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Previous Volume 349:2510-2518 December 25, 2003 Number 26 Next

	Full Text PDF PDA Full Text PowerPoint Slide Set Editorial by Yealy, D. M. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear PubMed Citation

ABSTRACT

Background The Canadian C-Spine (cervical-spine) Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC) are decision rules to guide the use of cervical-spine radiography in patients with trauma. It is unclear how the two decision rules compare in terms of clinical performance.

Methods We conducted a prospective cohort study in nine Canadian emergency departments comparing the CCR and NLC as applied to alert patients with trauma who were in stable condition. The CCR and NLC were interpreted by 394 physicians for patients before radiography.

Results Among the 8283 patients, 169 (2.0 percent) had clinically important cervical-spine injuries. In 845 (10.2 percent) of the patients, physicians did not evaluate range of motion as required by the CCR algorithm. In analyses that excluded these indeterminate cases, the CCR was more sensitive than the NLC (99.4 percent vs. 90.7 percent, P<0.001) and more specific (45.1 percent vs. 36.8 percent, P<0.001) for injury, and its use would have resulted in lower radiography rates (55.9 percent vs. 66.6 percent, P<0.001). In secondary analyses that included all patients, the sensitivity and specificity of CCR, assuming that the indeterminate cases were all positive, were 99.4 percent and 40.4 percent, respectively (P<0.001 for both comparisons with the NLC). Assuming that the CCR was negative for all indeterminate cases, these rates were 95.3 percent (P=0.09 for the comparison with the NLC) and 50.7 percent (P=0.001). The CCR would have missed 1 patient and the NLC would have missed 16 patients with important injuries.

Conclusions For alert patients with trauma who are in stable condition, the CCR is superior to the NLC with respect to sensitivity and specificity for cervical-spine injury, and its use would result in reduced rates of radiography.

Source Information

From the Departments of Emergency Medicine (I.G.S., J.R.W., G.G., M.R.) and Epidemiology and Community Medicine (G.A.W.), the Clinical Epidemiology Program (C.M.C.), and the Division of Neurosurgery (H.L.), University of Ottawa, Ottawa, Ont.; the Division of Emergency Medicine, University of British Columbia, Vancouver (R.D.M., I.M.); the Department of Emergency Medicine, Queens University, Kingston, Ont. (R.B.); the Division of Emergency Medicine, University of Toronto, Toronto (M.J.S., D.C., J.S.L., G.B.); the Division of Emergency Medicine, University of Alberta, Edmonton (B.H.R., B.H.); and the Division of Emergency Medicine, University of Western Ontario, London (M.A.E., J.D.) — all in Canada.

Address reprint requests to Dr. Stiell at the Clinical Epidemiology Unit, F657, Ottawa Health Research Institute, 1053 Carling Ave., Ottawa, ON K1Y 4E9, Canada.

Full Text of this Article

Related Letters:

The Canadian C-Spine Rule
Mower W. R., Wolfson A. B., Hoffman J. R., Todd K. H., Hall F. M., Stiell I. G., Rowe B. H., Lee J.
Extract | Full Text | PDF  
N Engl J Med 2004; 350:1467-1469, Apr 1, 2004. Correspondence

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