERENCES
Stiell IG, Clement CM, McKnight RD, Brison R, et al. (2003). The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. N Engl J Med 349:2510-2518

Stiell IG, Clement CM, Grimshaw J, Brison RJ, Howe BH et al (2009) Implementation of the Canadian C-spine rule: prospective 12 centre cluster randomised trial. BMJ 339: b4146.

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