Skip to main content

A new study is about to be published which questions the use of current cervical spine clearance criteria in the elderly(1). It goes further, recommending  “liberal c-spine imaging for older trauma patients with significant mechanism of trauma”.

Here is a typical case:

74 year old patient from home, has had a mechanical fall from a standing height. He has fractured 2 ribs and his clavicle. It is not certain if there has been a head strike but the patient states he broke his fall with his hands. On examination, the patient is GCS 15 with pain over the right lower ribs and clavicle on movement and palpation, but with no neck pain on palpation. You apply NEXUS criteria and there is no neck pain and clear the neck. Is it clear?

NEXUS and The Canadian C-Spine Rule

The idea of a distracting injury is difficult to protocolise. NEXUS states that a precise definition of a distracting injury is not possible. “This condition includes any condition thought by the clinician to be producing pain sufficient to distract the patient from a second(neck) injury” They include some examples such as long bone fractures, visceral injuries, lacerations, degloving or crash injuries.

The Canadian C Spine Rule automatically includes those that are older than 65 years as higher risk and mandates imaging.

The current approach by most practitioners would be to apply the NEXUS rule, to most cases, because for the most part it’s simple to remember. In a patient like this a percentage of physicians would clear the neck clinically. It is their judgement call about the level of distraction. The NEXUS rule is well validated and accepted, however there are potential issues with it. It relies very much on the clinical criteria of neck pain and on our interpretation of what may be distracting. If you take the collar off, please document your findings and impressions carefully.

What is emerging in the literature, is that in the elderly, ther response to neck pain post trauma, may reflect what we see in other areas, such as chest pain, or abdominal pain, it can be misleading. In fact there may be no neck tenderness on examination, even in the presence of a clinically significant fracture. (2)

New Study

The study at the centre of this discussion, is a retrospective study of 2390 patients who were 55 years or older. 1071 patients had a CT cervical spine, where it was found that 183 had a cervical spine fracture. 36 of these patients with a fracture had no neck pain. Of those with a fracture 19% required surgical intervention.

What this means is that 3.7% of patients with a clinically significant fracture had no neck pain.

Those with no neck pain and a fracture had a higher severity score and a longer hospitalisation. Their injury severity score was between 9 and 15(moderate injury) and there was a higher rate of another body region being injured in the asymptomatic group. This may be a masking phenomenon.


So who do we image? There certainly are a larger number of CT cervical spines being done in the elderly. This is because we see those getting CT brains also getting CT cervical spines.

Recommendations have been made that (3,4)

  • All elderly patients with a ‘trauma call’ should have a CT cervical spine
  • All elderly that have a CT brain or CT chest should also have a CT cervical spine.

Will this study change my practice? Not necessarily. I currently have a low threshold for CT cervical spine in the elderly, especially if I’m imaging the brain, or chest. I’m very vigilant when I consider those above 65 years of age.


  1. Healy C et al. Asymptomatic cervical fracture: Current Guidelines can Fail Older Patients. Journal of Trauma and Acute Care Surgery, 2017- Published ahead of schedule.
  2. Schrag S et al. Cervical Spine Fractures in Geriatric Blunt Trauma Patients with Low-Energy Mechanism: Are the Predictors Adequate?  Am J of Surg 195(2008)170-173
  3. Duane TM et al Defining the Cervical Spine Clearance Algorithm: A Single Institution Prospective Study of More than 9000 patients. J Trauma Acute Care Surg. 2016; 81:541-547
  4. Duane TM et al. Clinical Examination and its Reliability in Identifying Cervical Spine Fracture. J trauma. 2007;62:1405-1410

Peter Kas


  • Keenan says:

    Just want to say your article is as astounding. The
    clearness for your submit is just spectacular and that i could assume you’re knowledgeable in this subject.
    Well along with your permission allow me to snatch your RSS feed
    to stay updated with drawing close post. Thank you 1,000,000 and please keep up the gratifying work.

  • Damon says:

    I am truly thankful to the holder of this web page who has shared this fantastic article at at this time.

  • I’m really inspired together with your writing talents and
    also with the structure for your weblog. Is that this
    a paid subject matter or did you modify it yourself?
    Either way stay up the nice quality writing, it is rare to look a great blog like this one nowadays..

    My webpage … term treatment process

  • says:

    I don’t even know how I ended uup here, but I thought this post was good.
    I do not know whho you are but definitely you are going
    to a amous blogger if you are not already 😉 Cheers!

  • Angelika says:

    Every weekend i used to go to see this site, for the reason that i wish for enjoyment, since this this site conations actually
    nice funny information too.

  • Willard says:

    I really love your blog.. Very nice colors & theme.
    Did you develop this site yourself? Please reply back as I’m wanting to create my own website and would love to
    find out where you got this from or just what the theme is named.
    Appreciate it!

  • Cora says:

    I am actually grateful to the holder of this site who has shared this enormous post at here.

  • Tristan says:

    Fantastic beat ! I wish to apprentice while you amend your site, how can i subscribe
    for a blog site? The account aided me a acceptable deal.
    I had been tiny bit acquainted of this your broadcast provided bright
    clear concept

  • Michale says:

    Your mode of explaining all in this piece of writing is genuinely good,
    all be capable of effortlessly be aware of it, Thanks
    a lot.

  • Dyan says:

    My programmer is trying to convince me to move to .net from PHP.
    I have always disliked the idea because of the costs. But he’s tryiong none the less.
    I’ve been using Movable-type on several websites for about
    a year and am worried about switching to another platform. I have heard excellent things about

    Is there a way I can transfer all my wordpress posts into it?
    Any help would be really appreciated!

  • Louanne says:

    Paragraph writing is also a excitement,
    if you know then you can write or else it is complicated to write.

  • Ben says:

    At this time it seems like Expression Engine is the
    best blogging platform available right now. (from what I’ve read) Is that what you
    are using on your blog?

  • Oliva says:

    Hi there, You’ve done a fantastic job. I will definitely digg it and
    personally suggest to my friends. I’m sure they’ll be benefited from this site.

  • Hamish says:

    This is a topic which is near to my heart… Cheers!

    Where are your contact details though?

  • Kristen says:

    This site was… how do you say it? Relevant!! Finally I have found
    something which helped me. Thanks!

  • We are a group of volunteers and starting a new scheme in our community.
    Your web site offered us with valuable information to
    work on. You’ve done a formidable job and our whole community will be thankful
    to you.

    My page drug crime attorney

  • Marcella says:

    I know this if off topic but I’m looking into starting my own blog and was curious what all is required to get setup?
    I’m assuming having a blog like yours would cost a pretty penny?
    I’m not very internet savvy so I’m not 100% certain. Any recommendations or advice would be
    greatly appreciated. Appreciate it

Leave a Reply