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Source: JAMA -


Rule could aid in reducing use of imaging tests in alert and stable patients

CHICAGO - A newly developed clinical decision rule might help physicians be more selective in ordering neck X-rays for trauma patients who are alert and stable and at low risk for neck injuries, according to an article in the October 17 issue of The Journal of the American Medical Association (JAMA).

Ian G. Stiell, M.D., of the Division of Emergency Medicine at the University of Ottowa, Ontario, Canada, and colleagues developed the Canadian C-Spine Rule to establish a decision rule about when to order C-spine (cervical spine [the neck]) radiographs [X-rays]) for patients who come to emergency departments following trauma. The authors found that applying three clinical criteria to these patients can determine whether or not C-spine radiography is necessary and could help reduce routine ordering of neck x-rays for all trauma patients.

The authors studied 8,924 adult patients from October 1996 to April 1999 admitted to the emergency department (ED) of 10 Canadian community and university hospitals, after they sustained acute blunt trauma to the head or neck. All patients included in the study were alert and stable (had normal vital signs) when presenting to the ED.

The Canadian C-spine rule consists of three major questions:

-- Are there any high-risk factors that mandate radiography? (Including 65 years of age or older; the patient presented to the ED with abnormal sensations in their extremities; the mechanism of injury was dangerous, such as a motor vehicle collision that included a rollover, ejection or was high speed; or the patient was on a motorized recreational vehicle or a bicycle.)

-- Are there any low-risk factors that would allow safe assessment of a range of motion? (Being involved in simple rear-end collisions, patient able to sit up in emergency department, patient ambulatory at any time since injury, delayed onset of neck pain and absence of midline neck tenderness.)

-- Is the patient able to rotate their neck 45 degrees to the left or to the right?

Patients who meet all three criteria are at low risk of cervical spine injury and probably do not need radiography, according to the authors. None of the patients who met these criteria in the study had clinically significant C-spine injury at followup.

All patients were asked about their injury and examined by emergency physicians, who ordered radiographs if determined necessary. Patients who were considered at high risk were sent for C-spine radiography. Patients who were considered low risk were sent for radiography if the physician deemed it necessary. Patients not sent for radiographs were classified as having no clinically important C-spine injury 14 days after the injury if they met all of the following criteria at a telephone followup interview:

-- They had no or mild neck pain

-- Restriction of neck movement was rated as none or mild

-- The use of a cervical collar (neck brace) was not needed

-- Their neck injury did not prevent their return to normal activities

According the background information in the article, over 1 million people are treated in U.S. emergency rooms for neck injuries annually. The incidence of acute spinal fracture or injury in patients who present to the emergency department with intact neurological status is less than 1 percent. Most physicians, however, use C-spine radiography liberally, with more than 98 percent of C-spine radiographs negative for fracture.

"There are two potential implications of a decision rule or guideline for the use of C-spine radiography in alert and stable trauma patients," the authors state. "First, patient management would become standardized and more efficient. [Applying the rule] would allow much more rapid triage and evaluation of patients brought to the ED by ambulance stretcher. Such patients often languish for hours on an uncomfortable backboard before their C-spine is judged free of injury."

"Second, an accurate decision rule could lead to significant savings for our health care systems," the authors add. "The current variation in practice and very low yield of C-spine radiography among alert and stable trauma patients would suggest significant potential for reducing the use of this radiography. ... If prospectively validated in other cohorts, this rule has the potential to standardize and improve efficiency in the use of C-spine radiography in EDs."

(JAMA. 2001; 286:1841-1848; available post-embargo at

Editors Note: This study was funded by peer-reviewed grants from the Medical Research Council of Canada and the Ontario Ministry of Health Emergency Health Services Committee. Drs. Stiell and Laupacis hold Investigator Awards from the Canadian Institutes of Health Research.

Media Advisory: To contact Ian G. Stiell, M.D., call Ron Vezina at 613/737-8460.

To contact Richard H. Daffner, M.D., call Dan Laurent at 412/359-8602.

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