Annals of Emergency Medicine
Volume 42, Issue 3 , Pages 395-402, September 2003

The Canadian C-Spine rule performs better than unstructured physician judgment☆

  • Glen Bandiera, MD

      Affiliations

    • Division of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
    • Corresponding Author InformationAddress for correspondence: Glen Bandiera, MD, Sunnybrook and Women's College Health Sciences Center, Suite BG-13, 2075 Bayview Avenue, North York, Ontario, Canada M4N 3M5
    • ,
  • Ian G Stiell, MD, MSc

      Affiliations

    • University of Toronto, Toronto, Ontario; the Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • George A Wells, PhD

      Affiliations

    • Department of Epidemiology and Community Medicine, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • Catherine Clement, RN

      Affiliations

    • Clinical Epidemiology Unit, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • Valerie De Maio, MD, MSc

      Affiliations

    • Clinical Epidemiology Unit, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • Katherine L Vandemheen, BScN

      Affiliations

    • Clinical Epidemiology Unit, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • Gary H Greenberg, MD

      Affiliations

    • University of Toronto, Toronto, Ontario; the Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • Howard Lesiuk, MD

      Affiliations

    • Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • Robert Brison, MD, MPH

      Affiliations

    • University of Ottawa, Ottawa, Ontario; the Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • Daniel Cass, MD

      Affiliations

    • Division of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • Jonathan Dreyer, MD

      Affiliations

    • Queen's University, Kingston, Ontario; the Division of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • Mary A Eisenhauer, MD

      Affiliations

    • Queen's University, Kingston, Ontario; the Division of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • Iain MacPhail, MD, MHSc

      Affiliations

    • University of Western Ontario, London, Ontario; and the Division of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • R.Douglas McKnight, MD

      Affiliations

    • University of Western Ontario, London, Ontario; and the Division of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • Laurie Morrison, MD

      Affiliations

    • Division of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • Mark Reardon, MD

      Affiliations

    • University of Toronto, Toronto, Ontario; the Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • Michael Schull, MD, MSc

      Affiliations

    • Division of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • James Worthington, MBBS

      Affiliations

    • University of Toronto, Toronto, Ontario; the Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
    • ,
  • Canadian C-Spine and CT Head Study Group

Received 18 October 2002; received in revised form 9 April 2003; accepted 15 April 2003.

Abstract 

Study objective

We compare the predictive accuracy of emergency physicians' unstructured clinical judgment to the Canadian C-Spine rule.

Methods

This prospective multicenter cohort study was conducted at 10 Canadian urban academic emergency departments. Included in the study were alert, stable, adult patients with a Glasgow Coma Scale score of 15 and trauma to the head or neck. This was a substudy of the Canadian C-Spine and CT Head Study. Eligible patients were prospectively evaluated before radiography. Physicians estimated the probability of unstable cervical spine injury from 0% to 100% according to clinical judgment alone and filled out a data form. Interobserver assessments were done when feasible. Patients underwent cervical spine radiography or follow-up to determine clinically important cervical spine injuries. Analyses included comparison of areas under the receiver operating characteristic (ROC) curve with 95% confidence intervals (CIs) and the κ coefficient.

Results

During 18 months, 6,265 patients were enrolled. The mean age was 36.6 years (range 16 to 97 years), and 50.1% were men. Sixty-four (1%) patients had a clinically important injury. The physicians' κ for a 0% predicted probability of injury was 0.46 (95% CI 0.28 to 0.65). The respective areas under the ROC curve for predicting cervical spine injury were 0.85 (95% CI 0.80 to 0.89) for physician judgment and 0.91 (95% CI 0.89 to 0.92) for the Canadian C-Spine rule (P<.05). With a threshold of 0% predicted probability of injury, the respective indices of accuracy for physicians and the Canadian C-Spine rule were sensitivity 92.2% versus 100% (P<.001) and specificity 53.9% versus 44.0% (P<.001).

Conclusion

Interobserver agreement of unstructured clinical judgment for predicting clinically important cervical spine injury is only fair, and the sensitivity is unacceptably low. The Canadian C-Spine rule was better at detecting clinically important injuries with a sensitivity of 100%. Prospective validation has recently been completed and should permit widespread use of the Canadian C-Spine rule.

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☆ Dr. Stiell holds a Distinguished Investigator Award and Dr. Schull a New Investigator Award, both from the Canadian Institutes of Health Research.Supported by peer-reviewed grants from the Medical Research Council of Canada (MT-13699) and the Ontario Ministry of Health Emergency Health Services Committee (11896N).Reprints not available from the authors.

PII: S0196-0644(03)00422-0

doi:10.1016/S0196-0644(03)00422-0

Refers to article:

  • The intrinsic fallibility of clinical judgment

    E.John Gallagher
    Annals of Emergency Medicine September 2003 (Vol. 42, Issue 3, Pages 403-404)

Annals of Emergency Medicine
Volume 42, Issue 3 , Pages 395-402, September 2003

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