Cervical Spine Clearance (NEXUS/Canadian) — Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Can the c-spine be cleared clinically?
   Blunt trauma — can the cervical spine be cleared clinically? (Maintain c-spine immobilization until cleared. NEXUS (sensitivity ~99%): if all 5 low-risk criteria are met, no imaging is needed — 1) no posterior midline cervical tenderness; 2) no focal neurological deficit; 3) normal alertness (GCS 15); 4) no evidence of intoxication; 5) no painful distracting injury. The Canadian C-spine Rule (CCR, for the alert and stable) adds high-risk features (age ≥65/dangerous mechanism/extremity paresthesias) and the ability to actively rotate the neck 45°.)
   • Any high-risk feature / any NEXUS positive → Any positive → cervical spine CT
   • All low-risk criteria met → Low-risk met → clinical clearance
2. [End] Low-risk met → clinical clearance
   All NEXUS low-risk criteria met (or CCR: no high-risk + a low-risk factor + able to actively rotate the neck 45° each way): clear the c-spine clinically, no imaging needed, the collar can be removed. Re-evaluate/image if concern persists or delayed symptoms appear.
3. [End] Any positive → cervical spine CT
   Any NEXUS positive (midline tenderness/focal deficit/altered consciousness/intoxication/distracting injury) or CCR high-risk (age ≥65, dangerous mechanism, extremity paresthesias) or unable to rotate the neck 45°: maintain immobilization, obtain cervical spine CT (CT preferred over plain films for significant trauma); add MRI for a neurological deficit, or if CT is negative but ligamentous injury is strongly suspected.

Source guidelines & references

• NEXUS (NEJM 2000); Canadian C-spine Rule (Stiell 2001)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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