Name: Cervical spine injury — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

Clearing a neck after blunt trauma is a decision made by a validated rule, and the chart has to show the rule was actually satisfied. The defensible record names NEXUS or the Canadian C-Spine Rule, documents each element, and respects the traps — the intoxicated patient, the distracting injury, and the elder who fell from standing.

01What's at stake

A missed unstable cervical injury can mean paralysis, and the failures are predictable: clearing an intoxicated patient, underestimating a "distracting" injury, settling for inadequate films, or assuming a low-mechanism fall in an older adult is benign. Inadequate films "provide no legal protection," and a neuro exam charted as "WNL" is not a neuro exam.

02Can't-miss diagnoses

Unstable fracture/dislocation — e.g., flexion tear-drop, bilateral facet dislocation, atlanto-occipital dislocation; C1–C2 fractures dominate in the elderly and are the most missed.
Spinal cord injury — repeat the sensory exam; deficits ascend and respiratory failure can follow.
Blunt cerebrovascular injury (carotid/vertebral) — ~half have a normal initial exam; deficits can appear days later.
Ligamentous injury with a normal x-ray / SCIWORA — MRI is the gold standard; persistent pain warrants further imaging.
The elderly low-mechanism fall — double the fracture rate, unreliable tenderness; CT is the modality of choice.

03The decision rules

NEXUS — no imaging if ALL five: no midline tenderness, no focal deficit, normal alertness, no intoxication, no distracting injury. ~99.6% sensitive for clinically important injury. Applies to all blunt trauma. Hoffman JR, et al. N Engl J Med. 2000.
Canadian C-Spine Rule — (1) any high-risk factor (age >65, dangerous mechanism, extremity paresthesias) → image; (2) any low-risk factor (ambulatory, sitting, simple rear-end, delayed pain, no midline tenderness) allows ROM testing; (3) able to actively rotate 45° each way → no imaging. ~100% sensitive. Excludes children and pregnancy. Stiell IG, et al. JAMA. 2001.

Skip the typing

Work the case in the Head Injury Workup — it records the neuro exam, the NEXUS / Canadian CT decision, and the imaging rationale, and assembles an MDM that documents how the cervical spine was cleared (or why it was imaged).

04Imaging & clearance

CT (thin cuts, ≤3 mm) is the modality of choice for moderate-to-high risk and the elderly; plain films miss far more (especially at the cervicothoracic junction) and are reserved for low-risk patients.
MRI for suspected ligamentous injury or cord injury with deficit; flexion/extension views are largely obsolete.
Intoxicated/obtunded: do not clear until a sober, documented repeat exam (or MRI when doubt persists).
CTA for blunt cerebrovascular injury with high-risk fracture patterns (subluxation, C1–C3 body fracture, fracture through the transverse foramen).
Spine boards are extrication tools — remove early; immobilization itself has weak evidence and real harms.

05What to document

▼ weak

"MVC, neck nontender, neuro WNL, c-spine cleared clinically."

▲ defensible

"Blunt trauma; NEXUS applied — no midline tenderness, no focal deficit, normal alertness (not intoxicated), no distracting injury. Documented motor/sensory exam intact in all four extremities, reflexes symmetric. Able to actively rotate neck 45° both directions. Low-risk by both NEXUS and Canadian C-Spine Rule; imaging not indicated. Counseled on delayed-symptom return precautions."

06Where charts fail

Clearing an intoxicated patient before a sober, repeat exam.
Underestimating a distracting injury — it's the patient's threshold, not yours.
Charting the neuro exam as "WNL" instead of documenting each component.
Accepting inadequate films (cervicothoracic junction not seen).
Assuming an older adult's fall from standing is too minor to image.
Not considering blunt cerebrovascular injury with high-risk fracture patterns.

07Sources

Grossheim LF, Polglaze K, Smith R. Cervical spine injury: an evidence-based evaluation of the patient with blunt cervical trauma. Emergency Medicine Practice (EB Medicine). 2009;11(4).
Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine (NEXUS). N Engl J Med. 2000;343(2):94-99.
Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-Spine Rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841-1848.
Hendey GW, Wolfson AB, Mower WR, et al. Spinal cord injury without radiographic abnormality: results of the NEXUS study. J Trauma. 2002;53(1):1-4.

Cervical spine injury: documentation that holds up