Canadian C-Spine Rule

Cervical spine imaging decision after blunt trauma

For alert (GCS 15), stable adults after acute blunt trauma. Not for age < 16, non-trauma neck pain, known vertebral disease, or a return visit for the same injury.

Step 1 — high-risk factor (any → imaging)

Age ≥ 65 years

Dangerous mechanism (fall ≥ 1 m / 5 stairs, axial load, high-speed MVC, rollover, ejection, motorised recreational vehicle, bicycle collision)

Paraesthesias in the extremities

Step 2 — low-risk factor allowing safe rotation testing

Simple rear-end motor-vehicle collision

Sitting position in the emergency department

Ambulatory at any time

Delayed onset of neck pain

Absence of midline cervical-spine tenderness

Step 3 — rotation

Able to actively rotate the neck 45° left and right

Evidence

Original publication

Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-Spine Rule for radiography in alert and stable trauma patients. A three-step rule (high-risk factors, low-risk factors permitting range-of-motion testing, active 45° rotation) that was 100% sensitive for clinically important cervical spine injury and would have cut imaging substantially.

JAMA, 2001

Open source

Validation

Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine Rule versus the NEXUS low-risk criteria in patients with trauma. In a head-to-head comparison the Canadian C-Spine Rule was more sensitive (99.4% vs 90.7%) and more specific for important injury.

New England Journal of Medicine, 2003

Open source

Last reviewed: 2026-09

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