Who Needs A CT Scan for Spine Trauma From ENLS

The following decision rules on who needs CT of the spine for trauma is from the Emergency Neurological Life Support: Traumatic Spine Injury module 5-23-2013

8 Decision Rules

CT of the spine should be performed if any of the following are present:

Significant associated injuries:

  • Multiple trauma patient needs CT of head, chest, or abdomen/pelvis
  • Intubated
  • Depressed level of consciousness
  • Neurological deficit referable to the spine, or complaints of bilateral parathesias
  • Strong clinical suspicion of any spinal fracture
  • Multiple fractures
  • Pelvis fracture
  • Significant head or facial trauma

CT of the spine should be considered for significant mechanism of injury:

  • Motor vehicle collision with speed exceeding 35 mph
  • Ejection from vehicle
  • Pedestrian, bicyclist, or motorcyclist struck and thrown
  • Axial load injury (vehicle roll-over or diving injury)
  • Fall in excess of 10 ft.
  • Death at accident scene

Patient Factors

  • Age > 65 yr.
  • DJD, ankylosing spondylitis, rheumatoid arthritis
  • Depressed level of consciousness
  • Known cervical spine injury

If the mechanism is worrisome (clear history of neck injury or circumstances that have a reasonable likelihood of causing spinal trauma) one can consider using two validated clinical scales.  These are the NEXUS Rules and the Canadian C-spine Rules.  Each of these systems allows you to either move toward clinical clearance of the C-spine or escalate evaluation to spine imaging.

Canadian C-Spine Rules

These rules help one decide if spine imaging is indicated. First, consider any high-risk features; if none, examine any low risk features.  If after considering all of the features, and none apply, the patient can be cleared clinically and the cervical spine immobilization can be discontinued.

Canadian High-risk Features

Are there any high-risk factor that mandates radiography?

  • Age > 65 yrs. or dangerous mechanism (fall from elevation over 3 ft. or 5 stairs)?
  • An axial load to the head (e.g. diving)?
  • A motor vehicle collision exceeding 100 km/hr. or with roll-over or ejection, or a collision involving a motorized recreational vehicle, or a bicycle collision?

 IF YES to ANY of the above, consider CT criteria for imaging next.

 If NO to ALL of the above, move on to Canadian Low Risk features below.

 Canadian Low-risk Features

Do any of the following low risk features exist?

  • Simple rear-end motor vehicle collision
  • Sitting position in the emergency department
  • Ambulatory at any time
  • Delayed (not immediate) onset of neck pain
  • Absence of midline cervical-spine tenderness

If YES to ANY of the above, then proceed to testing of neck rotation.

If NO to ALL of the above, then consider CT criteria for clearance.

NEXUS Rules: 5 questions

 NEXUS Rules: These “rules” apply 5 criteria that used alone can help you clinically clear the cervical spine.  These include the presence of spinal tenderness and presence of focal neurological deficit among other things.  Use of the NEXUS rules is a reasonable protocol to clear the cervical spine; although we encourage you to look at the Canadian Rules as well.

 The NEXUS rules are:

  • No posterior midline cervical-spine tenderness.
  • No evidence of intoxication.
  • A normal level of alertness.
  • No focal neurological deficit.
  • No painful distracting injuries.

 If all of the above are true then you can clinically clear the cervical spine and remove the immobilization device. If any one or more is true, move on to the next step regarding spine imaging.

Review of the ENLS Traumatic Spine Injury Protocol


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