by Stacey Chamberlain
A 57-year-old man fell from a height of 12 feet while on a ladder. He did not pass out; he reports that he simply lost his footing. He fell onto a grassy area, hitting his head and complains of neck pain. He did not lose consciousness and denied headache, blurry vision, vomiting, weakness, numbness or tingling in any extremities. He denies other injuries. He was able to get up and ambulate after the fall and came in by private vehicle. He has not had previous spine surgery and does not have known vertebral disease. On exam, he is neurologically intact with a GCS of 15, does not appear intoxicated and has moderate midline cervical spine tenderness.
Should you get imaging to rule out a cervical spine fracture?
C-spine Imaging Rules
Canadian C-spine Rule
NEXUS Criteria for C-spine Imaging
- Age ≥ 65
- Extremity paresthesias
- Dangerous mechanism (fall from ≥ 3ft / 5 stairs, axial load injury, high-speed MVC/rollover/ejection, bicycle collision, motorized recreational vehicle)
- Focal neurologic deficit present
- Midline spinal tenderness present
- Altered level of consciousness present
- Intoxication present
- Distracting injury present
Both the Canadian C-spine Rule (CCR) and NEXUS Criteria are widely employed in clinical practice to reduce unnecessary cervical spine imaging in trauma patients with neck pain or obtunded trauma patients. The CCR uses mechanism and age criteria, whereas the NEXUS Criteria incorporates criteria including midline tenderness and additional factors that might limit a practitioner’s exam. The CCR can be difficult for some practitioners to remember all the criteria that qualify as a dangerous mechanism and is limited to ages > 16 and < 65. However, it can be used in intoxicated patients if the patients are alert and cooperative, allowing a full neurologic exam. The NEXUS Criteria are applicable over any age range (> 1 year old), but the sensitivity may be low in patients > 65 years of age. A single comparison study found the CCR to have better sensitivity (99.4% versus 90.7%); however, the study was performed by hospitals involved in the initial CCR validation study.
By applying either criteria to this case, the patient would require C-spine imaging as by CCR, the patient would meet criteria for dangerous mechanism, and by NEXUS, the patient has midline tenderness to palpation.