Clinical Clearance of the Spine in the Prehospital Setting

Abstract & Commentary

Source: Domeier RM, et al. Multicenter prospective validation of prehospital clinical spinal clearance criteria. J Trauma Injury Infect Crit Care 2002:53:744-750.

This study prospectively evaluated a clinical decision rule used to identify injured patients at low-risk for spinal injury in the prehospital setting. The presence or absence of five criteria were recorded during the field assessment: altered mental status, neurologic deficit, spinal tenderness, evidence of intoxication, or suspected extremity fracture. Patients lacking all five criteria were categorized as "low risk." All adult and pediatric blunt trauma patients who underwent spinal immobilization were eligible for enrollment. No attempts were made to alter immobilization practice. Outcome measures included the presence or absence of fracture and injury management.

Two hundred ninety-five patients with spinal injury were present in 8975 (3.3%) cases; 280 (94.9%) of these were identified by the decision rule [sensitivity 94.9%, specificity 35%, NPV 99.5%]. Thirteen of 15 missed injures were stable, requiring only simple immobilization and/or pain control. Two missed patients required surgical stabilization. The first, a patient with a C1-2 injury, was found to have three criteria during emergency department evaluation: evidence of intoxication, altered mental status, and cervical pain. The second, a patient with a C6-7 subluxation, had a fracture dislocation of the hip, meeting criteria for a "suspected extremity fracture."

Commentary by Michael A. Gibbs, MD, FACEP

The results of this study are in keeping with the findings of NEXUS, which employed similar criteria to effectively risk-stratify patients for spinal injury in the ED.1 Substituting the "distracting injury" criteria used in NEXUS with "suspected extremity fracture" makes good sense, and is supported in a recent analysis of this specific variable.2

The fact that paramedics missed two significant injuries underscores the importance of adequate training, and reminds us that the prehospital environment can be a challenging place to assess patients. With adequate training, careful oversight, and attention to detail, there is no reason that paramedics should not be able to "clinically clear" the spine in the field.

Dr. Gibbs, Chief, Department of Emergency Medicine, Maine Medical Center, Portland, Maine, is on the Editorial Board of Emergency Medicine Alert.


1. Hoffman JR. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000;343:94-99.

2. Ulrich A. Distracting painful injuries associated with cervical spine injuries in blunt trauma. Acad Emerg Med 2001;8:25-29.