🧭 REBEL Rundown
📌 Key Points
- 🧠 Decision rules help: 98% of c-spine CTs are negative—rules reduce unnecessary imaging.
- 📊 Both NEXUS & CCR rule out >99% of serious injuries; CCR may lower imaging rates.
- 📏 NEXUS is simpler but excludes intoxicated patients and can’t clear midline tenderness.
- 📚 CCR is more validated, includes MOI, allows intoxication if alert, and can clear some with midline tenderness.
- 🔞 CCR excludes age <16 or >65; NEXUS has no age cutoffs but less sensitive >65.
- 💡 Bottom line: Know the strengths & limits—choose the rule that fits your patient.
- 👉 Click the link to access MDCalc’s Nexus Criteria
- 👉 Click the link to access MDCalc’s Canadian C-Spine Rules
🤕 Case
A 45 year old man presents with neck pain after a motor vehicle collision. He was a restrained driver travelling at approximately 30 MPH, and was rear-ended by another car. Airbags were deployed. He was able to walk at the scene. He denies head injury, focal weakness or paresthesias. He states he had “one beer with dinner an hour ago.” On exam, pt is GCS 15, with mild midline tenderness to palpation at C6 and C7. He has full motor strength and a nonfocal neurologic exam including normal speech and decision-making capacity. No other injuries are noted. He asks you, “Do I really need a CT Scan?”
🔨 Why Do We Need a Clinical Decision Rule?
Over 1 million blunt trauma patients visit US emergency departments each year for possible c-spine injuries. Yet, 98% of c-spine imaging shows no fracture. Using clinical decision tools can safely and significantly reduce unnecessary imaging.
🎯 Quick Hits
| Category | NEXUS Criteria | Canadian C-Spine Rule |
|---|---|---|
| Purpose | Clinically clears cervical spine fracture without imaging in alert, stable trauma patients. | Clinically clears cervical spine fracture without imaging in alert, stable trauma patients. |
| Ease of Use | Fewer inputs than CCR. “Distracting injury” and "intoxication" are at the discretion of the clinician. | Difficult to memorize (three-step process). |
| Midline Tenderness | Cannot clinically rule out c-spine fx if pt has midline tenderness. | Able to clinically rule out c-spine fx in pts with midline tenderness. |
| Age | No age cutoffs, sensitivity may decrease in pts >65 years old. | Should not be applied to patients ages 65. |
| Intoxication | Cannot clinically rule out c-spine injury for intoxicated patients. | Can be used in intoxicated patients if alert and cooperative. |
| Mechanism of Injury (MOI) | Does not consider MOI | Considers MOI |
| Performance | Rules out >99% of clinically-significant injuries. | Rules out >99% of clinically-significant injuries. CCR may result in lower imaging rates than NEXUS. CCR may be more accurate and is more extensively validated. |
💬 Case Resolution
You explain to your patient that the Canadian C-Spine Rule is highly reliable-catching over 99% of serious injuries-though it might miss the tiniest ones. Satisfied, he asks to be discharged so he can make it to happy hour.
🚨 Clinical Bottom Line
Both CCR and NEXUS are effective at ruling out c-spine fractures. CCR contains more steps, but can be applied to patients who have midline tenderness on physical exam.
Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_Propersi), and Mark Ramzy, DO (X: @MRamzyDO)
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