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Validation of the Canadian c-spine rule in the UK emergency department setting
  1. Frank Coffey1,
  2. Susanne Hewitt2,
  3. Ian Stiell3,
  4. Nick Howarth2,
  5. Phil Miller1,
  6. Cathy Clement5,
  7. Paul Emberton4,
  8. Abdul Jabbar1
  1. 1Emergency Department, Nottingham University Hospitals NHS Trust, Queens Medical Centre Campus, Nottingham, UK
  2. 2Emergency Department, Derby Hospitals NHS Foundation Trust, Derby, UK
  3. 3Department of Emergency Medicine, University of Ottawa, Canada
  4. 4Nottingham University Hospitals NHS Trust, Nottingham, UK
  5. 5Clinical Epidemiology Programme, Ottawa Hospital Research Institute, Ottawa, Canada
  1. Correspondence to Frank Coffey, Emergency Department, Nottingham University Hospitals NHS Trust, Queens Medical Centre Campus, Derby Road, Nottingham NG7 2UH, UK; frank.coffey{at}


Aim To determine the potential of the Canadian Cervical Spine Rule (CCR) to safely reduce the number of cervical spine (c-spine) radiographs performed in the UK emergency department setting.

Methods The study was conducted in two UK emergency departments with a combined annual attendance of >150 000 adult patients. Over the 24 month trial period, 148 doctors were provided training in the use of the CCR and instructed to assess eligible patients presenting with potential c-spine injury. Doctors were instructed to manage patients according to existing practice and not according to the decision obtained from the rule. A subsample of patients was reassessed by a second doctor to test interobserver reliability.

Results A total of 1420 patients were enrolled in the study (50.4% male). 987 (69.5%) had c-spine radiography performed, with 8 (0.6%) having a c-spine injury. If the decision for radiography had been made according to the outcome of the CCR, only 815 (57.4%) would have had c-spine radiography and all 8 abnormal cases would have undergone imaging. Doctors were comfortable using the rule in 91% of cases. Interobserver reliability was good (κ=0.75 95% CI 0.44 to 1.06).

Conclusion The CCR can be applied successfully in the UK. Had the CCR been in use during the study period, a 17.4% reduction in radiography could have been achieved without compromising patient care.

  • Cervical-spine injuries
  • medical-decision-making
  • clinical-protocol
  • cohort-study
  • imaging, x-ray
  • paramedics
  • guidelines
  • research
  • cost effectivenss
  • trauma
  • spine and pelvis
  • trauma

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  • Funding The study was partially funded by the Special Trustees Fund of the University Hospital Nottingham.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Nottingham Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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