Prevalence of midline cervical spine tenderness in the non-trauma population

Emerg Med J. 2022 Apr;39(4):308-312. doi: 10.1136/emermed-2021-211288. Epub 2021 Sep 21.


Objective: The Canadian C-Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) criteria are two commonly used clinical decision rules which use midline cervical spine (c-spine) tenderness on palpation as an indication for c-spine imaging post-trauma. This study was undertaken to determine the prevalence and location of midline c-spine tenderness in the non-trauma population.

Methods: We prospectively evaluated consenting adult patients presenting to an urban ED or university sport medicine clinic in Montreal, Canada between 2018 and 2020 for atraumatic non-head and neck-related reports over a 20-month period. The presence and location of pain during midline c-spine palpation as assessed by two examiners during separate evaluations was recorded. Patient information such as age, neck length and circumference, gender, body mass index (BMI) and scaphoid tenderness was also collected.

Results: Of 478 patients enrolled, 286 (59.8%) had midline c-spine tenderness on palpation with both examiners. The majority of those with tenderness were female (70.6%). When examining all patients, tenderness was present in the upper third of the c-spine in 128 (26.8%) patients, middle third in 270 (56.5%) patients and lower third in 6 (1.3%) patients. Factors associated with having increased odds of midline c-spine tenderness on palpation included a lower BMI and the presence of scaphoid tenderness on palpation.

Conclusions: There is a high prevalence of c-spine tenderness on palpation in patients who have not undergone head or neck trauma. This finding may help explain the low specificity in some of the validation studies examining the CCR and the NEXUS criteria.

Keywords: clinical assessment; imaging; musculoskeletal; trauma.

MeSH terms

  • Adult
  • Canada / epidemiology
  • Cervical Vertebrae / injuries
  • Decision Support Techniques
  • Female
  • Humans
  • Male
  • Pain
  • Prevalence
  • Spinal Injuries* / epidemiology
  • Wounds, Nonpenetrating* / epidemiology