Quality statement 4: Assessment for cervical spine injury

Quality statement

People with full in-line spinal immobilisation have their risk of cervical spine injury assessed using the Canadian C‑spine rule.

Rationale

If a person might have a spinal injury, it is important to immobilise their spine during assessment to prevent any damage. However, continuing immobilisation for longer than necessary can lead to avoidable adverse effects, such as discomfort and skin breakdown. Using a risk assessment tool as soon as possible to determine whether to carry out, maintain or remove immobilisation will reduce the risk of spinal cord injury and minimise discomfort for the person. It will also help to determine whether further investigations, such as prompt imaging, are needed.

Quality measures

Structure

Evidence of the documented use of checklists to ensure that the Canadian C‑spine rule is used to assess people with full in‑line spinal immobilisation for their risk of cervical spine injury.

Data source: Local data collection, for example service specifications.

Process

Proportion of people with full in‑line spinal immobilisation who have had their risk of cervical spine injury assessed using the Canadian C‑spine rule.

Numerator – the number in the denominator who have had their risk of cervical spine injury assessed using the Canadian C‑spine rule.

Denominator – the number of people with full in‑line spinal immobilisation.

Data source: Local data collection, for example, local audit of patient records. The Trauma Audit and Research Network collects data on spinal immobilisation.

Outcomes

a) Rates of neurological deterioration caused by inappropriate removal of spinal immobilisation.

Data source: Local data collection, for example, local audit of patient records.

b) Rates of appropriate removal of full in-line spinal immobilisation.

Data source: Local data collection, for example patient surveys.

What the quality statement means for different audiences

Service providers (ambulance services, major trauma centres, trauma units and district general hospitals) train staff in using the Canadian C‑spine rule and implement its use in pre‑hospital and hospital settings to carry out risk assessment for cervical spine injury for people with full in‑line spinal immobilisation.

Healthcare professionals (paramedics and trauma teams) use the Canadian C‑spine rule to carry out risk assessment for people with full in‑line spinal immobilisation, and document this. A digital reference tool that contains the Canadian C‑spine rule, such as MDCalc, can be used when doing the assessment. The level of risk of cervical spine injury should be used to make decisions on whether spinal immobilisation and prompt imaging are needed.

Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that have checklists to document the use of the Canadian C‑spine rule to assess the risk of cervical spine injury for people with full in‑line spinal immobilisation, and inform decisions about when to carry out or continue with spinal immobilisation and request prompt imaging.

People with a possible spinal injury who have their spine immobilised to prevent further injury, using a special collar and head supports, are asked questions by the ambulance team to try to find out how likely it is that they have a spinal injury, and which part of the spine might be injured. These questions include their age, the type of injury they have had and how they became injured. The same questions are asked again when the person arrives at the hospital. If the hospital staff think the person might have a spinal injury, they offer a scan. If the spine is unlikely to be injured, hospital staff remove the collar and head supports.

Source guidance

Spinal injury: assessment and initial management (2016) NICE guideline NG41, recommendations 1.1.5 and 1.4.5

Definitions of terms used in this quality statement

People with full in-line spinal immobilisation

Full in-line spinal immobilisation usually involves fitting the person with a collar, placing them on a scoop stretcher, and using head blocks and tape to keep their head still.

[NICE's information for the public in its guideline on spinal injury: assessment and initial management]

Canadian C-spine rule

The person with suspected spine injury should be assessed as having high, low or no risk of cervical spine injury using the following rule:

  • the person is at high risk if they have at least one of the following high‑risk factors:

    • age 65 years or older

    • dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 steps, axial load to the head – for example diving, high‑speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents)

    • paraesthesia in the upper or lower limbs

  • the person is at low risk if they have no high-risk features and at least one of the following low‑risk factors:

    • involved in a minor rear‑end motor vehicle collision

    • comfortable in a sitting position

    • ambulatory at any time since the injury

    • no midline cervical spine tenderness

    • delayed onset of neck pain

  • the person remains at low risk if they are:

    • unable to actively rotate their neck 45 degrees to the left and right (the range of the neck can only be assessed safely if the person is at low risk and there are no high‑risk factors).

  • the person has no risk if they:

    • have one of the above low‑risk factors and

    • are able to actively rotate their neck 45 degrees to the left and right.

Applying the Canadian C‑spine rule to children is difficult and the child's developmental stage should be taken into account.

[Expert opinion and NICE's guideline on spinal injury: assessment and initial management, recommendations 1.1.5 and 1.1.6]