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Trauma SurgeryDiagnostic

Cervical Spine Clearance (CCR/NEXUS)

Cervical Spine Clearance (CCR/NEXUS): Trauma Patient - C-Spine Concern → Eligible for Clinical Clearance? → Cannot Clinically Clear → Imaging Results → ...

Pathway Overview

13 steps

Algorithm Steps

13 total

  1. 01Start

    Trauma Patient - C-Spine Concern

    Blunt trauma with potential cervical spine injury

  2. 02Decision

    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)
  3. 03Warning

    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
  4. 04Decision

    Imaging Results

    CT cervical spine findings

  5. 05Warning

    Injury Identified

    Cervical spine injury present

    • Maintain immobilization
    • Spine surgery consultation
    • Classify injury (stable vs unstable)
    • MRI for ligamentous injury assessment
  6. 06Outcome

    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
  7. 07Decision

    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
  8. 08Warning

    High Risk → Imaging Required

    Cannot clear clinically

    • CT cervical spine (C1-T1)
    • Maintain cervical immobilization
    • If CT negative but high suspicion: MRI
  9. Path rejoins step 04Shared downstream outcome
  10. 09Decision

    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
  11. 10Warning

    No Low-Risk Factors → Image

    Cannot proceed to ROM assessment

  12. Path rejoins step 04Shared downstream outcome
  13. 11Decision

    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
  14. 12Warning

    Unable to Rotate → Image

    Limited ROM requires imaging

  15. Path rejoins step 04Shared downstream outcome
  16. 13Outcome

    C-Spine Cleared (CCR)

    No imaging needed, remove collar

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

Guideline Source

Canadian C-Spine Rule (CCR) - Stiell et al. NEJM 2003

DOI: 10.1056/NEJMoa031375View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • CCR requires GCS 15 (alert patient)
  • Does not apply to age <16 years
  • Not validated for penetrating trauma
  • Clinical judgment supersedes rules in high-risk scenarios

Contraindicated Populations

pediatric

Applicable Regions

USEUGlobal

US: Both CCR and NEXUS widely used; CCR has higher sensitivity

Canada: CCR preferred per original validation

Version 1Next review: 2027-01-01

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Frequently Asked Questions

What is the Cervical Spine Clearance (CCR/NEXUS)?

The Cervical Spine Clearance (CCR/NEXUS) is a diagnostic clinical algorithm for Trauma Surgery. It provides a structured decision tree to guide clinical decision-making, based on Canadian C-Spine Rule (CCR) - Stiell et al. NEJM 2003.

What guideline is the Cervical Spine Clearance (CCR/NEXUS) based on?

This algorithm is based on Canadian C-Spine Rule (CCR) - Stiell et al. NEJM 2003 (DOI: 10.1056/NEJMoa031375).

What are the limitations of the Cervical Spine Clearance (CCR/NEXUS)?

Known limitations include: CCR requires GCS 15 (alert patient); Does not apply to age <16 years; Not validated for penetrating trauma; Clinical judgment supersedes rules in high-risk scenarios. Individual patient factors may require deviation from these recommendations.

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