Cervical Fracture

Procedure

Assess alert, stable patient for age ≥65, mechanism of injury (fall >1 m or ejection from vehicle), paresthesia in extremities, and inability to rotate neck 45° bilaterally. If any factor present, imaging is indicated.

Positive Finding

Presence of one or more criteria: age ≥65, dangerous mechanism, paresthesia, or limited cervical rotation

Sensitivity / Specificity

Reference: Stiell IG, Wells GA, Vandemheen KL, et al. JAMA 2001;286(15):1841-8; PMID 11597285

Interpretation

The CCR applies only to alert (GCS 15) and stable blunt trauma patients. It is applied as three sequential questions. (1) Is any HIGH-RISK factor present that mandates radiography — age 65 or over, a dangerous mechanism (fall from height, axial load to the head, high-speed motor vehicle collision, ejection, motorised recreational vehicle, bicycle collision), or paraesthesia in the extremities? If yes, image. (2) Is any LOW-RISK factor present that permits safe assessment of range of motion — simple rear-end collision, sitting position on assessment, ambulatory at any time since injury, delayed onset of neck pain, or absence of midline cervical tenderness? If no, image. (3) Can the patient actively rotate the neck 45 degrees left AND right? If not, image. Reported sensitivity for clinically important cervical spine injury is approximately 100% with specificity around 43%. As with NEXUS, this is an emergency triage rule and the osteopathic role is recognition and immediate referral, not clearance.

Procedure

Apply the FIVE NEXUS low-risk criteria. Cervical spine imaging may be withheld only if ALL FIVE are satisfied: (1) no posterior midline cervical tenderness; (2) no focal neurological deficit; (3) normal level of alertness; (4) no evidence of intoxication; (5) no painful distracting injury. Maintain spinal immobilisation throughout the assessment.

Positive Finding

Any ONE criterion not satisfied = NEXUS positive = imaging required. All five satisfied = low probability of clinically significant cervical spine injury.

Sensitivity / Specificity

Reference: Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI, N Engl J Med 2000;343(2):94-9; PMID 10891516

Interpretation

NEXUS is a rule-OUT instrument validated prospectively in over 34,000 blunt trauma patients, with reported sensitivity of approximately 99.6% for clinically significant cervical spine injury. Only when ALL FIVE criteria are met is imaging considered unnecessary; a single criterion present mandates imaging. IMPORTANT: an intoxicated patient, or one with a painful distracting injury, cannot be cleared clinically even if they deny neck pain — those two factors mask symptoms, which is precisely why they are in the rule. (A previous version of this page listed only four criteria, omitting painful distracting injury, and described the rule as merely "reducing fracture likelihood".) Note the scope: NEXUS is an emergency-department triage instrument. In osteopathic practice the role is recognition, immobilisation and immediate emergency referral — not clinical clearance of a potentially fractured cervical spine.

Procedure

Patient seated; examiner applies gentle axial compression to the head in neutral and then extended positions, with and without ipsilateral lateral flexion. Note any radicular or neck pain reproduction.

Positive Finding

Reproduction of arm pain, paraesthesia, or sharp pain radiating into the arm on the side of compression

Sensitivity / Specificity

Reference: Wainner RS et al., Spine 2003; PMID 12544957

Interpretation

Primarily used for cervical radiculopathy rather than acute fracture; positive finding in trauma suggests nerve root irritation or compression secondary to fracture or disc herniation. Requires imaging confirmation. Note: these figures derive from cervical radiculopathy populations (Wainner 2003); not validated specifically for cervical fracture.

Procedure

Patient seated or supine; examiner palpates spinous processes of C3–C7 along the midline, feeling for discontinuity, bony prominence, or step-off suggesting vertebral body displacement or fracture.

Positive Finding

Palpable step-off, tenderness over a spinous process, or deviation in the normal contour of the cervical spine

Related reference: Stiell IG et al., NEJM 2003; PMID 14695411

Interpretation

Suggests possible cervical fracture or significant structural injury; warrants imaging (CT or MRI) to rule out fracture and instability.

Procedure

Patient seated or standing; examiner passively flexes the cervical spine by bringing chin toward chest. Patient reports any symptoms that occur.

Positive Finding

Sharp, electric shock-like sensation radiating down the spine or into the limbs during passive cervical flexion

Related reference: Khare S & Seth D, Ann Indian Acad Neurol 2015; PMID 26019410

Interpretation

Suggests cervical myelopathy or spinal cord irritation/compression; indicates need for urgent MRI and imaging to assess for fracture with cord involvement.

Procedure

Test CN IX–XII (gag reflex, tongue protrusion, shoulder shrug). Assess deep tendon reflexes (biceps, triceps, brachioradialis) and check for hyperreflexia, clonus, or Babinski sign indicating upper motor neuron involvement.

Positive Finding

Abnormal reflexes, hyperreflexia, clonus, positive Babinski sign, or cranial nerve deficits; weakness in C5–T1 distribution

Related reference: ASIA International Standards 2019

Interpretation

Indicates possible cervical cord compression or myelopathic involvement; fracture with neurovascular compromise is a medical emergency requiring immediate imaging and immobilization.