The out-of-hospital validation of the Canadian C-Spine Rule by paramedics

Ann Emerg Med. 2009 Nov;54(5):663-671.e1. doi: 10.1016/j.annemergmed.2009.03.008. Epub 2009 Apr 24.


Study objective: We designed the Canadian C-Spine Rule for the clinical clearance of the cervical spine, without need for diagnostic imaging, in alert and stable trauma patients. Emergency physicians previously validated the Canadian C-Spine Rule in 8,283 patients. This study prospectively evaluates the performance characteristics, reliability, and clinical sensibility of the Canadian C-Spine Rule when used by paramedics in the out-of-hospital setting.

Methods: We conducted this prospective cohort study in 7 Canadian regions and involved alert (Glasgow Coma Scale score 15) and stable adult trauma patients at risk for neck injury. Advanced and basic care paramedics interpreted the Canadian C-Spine Rule status for all patients, who then underwent immobilization and assessment in the emergency department to determine the outcome, clinically important cervical spine injury.

Results: The 1,949 patients enrolled had these characteristics: median age 39.0 years (interquartile range 26 to 52 years), female patients 50.8%, motor vehicle crash 62.5%, fall 19.9%, admitted to the hospital 10.8%, clinically important cervical spine injury 0.6%, unimportant injury 0.3%, and internal fixation 0.3%. The paramedics classified patients for 12 important injuries with sensitivity 100% (95% confidence interval [CI] 74% to 100%) and specificity 37.7% (95% CI 36% to 40%). The kappa value for paramedic interpretation of the Canadian C-Spine Rule (n=155) was 0.93 (95% CI 0.87 to 0.99). Paramedics conservatively misinterpreted the rule in 320 (16.4%) patients and were comfortable applying the rule in 1,594 (81.7%). Seven hundred thirty-one (37.7%) out-of-hospital immobilizations could have been avoided with the Canadian C-Spine Rule.

Conclusion: This study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing any important cervical spine injuries. The adoption of the Canadian C-Spine Rule by paramedics could significantly reduce the number of out-of-hospital cervical spine immobilizations.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't
  • Validation Study

MeSH terms

  • Adult
  • Canada
  • Cervical Vertebrae / injuries*
  • Clinical Competence
  • Cohort Studies
  • Confidence Intervals
  • Decision Support Techniques
  • Emergency Medical Services / methods
  • Emergency Medical Services / standards*
  • Emergency Medical Technicians / standards*
  • Female
  • Humans
  • Immobilization / methods
  • Male
  • Middle Aged
  • Neck Injuries / diagnosis
  • Neck Injuries / therapy
  • Outcome Assessment, Health Care
  • Practice Guidelines as Topic
  • Prospective Studies
  • Reproducibility of Results
  • Risk Assessment
  • Sensitivity and Specificity
  • Spinal Injuries / diagnosis*
  • Spinal Injuries / therapy*
  • Unnecessary Procedures / statistics & numerical data
  • Wounds, Nonpenetrating / diagnosis
  • Wounds, Nonpenetrating / therapy