Clearing the Cervical Spine

C-spines must be cleared radiographically and clinically.  Therefore patient with possible C-spine injury should be left in precautions until they are awake and alert for a clinical assessment.

Canadian C-spine Rule

Patient must be alert and stable – but complain of neck pain.  The rule was designed to identify patients who are unlikely to suffer significant C-spine fractures.  Those who fit the rule will receive C-spine X rays.

High risk factors (if yes X ray):

  • ≥65 years old
  • Dangerous mechanism
    • Fall from ≥ 3 feet or 5 stairs
    • High speed (roll over, ejection, ≥ 100kph)
    • Motorized recreational vehicle (ATV, snowmobile)
    • Bicycle collision
    • Axial load (diving)
  • Paresthesias in extremities

Low risk factors that allow safe assessment of ROM (if no X ray):

  • Simple rear-end motor vehicle collision
    • Excludes pushed into oncoming traffic, rollover, hit by large vehicle, hit by high speed vehicle
    • Sitting position in ED
    • Ambulatory at any time
    • Delayed onset of neck pain
    • Absence of midline C-spine tenderness

If deemed safe to assess ROM, and unable to rotate neck 450 to each side must X ray.



  • X ray views
    • Lateral (from occiput to T1) – may need a swimmers view to assess down to T1
      • Mandatory in all trauma
    • AP (not super useful)
    • Odontoid view (open mouth)
  • Assessment of the lateral view
    • Alignment
    • Ant vertebral body line
    • Post vertebral body line
      • Spinolaminar line
      • Spinous processe
  • Bone contour
  • Cartilage: check intervetebral disc space margins (should be parallel)
  • Soft tissue
    • <6mm @ C2; <22mm @ C6 <7mm @ C3; <21mm @ C7

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