Improving care for people with neck injuries: Ottawa hospital-led study paves the way for worldwide adoption of Canadian C-Spine Rule

November 18, 2009

A 12-hospital clinical trial has shown that active promotion of the Canadian C-Spine Rule in emergency departments can significantly reduce the use of unnecessary neck x-rays without compromising the detection of serious neck injuries. The study is published in the British Medical Journal by a team of Canadian researchers led by Dr. Ian Stiell of the Ottawa Hospital Research Institute (OHRI) and the University of Ottawa. The results show that six hospitals that promoted the C-Spine Rule saw their use of neck x-rays decrease by 12.8 per cent over a year, while six control hospitals that did not promote the Rule saw their use of neck x-rays increase by 12.5 per cent over the same time period. No serious neck injuries were missed in either group.

“The Canadian C-Spine Rule helps emergency physicians provide better and more efficient care for people who have had traumatic injuries,” said Dr. Stiell, a Senior Scientist at OHRI, Chair of Emergency Medicine at the University of Ottawa and Physician in The Ottawa Hospital Emergency Department. “It allows physicians to identify patients who have zero risk of neck injury, so that their other injuries can be treated promptly without them having to wait hours on an emergency department stretcher for a neck x-ray. This also frees up space and resources for other patients who need emergency care.”

More than 13 million people are treated for possible traumatic neck injuries each year in Canada and the United States. Physicians typically order neck x-rays for the majority of these patients, even though serious fractures are only detected in two per cent of cases. This inefficiency prompted Dr. Stiell and his team to begin developing the Canadian C-Spine Rule nearly 15 years ago. The Rule is based on three questions that a physician can answer by simply examining the patient and asking about his or her injuries. Several previous studies have shown that the Rule can safely and effectively reduce the use of neck X-rays, but the current study is by far the largest and most informative, with a total of 11,824 patients included. It was funded by the Canadian Institutes of Health Research.

“Most clinical decision rules are unfortunately never used, because there is a lack of evidence showing that they actually work in a practical setting,” said Dr. Jeremy Grimshaw, a co-author of the study and a world leader in knowledge translation research at OHRI and the University of Ottawa. “This study goes the extra distance, showing that a simple and affordable promotion campaign has tangible results in a real-world hospital setting. I expect that hospitals around the world will pay attention to these results and we will see a greater use of the Canadian C-Spine Rule.”

The promotion campaign included distribution of previous research studies, along with pocket cards and posters depicting the Rule. A one hour educational session was also provided, and every time a neck x-ray was ordered, the physician was required to check off the answers to the Rule questions. Participating hospitals included The Ottawa Hospital, Vancouver General Hospital, London Health Sciences Centre, Sturgeon Community Hospital, North York General Hospital, Surrey Memorial Hospital, University of Alberta Hospital, Sunnybrook Health Sciences Centre, Kingston General Hospital, Royal Columbian Hospital, Credit Valley Hospital and St. Thomas Elgin Hospital. The hospitals were assigned to either the promotion campaign or the control group using cluster randomization methods.

In an editorial in the same edition of the British Medical Journal, Dr. Vido Podichetty of the Cleveland Clinic Florida calls the study “well designed and carefully conducted” and concludes that the Canadian C-Spine Rule provides a “reliable and safe way of identifying cervical spine injuries”.

Researchers at OHRI and the University of Ottawa are considered world leaders in the development of clinical decision rules, with other examples including the Ottawa Ankle Rules, the Ottawa Knee Rules, the Canadian CT Head Rules and the Wells Rules for Diagnosing Deep Vein Thrombosis and Pulmonary Embolism. Studies have shown that nearly 90 per cent of Canadian physicians use The Ottawa Ankle Rules and they have been mentioned on TV shows such as ER. OHRI clinical decision rules are available for free at The British Medical Journal publication is available at

About the Ottawa Hospital Research Institute
The Ottawa Hospital Research Institute (OHRI) is the research arm of The Ottawa Hospital and is an affiliated institute of the University of Ottawa, closely associated with the University’s Faculties of Medicine and Health Sciences. The OHRI includes more than 1,500 scientists, clinical investigators, graduate students, postdoctoral fellows and staff conducting research to improve the understanding, prevention, diagnosis and treatment of human disease.

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