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We thank Dr. Delaney and colleagues for their valuable research into the concept of midline cervical tenderness. Unlike the NEXUS critiera, the Canadian C-Spine Rule does not use midline tenderness as a positive indication for imaging. Our original study in JAMA 2001 found that assessment of this criterion amongst alert trauma patients at risk of c-spine tenderness had excellent interobserver agreement between ED physicians with a kappa of 0.78. We found that absence of midline tenderness was a good negative predictor of c-spine injury but that presence of of such tenderness was non-specific and not useful. Hence, absence of midline tenderness is considered a low-risk factor. Our NEJM 2003 validation study found that the CCR had both better sensitivity and specificity than NEXUS.
1. Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, De Maio VJ et al. The Canadian Cervical Spine Radiography Rule for alert and stable trauma patients. JAMA 2001; 286(15):1841-1848.
2. Stiell IG, Clement C, McKnight RD, Brison R, Schull MJ, Rowe BH et al. The Canadian C-spine Rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 2003; 349:2510-2518.