Synopsis
Use reliable clinical rules and age-appropriate imaging to clear the cervical spine, maintain proportionate movement restriction until assessment is complete, and avoid airway, pressure and transfer harm from indiscriminate immobilisation.
- Use manual in-line stabilisation during the primary survey and ask about neck pain, paraesthesia and weakness while assessing all four limbs and sacral function.
- Apply the Canadian C-spine rule only to an alert, stable, cooperative adult for whom the rule is validated; intoxication, distracting injury or reduced consciousness makes clinical clearance unreliable.
- High-risk Canadian features are age 65 or over, dangerous mechanism or limb paraesthesia; these require imaging and no active rotation test.
- If low-risk features permit safe assessment, ask the patient to rotate the neck actively 45 degrees left and right; inability means imaging, while painless full rotation permits clinical clearance.
- CT is the preferred adult imaging when NICE criteria indicate; obtain MRI after CT when a neurological abnormality could be attributable to spinal-cord injury.
- Children usually need an age-appropriate senior pathway, often plain radiography first when imaging is indicated, with CT for inadequate or suspicious films or strong clinical concern.
- A collar is one part of movement restriction and may be removed or modified for airway access, severe agitation, fixed deformity or pressure harm while trained manual stabilisation continues.
- Clear early when safe, document who cleared and by what criteria, and reassess after waking, sobriety or transfer if the original examination was unreliable.
Key red flags
New limb weakness or numbness, sacral sensory change, priapism, diaphragmatic breathing, loss of anal tone or spinal shock requires emergency spinal-cord assessment and MRI after CT when indicated.
Age 65 or over, paraesthesia or a dangerous mechanism makes the Canadian C-spine rule high risk and requires imaging rather than active neck rotation clearance.
Severe pain, fixed deformity, agitation, airway compromise, penetrating injury or pressure vulnerability means a rigid collar may be harmful; use manual support and an individual movement plan.
Investigation priorities
Determine whether clinical clearance or imaging is appropriate.
Detect fracture, displacement and major instability when imaging criteria are met.
Management branches
Mechanism, pain, consciousness or neurology creates possible cervical injury.
- Provide manual in-line stabilisation, manage airway and breathing, and avoid forcing deformity into neutral or letting a collar block lifesaving access.
- Document GCS, neck symptoms, all-limb motor and sensory findings and sacral function when cord injury is possible.
- Decide whether the patient is reliable and eligible for the Canadian C-spine rule or requires direct imaging.
- Use coordinated scoop or minimal-movement transfer with pressure protection, recording every device and reassessment.
The patient is stable enough for clinical decision and imaging where required.
- Image every high-risk or unreliable adult and anyone unable to rotate after a valid low-risk assessment; do not force active movement.
- Use complete CT in adults and an age-appropriate paediatric pathway, checking image adequacy and the final authorised report.
- Obtain MRI and spinal review for neurological abnormality attributable to the cord or persistent serious clinical-imaging discordance.
- Remove restriction promptly after documented clinical or radiological clearance and inspect pressure areas and active comfort.