Canadian C-Spine Rule

Q: What are the three questions of the Canadian C-Spine Rule?

1) Any high-risk factor mandating imaging? 2) Any low-risk factor allowing safe range-of-motion assessment? 3) Can the patient actively rotate the neck 45° left and right?

Q: Canadian C-Spine Rule or NEXUS?

In alert, stable adults the Canadian rule is more specific; NEXUS is simpler and was validated in a broader population.

Q: Is X-ray or CT used after a positive rule?

The rule was derived for radiography; most current adult pathways, including NICE, use CT.

Need for cervical-spine imaging in alert, stable adults after blunt trauma

Sources last checked: 2026-10-13

Canadian C-Spine Rule

Need for cervical-spine imaging in alert, stable adults after blunt trauma

Does the rule apply?

High risk: age ≥ 65 yearsHigh risk: dangerous mechanism (fall from ≥ 3 ft / 1 m or 5 stairs, axial load e.g. diving, high-speed or rollover collision, ejection, motorised recreational vehicle, bicycle collision)High risk: paraesthesias in the extremitiesLow risk: simple rear-end motor vehicle collisionLow risk: sitting position in the emergency departmentLow risk: ambulatory at any time since the injuryLow risk: delayed onset of neck painLow risk: no midline cervical-spine tendernessAble to actively rotate the neck 45° to the left and right

Fill in every field to see the result.

Derived for radiography decisions; today CT is the usual first-line imaging in adults. For excluded groups (children, GCS < 15, unstable patients, known spinal disease such as ankylosing spondylitis) the rule makes no statement.

Source: Stiell IG, Wells GA, Vandemheen KL et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286(15):1841-1848.Open

Interpretation

Rule not applicable	The patient is outside the population the rule was derived in, so the rule makes no statement about imaging for this patient.
No imaging required by the rule	No high-risk factor, a low-risk factor allows safe assessment, and active rotation 45° both ways is possible.
Imaging indicated by the rule — range of motion cannot be assessed safely	No low-risk factor is present; in this situation the rule does not permit a neck-rotation test before imaging.
Imaging indicated by the rule — unable to rotate the neck	Active rotation of 45° to the left and right is not possible.
Imaging indicated by the rule — high-risk factor	Under the rule, age ≥ 65, a dangerous mechanism or paraesthesias indicate imaging, and range of motion is not tested.

What is the Canadian C-Spine Rule?

The Canadian C-Spine Rule decides which alert, stable adults after blunt trauma need cervical-spine imaging. Stiell and colleagues derived it in 2001 from 8,924 patients in ten Canadian emergency departments. It works in three steps — high-risk factors, low-risk factors that allow a range-of-motion test, and active neck rotation.

When to use it

Adults (≥ 16 years) with blunt head or neck trauma, GCS 15 and stable vital signs.
Clinical clearance of the cervical spine in the emergency department or minor-injury unit.
Reducing imaging in low-risk mechanisms such as simple rear-end collisions.

When not to use it

GCS < 15, unstable vital signs, penetrating trauma or acute paralysis.
Known vertebral disease (e.g. ankylosing spondylitis) or previous cervical surgery.
Children under 16.

How it is calculated

Applies to: age ≥ 16, alert (GCS 15), stable, blunt trauma to head/neck. 1. Any high-risk factor (age ≥ 65, dangerous mechanism, paraesthesias)? → imaging. 2. Any low-risk factor allowing safe range-of-motion assessment (simple rear-end collision, sitting in ED, ambulatory at any time, delayed onset of neck pain, no midline tenderness)? If none → imaging. 3. Able to actively rotate neck 45° left and right? No → imaging; yes → no imaging.

Clinical pearls and limitations

Derived for radiography decisions; today CT is the usual first-line imaging in adults. For excluded groups (children, GCS < 15, unstable patients, known spinal disease such as ankylosing spondylitis) the rule makes no statement.
The rule does not allow a rotation test when a high-risk factor is present or no low-risk factor exists.
Sensitivity was 100 % for clinically important injury in derivation, with 42.5 % specificity — better than NEXUS.
NICE NG232 uses the same low-risk features for deciding whether neck movement can be assessed safely.
In older adults, falls from standing height can cause significant injury — in this rule, age ≥ 65 alone indicates imaging.

Frequently asked questions

What are the three questions of the Canadian C-Spine Rule?

1) Any high-risk factor mandating imaging? 2) Any low-risk factor allowing safe range-of-motion assessment? 3) Can the patient actively rotate the neck 45° left and right?

Canadian C-Spine Rule or NEXUS?

In alert, stable adults the Canadian rule is more specific; NEXUS is simpler and was validated in a broader population.

Is X-ray or CT used after a positive rule?

The rule was derived for radiography; most current adult pathways, including NICE, use CT.

Evidence and guidelines

Have a follow-up question?

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