Definition: Efforts to Determine if a Cervical Collar is Required or Can Be Removed

Clearing a Cervical Collar

• First Determine if CT is Required (NEXUS Criteria or Canadian C-Spine Rules)
• Positive CT: Requires Neurosurgery or Spine Surgery Evaluation
• Negative CT:
  • Alert: Clinically Clear
  • Obtunded, Intoxicated, or Non-Examinable:
    • Any Focal Neurologic Deficit: MRI
    • No Focal Neurologic Deficits: Controversial (Removal vs MRI First)

Clinical Clearance

• Evaluation:
  • First: Palpate Along the Cervical Spine for Midline Tenderness
    • Lateral Paraspinous Muscle Tenderness is OK
  • Second: Evaluate for Pain with Range of Motion (Up/Down and Left/Right)
• Can Remove Collar if There is No Pain Along Midline or with Range of Motion
• If Fails, Consider MRI vs Neurosurgery or Spine Surgery Evaluation

NEXUS (National Emergency X-Radiography Utilization Study) Criteria

• Low-Risk Criteria:
  • No Neurologic Deficit
  • No Spine (Cervical) Tenderness – Not Perimuscular
  • No Altered Mental Status
  • Not Intoxicated
  • No Distracting Injury
  • MNEMONIC: “NSAID”
• All Criteria Met: Can Clinically Clear
• Any Criteria Not Met: Requires CT

Canadian C-Spine Rules

• Rules:
  • Rule 1. CT if Any High-Risk Factors
    • If None Look at Low-Risk Features
  • Rule 2. CT if No Low-Risk Factors Allowing Safe Assessment of Range of Motion
    • If At Least One Low-Risk Feature Assess Range of Motion
  • Rule 3. CT if Unable to Rotate Neck 45 Degrees Left/Right
    • If Able to Rotate Neck, Then Clinically Clear
• High-Risk Features:
  • Age ≥ 65 Years
  • Dangerous Mechanism:
    • Fall ≥ 3 Feet or 5 Stairs
    • Axial Load to Head
    • High Speed MVC, Rollover or Ejection
    • Motorized Recreational Vehicles
    • Bicycle Struck or Collision
  • Extremity Paresthesia
• Low-Risk Features:
  • Simple Rear-Ended MVC
  • Sitting Position in ED
  • Ambulatory at Any Time
  • Delayed Onset of Neck Pain
  • No Midline C-Spine Tenderness

Accuracy of High-Quality CT

• 2015 EAST Guidelines:
  • 91% Negative Predictive Value for Stable Injuries
  • 100% Negative Predictive Value for Unstable Injuries
• 2016 Western Trauma Association Study of Patients that Failed NEXUS Criteria
  • 0.03% False Negative Rate for Clinically Significant Injuries – However All Had a Focal Neurologic Abnormality on Their Index Clinical Examination Consistent with Central Cord Syndrome
  • For Clinically Significant Injuries:
    • 98.5% Sensitivity
    • 91.0% Specificity
    • 99.97% Negative Predictive Value