Perhaps Stiell is implying that absence of c-spine tenderness helps to rule out injury, but that's not to say that presence of c-spine tenderness rules injury in (which was my original point). Anyway, it's such a nebulous "sign" that I'm sure it will continue to defy any attempts at scientific analysis, no matter how huge the studies or how impressive the statistics. Also, I get the impression you don't have to satisfy all the Step 2 criteria to avoid an x-ray, any one of the criteria will suffice.

Limitations:

• By the time you answer all of these questions the radiographs could be done and read.

That's nonsense Robert, you should be able to answer these questions within one to two minutes (much will have been gleaned at triage), and I've never got c-spine views in a stable patient in anywhere near these times.

Adrian Fogarty
----- Original Message -----
From: [log in to unmask] href="mailto:[log in to unmask]">Robert Spykerman
To: [log in to unmask] href="mailto:[log in to unmask]">[log in to unmask]
Sent: Tuesday, August 27, 2002 8:45 PM
Subject: Re: Clearance of c-spines

Hmmm... midline tenderness is part of step 2 of his decision instrument (Ottawa Neck rules? Heh, I like that!)... Step 2 being the step involved in deciding if it's safe to get the patient to rotate the head. Was Stiell describing exactly what I am copying out below in Edinburgh? RS

The Canadian C-Spine Rule

Patient selection: A trauma patient who

(1) is alert with Glasgow coma score = 15

(2) is clinically stable

(3) may have a cervical spine injury based on clinical assessment

Step 1: Determine if the patient has a high risk factor that mandates radiography with one or more of the following:

(1) age >= 65 years

(2) trauma involved a dangerous mechanism

(3) paresthesias are noted in the extremities

Dangerous mechanism includes:

(1) fall from >= 1 meter

(2) fall >= 5 stairs

(3) axial load to head (diving etc.)

(4) high speed motor vehicle accident (> 100 km/h or > 62 miles/h)

(5) motor vehicle accident with rollover or ejection

(6) motorcycle or recreational vehicle accident

(7) bicycle collision

Step 2: Determine if the patient has low risk factors that allow for safe assessment of the range of neck motion based on the following features:

(1) simple rear-end motor vehicle collision (MVC)

(2) sitting position in the ED

(3) ambulatory at any time

(4) delayed onset of neck pain

(5) absence of midline cervical spine tenderness

Simple rear-end motor vehicle accident is excluded if

(1) the person is pushed into oncoming traffic

(2) the person has been hit by a bus or large truck

(3) rollover occurred

(4) hit by a high-speed vehicle

Step 3: If the patient is determined by Step 2 to be low risk then can the patient actively rotate the neck 45 degrees to the left and right?

Radiographs are done if any of the following are present:

(1) step 1: One or more items indicate that radiography is mandatory.

(2) step 2: There is no evidence that the risk for neck rotation is low.

(3) step 3: The patient is unable to actively rotate the neck.

Else: No radiography is required.

Performance:

• In 8 924 patients in the study the sensitivity for detecting a clinical important injury was 100% and the specificity was 42.5%.

----- Original Message -----
From: [log in to unmask] href="mailto:[log in to unmask]">Steve Mccabe
To: [log in to unmask] href="mailto:[log in to unmask]">[log in to unmask]
Sent: Tuesday, August 27, 2002 1:20 AM
Subject: Re: Clearance of c-spines

Ian Stiell spoke about C-Sp clearance at Edinburgh and one of his messages was that midline tenderness was of no discriminant value.
 
Of more value was the ability to rotate 45degrees in both directions as being highly useful in ruleout where the other classically taught risk factors( GCS,mechanism,distracting injury,neurology-symptoms or signs ) are absent.
 
Next rules Neck rules from Ottawa
 
Steve McCabe