Cervical Spine Fracture Evaluation Guidelines

Updated: Aug 18, 2017
  • Author: Moira Davenport, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Guidelines Summary

The Canadian C-Spine Rules (CCR) and the National Emergency X-Radiography Utilization Group (NEXUS) criteria allow clinicians to "clear" low-risk patients of c-spine injury, obviating the need for radiography. Additionally, a model was developed specifically for injured children. [1, 33]

To be clinically cleared using the CCR, a patient must be alert (GCS 15), not intoxicated, and not have a distracting injury (eg, long bone fracture, large laceration). The patient can be clinically cleared providing the following:

  • The patient is not high risk (age >65 y or dangerous mechanism or paresthesias in extremities).

  • A low risk factor that allows safe assessment of range of motion exists. This includes simple rear end motor vehicle collision, seated position in the ED, ambulation at any time posttrauma, delayed onset of neck pain, and the absence of midline cervical spine tenderness.

  • The patient is able to actively rotate their neck 45 degrees left and right.

The NEXUS criteria state that a patient with suspected c-spine injury can be cleared providing the following:

  • No posterior midline cervical spine tenderness is present.

  • No evidence of intoxication is present.

  • The patient has a normal level of alertness.

  • No focal neurologic deficit is present.

  • The patient does not have a painful distracting injury.

Both studies have been prospectively validated as being sufficiently sensitive to rule out clinically significant c-spine pathology. The CCR were shown to be more sensitive than the NEXUS criteria (99.4% sensitive vs 90.7%), and the rates of radiography were lower with the CCR (55.9% vs 66.6%). [34] Debate still exists as to which criteria are more useful and easier to apply.

The American College of Orthopaedic Surgeons now recommends routine cervical spine screening via CT scan instead of plain radiography. Low-dose multidetector CT scanning has been found to be as sensitive and specific as standard dose multidetector CT scans. [37, 38]


The American Spinal Injury Association, defines spinal cord injury as follows [44, 16] :

A = Complete. No sensory or motor function is preserved in the sacral segments S4-5.

B = Sensory Incomplete. Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5 (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body.

C = Motor Incomplete. Motor function is preserved at the most caudal sacral segments for voluntary anal contraction (VAC) OR the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudal sacral segments (S4-S5) by LT, PP or DAP), and has some sparing of motor function more than three levels below the ipsilateral motor level on either side of the body.

(This includes key or non-key muscle functions to determine motor incomplete status.) For AIS C – less than half of key muscle functions below the single neurological level of injury (NLI) have a muscle grade ≥3.

D = Motor Incomplete. Motor incomplete status as defined above, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade ≥3.

E = Normal. If sensation and motor function as tested with the INTERNATIONAL STANDARDS FOR NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURY (ISNCSCI) are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade.