Cervical Spine Clearance (CCR/NEXUS)

Algorithm Steps

1. ▶

   Start

   Trauma Patient - C-Spine Concern

   Blunt trauma with potential cervical spine injury

   1. ◆

      Decision

      Eligible for Clinical Clearance?

      Check prerequisites for decision rules

      • GCS = 15 (alert and oriented)
      • Hemodynamically stable
      • No distracting painful injury preventing assessment
      • Age ≥16 years
      • Blunt mechanism (not penetrating)
      1. ⚠

         Warning

         Cannot Clinically Clear

         Maintain immobilization, obtain imaging

         • Keep cervical collar in place
         • CT cervical spine (preferred)
         • Consider MRI if neurological deficits
         • Consult spine surgery if injury found
         1. ◆

            Decision

            Imaging Results

            CT cervical spine findings

            1. ⚠

               Warning

               Injury Identified

               Cervical spine injury present

               • Maintain immobilization
               • Spine surgery consultation
               • Classify injury (stable vs unstable)
               • MRI for ligamentous injury assessment
            2. ✓

               Outcome

               Imaging Negative → Cleared

               No bony injury on CT

               • Remove collar
               • Consider MRI if persistent pain/deficits
               • Flexion-extension views if needed
               • Follow-up for persistent symptoms
      2. ◆

         Decision

         CCR Step 1: High-Risk Factors?

         Any of the following present?

         • Age ≥65 years
         • Dangerous mechanism:
         • - Fall ≥1 meter or 5 stairs
         • - Axial load (diving)
         • - MVC high speed (>100 km/h), rollover, ejection
         • - Motorized recreational vehicle
         • - Bicycle collision
         • Paresthesias in extremities
         1. ⚠

            Warning

            High Risk → Imaging Required

            Cannot clear clinically

            • CT cervical spine (C1-T1)
            • Maintain cervical immobilization
            • If CT negative but high suspicion: MRI
         2. ◆

            Decision

            CCR Step 2: Low-Risk Factors?

            Any factor allowing safe ROM assessment?

            • Simple rear-end MVC
            • Sitting position in ED
            • Ambulatory at any time since injury
            • Delayed onset of neck pain
            • Absence of midline c-spine tenderness
            1. ⚠

               Warning

               No Low-Risk Factors → Image

               Cannot proceed to ROM assessment

            2. ◆

               Decision

               CCR Step 3: Active ROM

               Can patient rotate neck 45° L and R?

               • Remove collar with manual stabilization
               • Ask patient to actively rotate
               • 45 degrees left AND right
               • Do NOT force passive ROM
               1. ⚠

                  Warning

                  Unable to Rotate → Image

                  Limited ROM requires imaging

               2. ✓

                  Outcome

                  C-Spine Cleared (CCR)

                  No imaging needed, remove collar

                  • Remove cervical collar
                  • No radiographic imaging required
                  • Document CCR criteria met
                  • Provide discharge instructions