EM · Cervical spine injury & clearance
Cervical spine injury and clearance in trauma
Also known as C-spine injury · Cervical spine clearance · Spinal cord injury · NEXUS criteria
Cervical spine injury and clearance — the NEXUS and the Canadian C-spine clinical decision rules for the safe clearance of the C-spine without the imaging, the CT as the standard imaging (replacing the plain radiographs), the spinal-cord-injury syndromes (the complete, the central cord, the anterior cord, the Brown-Séquard), the SCIWORA, the immobilisation (the collar, the head blocks, the manual in-line stabilisation), the methylprednisolone controversy (a guideline option only within 8 hours, never a standard), and the neurosurgical referral. ACEM-primary, globally tagged.
Practise this topic
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- A patient with a cervical-spine injury and a neurological deficit has a spinal cord injury until proven otherwise — the MRI and the neurosurgery are the urgent steps
- The C-spine is immobilised from the first contact (the collar, the head blocks, the manual in-line) until it is clinically or radiologically cleared — never remove the collar without the clearance
- A normal CT does NOT exclude a purely ligamentous injury — the MRI is the definitive test for the ligamentous and the cord injury
- The central cord syndrome (the upper-limb weakness greater than the lower-limb, after a hyperextension in the elderly) is the commonest incomplete cord syndrome and may present with a normal CT
- The SCIWORA (the spinal cord injury without a radiographic abnormality) is a paediatric entity — the cord is injured but the CT is normal; the MRI is the diagnostic test
Meet the patient
A 42-year-old man arrives 30 minutes after a high-speed rollover crash at 110 km per hour. He was the restrained driver, extracted by paramedics in a rigid collar with head blocks. His GCS is 15, he is not intoxicated, and he complains of midline cervical tenderness at C5 and paraesthesia in both hands. The collar stays on until the clearance is confirmed.[1]
Two questions decide his next 30 minutes: can I clear this clinically, or does he need a CT? and if the CT is normal but the paraesthesia persists, what is the next test? The dangerous mechanism (a rollover at 110 km per hour) is a high-risk factor under the Canadian C-spine rule — he needs the CT. And if the CT is normal but the deficit persists, the MRI is the definitive test, because a normal CT does not exclude a purely ligamentous or a cord injury.[2]
References13ShowHide
- [1]Anderson GA, Kashikar A, Inaba K Cervical spine clearance in adult trauma patients: What you need to know. J Trauma Acute Care Surg, 2026.PMID 42224714
- [2]de Oliveira Manduca Palmiero H, Gadelha Figueiredo E Cervical Spine Clearance in Adult and Pediatric Trauma: A Systematic Review J Emerg Med, 2026.PMID 41955954
- [3]Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma N Engl J Med, 2000.PMID 10891516
- [4]Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients JAMA, 2001.PMID 11597285
- [5]Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma N Engl J Med, 2003.PMID 14695411
- [6]Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Lancet, 2009.PMID 19758692
- [7]Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study of cervical spine injury in children Pediatrics, 2001.PMID 11483830
- [8]Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) PLoS One, 2012.PMID 22384132
- [9]Núñez-Patiño RA, Rubiano AM, Godoy DA Impact of Cervical Collars on Intracranial Pressure Values in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prospective Studies Neurocrit Care, 2020.PMID 31190321
- [10]Bracken MB, Shepard MJ, Collins WF, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study N Engl J Med, 1990.PMID 2278545
- [11]Fehlings MG, Wilson JR, Tetreault LA, et al. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Use of Methylprednisolone Sodium Succinate Global Spine J, 2017.PMID 29164025
- [12]Karsy M, Hawryluk G Modern Medical Management of Spinal Cord Injury Curr Neurol Neurosci Rep, 2019.PMID 31363857
- [13]Gee CM, Tsang A, Bélanger LM, et al. All over the MAP: describing pressure variability in acute spinal cord injury Spinal Cord, 2022.PMID 35418625