Cervical Fracture

Procedure

Only for alert (GCS 15), stable patients after blunt trauma. Step 1: is any high-risk factor present (age 65 or over, a dangerous mechanism, or tingling in the arms or legs)? If yes, image. Step 2: is any low-risk factor present that makes it safe to test movement (simple rear-end collision, sitting up when assessed, walking at any time since the injury, delayed onset of neck pain, or no midline neck tenderness)? If none, image. Step 3: if a low-risk factor is present, ask the patient to actively turn the head 45° to the left and to the right.

Positive Finding

Imaging is needed if any high-risk factor is present, if no low-risk factor is present, or if the patient cannot actively turn the head 45° to both sides.

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

Do not perform when a cervical fracture is suspected. Compression through the head can displace an unstable fracture and injure the spinal cord.

Positive Finding

Not applicable when fracture is suspected.

Sensitivity / Specificity

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

Interpretation

Spurling's and other compression tests are for nerve-root irritation in a stable neck. After trauma, use the NEXUS criteria or the Canadian C-Spine Rule, keep the neck immobilised, and refer for emergency imaging. Note: these figures derive from cervical radiculopathy populations (Wainner 2003); not validated specifically for cervical fracture.

Procedure

Only while the neck is kept still (manual in-line stabilisation), palpate gently along the posterior midline without moving the head. Do not move the neck to examine it.

Positive Finding

Midline bony tenderness, a step, or a gap between spinous processes.

Interpretation

Midline tenderness after trauma is one of the NEXUS criteria that mandate imaging. Any positive finding means: keep the neck immobilised and arrange emergency transfer.

Procedure

Do not flex the neck when a fracture is suspected. Instead, ask whether the patient has had electric-shock sensations down the spine or limbs since the injury.

Positive Finding

The patient reports electric-shock sensations since the injury.

Interpretation

Suggests spinal cord irritation. After trauma, this means: keep the neck immobilised and arrange emergency transfer for imaging.

Procedure

With the neck kept still, test strength, sensation and reflexes in all four limbs, and look for upper motor neuron signs (brisk reflexes, clonus, Babinski sign). Ask about numbness or tingling anywhere.

Positive Finding

Any weakness, sensory change, paraesthesia or upper motor neuron sign.

Interpretation

Any focal neurological deficit after neck trauma mandates imaging under NEXUS and the Canadian C-Spine Rule. Keep the neck immobilised and arrange emergency transfer.