Cervical Spine Rules

Author: Michelle Lin, MD
Updated: 12/10/2010

Cervical Spine Rules

The National Emergency X-radiography Utilization Study (NEXUS) and Canadian C-spine Rules (CCR) are both validated studies which both quote a high sensitivity (over 99%) in detecting clinically significant cervical spine fractures. Both studies primarily used plain films in evaluating their patients.

Study Sensitivity Specificity
NEXUS 99.6% 12.6%
Canadian C-spine Rules 99.4% 45.1%

NEXUS study

A patient's neck can be clinically cleared safely without radiographic imaging if all five low-risk conditions are met:

  1. No posterior midline neck pain or tenderness
  2. No focal neurologic deficit
  3. Normal level of alertness
  4. No evidence of intoxication
  5. No clinically apparent, painful distracting injury

Canadian C-spine Rules (CCR)

The basic approach in the flowchart:

  1. Make sure that the patient meets the eligibility requirements as in the CCR study.
  2. Determine if there are high-risk findings. If so, go directly to imaging.
  3. If there are no high-risk findings, check to see if the patient qualifies as a low-risk candidate where you might be able to clinically clear the c-spine without imaging.
  4. If the patient is neither high or low risk, then the patient is moderate risk and requires imaging.

Canadian C-spine Rule flowchart


  • Stiell IG et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17;286(15):1841-8. [Source]
  • Hoffman JR, et al.Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. NEJM 2000; 343: 94-9; [PubMed]
  • Stiell IG et al. The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. N Engl J Med 2003;349:2510-8 [Source]