Blunt trauma · C-spine clearance
The Canadian C-Spine Rule is a three-arm clinical decision rule for alert (GCS 15), stable adult trauma patients with blunt trauma to the head or neck and a c-spine concern. It moves from high-risk factors, through low-risk factors, to active neck rotation before a clinical-clearance decision.
Rule anatomy
03
arms
one imaging pathway
Start with the right patient
Use the Canadian C-Spine Rule only when the patient is alert (GCS 15), clinically stable, and an adult with blunt trauma to the head or neck plus a c-spine concern. The patient must be able to participate in the examination; this is not a general trauma screen or a replacement for immobilization and local assessment.
The rule is not validated for patients younger than 16, penetrating trauma, or acute paralysis. If the presentation falls outside the intended population, follow the institutional trauma pathway rather than forcing the three-arm sequence.
The decision in one line
No high-risk factor + ≥1 low-risk factor + active 45° rotation both ways.
Only that sequence opens the possibility of clinical clearance without imaging. Any arm that fails the pathway sends the patient to imaging and the next step in your local c-spine protocol.
Arm 1 · High-risk factors
Check the three high-risk factors first. Any one present mandates imaging; there is no need to count them or continue into arm 2.
Age 65 or older is a high-risk factor. A single arm 1 factor is enough to stop clinical clearance and move to imaging.
Examples include a fall ≥ 3 ft / 5 stairs, axial load to the head, high-speed MVC (≥ 100 km/h), rollover or ejection, a motorized recreational vehicle, or a bicycle collision with an object.
Subjective numbness, tingling, or pins-and-needles in the arms or legs counts as an arm 1 high-risk finding.
Arm 2 · Low-risk factors
These five findings do not clear the c-spine by themselves. At least one is needed after a negative arm 1 screen before proceeding to arm 3 and testing range of motion.
Arm 2 gate
No arm 2 factor means no clinical-clearance attempt: image the c-spine.
Five ways to proceed to arm 3
An uncomplicated rear-end collision; exclude being pushed into oncoming traffic, struck by a bus or large truck, rollover, or high-speed impact.
The patient arrived sitting upright rather than supine or on a backboard.
The patient walked at the scene, during transport, or in the emergency department.
Neck pain was not immediate after the event and developed over time.
There is no midline c-spine tenderness on posterior-neck palpation; paravertebral or off-midline tenderness is different.
Arm 3 · Active range of motion
This is an active test, not passive movement by the examiner. The patient must rotate the neck 45° to the left and 45° to the right without assistance.
If either direction fails, the Canadian C-Spine Rule does not support clinical clearance; continue to imaging and the institution’s trauma pathway.
Arm 3 checkpoint
Left
45°
Active rotation
Right
45°
Active rotation
Clinical pathway
The three arms are sequential. A positive high-risk factor or a failed later gate ends the clinical-clearance pathway and returns the patient to imaging and local trauma management.
Arm 1 · High-risk screen
Age ≥ 65 years, a dangerous mechanism, or extremity paresthesias is enough to mandate imaging. Do not advance to low-risk or range-of-motion clearance.
Arm 2 · Low-risk screen
If the high-risk screen is negative but none of the five low-risk factors is present, do not proceed to clinical clearance. Image the c-spine according to the trauma pathway.
Arm 3 · Range-of-motion assessment
Only after at least one low-risk factor is present should the patient be asked to actively rotate the neck 45° left and right without assistance.
Arm 3 · Pass
When the patient actively rotates 45° to the left and 45° to the right in the appropriate context, the c-spine may be cleared clinically with no imaging.
Arm 3 · Fail
If the patient cannot actively rotate 45° left and right, clinical clearance fails. Continue the local trauma pathway and image the c-spine.
Imaging modality
CT preferred.
When imaging is indicated, CT is preferred; plain radiographs are acceptable or pathway-dependent according to the patient, resources, and institutional trauma protocol.
Open the calculator
The live calculator keeps the three arms together in one bedside view. It is account-gated for subscribers; continue to the existing access flow to sign in or review access before using it.
Open the Canadian C-Spine calculator →Informational only. Not a substitute for clinical judgement. Not a patient record — CCSPR results are not persisted; a refresh clears the result. Applicable only to alert (GCS 15) stable adults with blunt trauma to the head/neck and a c-spine concern; not validated for age < 16, penetrating trauma, or acute paralysis. Always follow your institution’s c-spine clearance pathway.