Cervical Spine - Clinical Tree

Clinical Summary and Recommendations

Patient History
Complaints	The utility of the patient history has been studied only in the context of identifying cervical radiculopathy. Subjective reports of symptoms were generally not helpful, with diagnoses including complaints of “weakness,” “numbness,” “tingling,” “burning,” or “arm pain.” The patient complaints most useful in diagnosing cervical radiculopathy were (1) a report of symptoms most bothersome in the scapular area (+LR [likelihood ratio] = 2.30) and (2) a report that symptoms improve with moving the neck (+LR = 2.23).
Physical Examination
Screening	Traditional neurologic screening (sensation, reflex, and manual muscle testing [MMT]) is of moderate utility in identifying cervical radiculopathy. Sensation testing (pinprick at any location) and MMT of the muscles in the lower arm and hand are unhelpful. Muscle stretch reflex (MSR) and MMT of the muscles in the upper arm (especially the biceps brachii muscle) exhibit good diagnostic utility and are recommended. A 2012 systematic review evaluating the accuracy of the Canadian C-Spine Rule (CCR) and the NEXUS Low-Risk Criteria in screening for clinically important cervical spine injury in patients following blunt trauma concluded that the CCR appears to have better diagnostic accuracy than the NEXUS Criteria at ruling out clinically important cervical spine injuries that require diagnostic imaging. We recommend use of the CCR because it has been consistently shown to have perfect sensitivity (−LR = .00).
Range-of-Motion and Manual Assessment	Measuring the cervical range of motion is consistently reliable but is of unknown diagnostic utility. The results of studies assessing the reliability of passive intervertebral motion are highly variable, but generally, the results show that this maneuver has poor reliability as an assessment for limitations of movement and moderate reliability as an assessment for pain. Assessing for both pain and limited movement during manual assessment is highly sensitive for zygapophyseal joint pain and is recommended to rule out zygapophyseal involvement (−LR = .00 to .23).
Special Tests	Although of questionable reliability, multiple studies demonstrate the high diagnostic utility of Spurling’s test in identifying cervical radiculopathy, cervical disc prolapse, and neck pain (+LR = 1.9 to 18.6). Using a combination of Spurling’s A test, the upper limb tension test A, a distraction test, and assessment for cervical rotation of less than 60 degrees to the ipsilateral side is very good for identifying cervical radiculopathy and is recommended (+LR = 30.3 if all four factors are present). Using a combination of gait deviation, the Hoffmann test, the inverted supinator sign, the Babinski test, and age more than 45 years is very good at identifying cervical myelopathy and is recommended (+LR = 30.9 if three of five factors are present).
Interventions	Factors associated with improvement from cervical thrust manipulation in patients with neck pain include symptom duration of less than 38 days, a positive expectation that manipulation will help, a side-to-side difference in cervical rotation range of motion of 10 degrees or greater, and pain with posteroanterior spring testing of the middle cervical spine (+LR 13.5 if three or more of the four factors are present).

Anatomy

Osteology

Figure 3-1, Bony framework of the head and neck.

Arthrology

Figure 3-3, Joints of the cervical spine.

Joint	Type and Classification	Closed Packed Position	Capsular Pattern
Atlantooccipital	Synovial: plane	Not reported	Not reported
Atlantoodontoid/dens	Synovial: trochoid	Extension	Not reported
Atlantoaxial apophyseal joints	Synovial: plane	Extension	Not reported
C3-C7 Apophyseal joints	Synovial: plane	Full extension	Limitation in side-bending = rotation = extension
C3-C7 Intervertebral joints	Amphiarthrodial	Not applicable	Not applicable

Ligaments

Ligaments	Attachments	Function
Alar	Sides of dens to lateral aspects of foramen magnum	Limits ipsilateral head rotation and contralateral side-bending
Ligaments	Attachments	Function
Apical	Dens to posterior aspect of foramen magnum	Limits separation of dens from occiput
Tectorial membrane	Body of C2 to occiput	Limits forward flexion
Cruciform ligament (superior longitudinal)	Transverse ligament to occiput	Maintains contact between dens and anterior arch of atlas
Cruciform ligament (transverse)	Extends between lateral tubercles of C1
Cruciform ligament (inferior)	Transverse ligament to body of C2

Ligaments	Attachments	Function
Anterior longitudinal	Extends from anterior sacrum to anterior tubercle of C1. Connects anterolateral vertebral bodies and discs	Maintains stability of vertebral body joints and prevents hyperextension of vertebral column
Posterior longitudinal	Extends from sacrum to C2. Runs within vertebral canal attaching posterior vertebral bodies	Prevents hyperflexion of vertebral column and posterior disc protrusion
Ligamentum nuchae	An extension of supraspinous ligament (occipital protuberance to C7)	Prevents cervical hyperflexion
Ligamenta flava	Attaches lamina above each vertebra to lamina below	Prevents separation of vertebral lamina
Supraspinous	Connects apices of spinous processes C7-S1	Limits separation of spinous processes
Interspinous	Connects adjoining spinous processes C1-S1	Limits separation of spinous processes
Intertransverse	Connects adjacent transverse processes of vertebrae	Limits separation of transverse processes

Muscles

Anterior Muscles of the Neck

Muscle	Proximal Attachment	Distal Attachment	Nerve and Segmental Level	Action
Sternocleidomastoid	Lateral aspect of mastoid process and lateral superior nuchal line	Sternal head: anterior aspect of manubrium Clavicular head: superomedial aspect of clavicle	Spinal root of accessory nerve	Neck flexion, ipsilateral side-bending, and contralateral rotation
Scalene (anterior)	Transverse processes of vertebrae C4-C6	First rib	C4, C5, C6	Elevates first rib, ipsilateral side-bending, and contralateral rotation
Scalene (middle)	Transverse processes of vertebrae C1-C4	Superior aspect of first rib	Ventral rami of cervical spinal nerves	Elevates first rib, ipsilateral side-bending, contralateral rotation
Scalene (posterior)	Transverse processes of vertebrae C1-C4	External aspect of second rib	Ventral rami of cervical spinal nerves C3, C4	Elevates second rib, ipsilateral side-bending, contralateral rotation
Platysma	Inferior mandible	Fascia of pectoralis major and deltoid	Cervical branch of facial nerve	Draws skin of neck superiorly with clenched jaw, draws corners of mouth inferiorly

Suprahyoid and Infrahyoid Muscles

Muscle	Proximal Attachment	Distal Attachment	Nerve and Segmental Level	Action
Suprahyoids
Mylohyoid	Mandibular mylohyoid line	Hyoid bone	Mylohyoid nerve	Elevates hyoid bone, floor of mouth, and tongue
Geniohyoid	Mental spine of mandible	Body of hyoid bone	Hypoglossal nerve	Elevates hyoid bone anterosuperiorly, widens pharynx
Stylohyoid	Styloid process of temporal bone	Body of hyoid bone	Cervical branch of facial nerve	Elevates and retracts hyoid bone
Digastric	Anterior belly: digastric fossa of mandible Posterior belly: mastoid notch of temporal bone	Greater horn of hyoid bone	Anterior belly: mylohyoid nerve Posterior belly: facial nerve	Depresses mandible and raises hyoid
Infrahyoids
Sternohyoid	Manubrium and medial clavicle	Body of hyoid bone	Branch of ansa cervicalis (C1, C2, C3)	Depresses hyoid bone after it has been elevated
Omohyoid	Superior border of scapula	Inferior aspect of hyoid bone	Branch of ansa cervicalis (C1, C2, C3)	Depresses and retracts hyoid bone
Sternothyroid	Posterior aspect of manubrium	Thyroid cartilage	Branch of ansa cervicalis (C2, C3)	Depresses hyoid bone and larynx
Thyrohyoid	Thyroid cartilage	Body and greater horn of hyoid bone	Hypoglossal nerve (C1)	Depresses hyoid bone, elevates larynx

Scalene and Prevertebral Muscles

Muscle	Proximal Attachment	Distal Attachment	Nerve and Segmental Level	Action
Longus capitis	Basilar aspect of occipital bone	Anterior tubercles of transverse processes C3-C6	Ventral rami of C1-C3 spinal nerves	Flexes head on neck
Longus colli	Anterior tubercle of C1, bodies of C1-C3, and transverse processes of C3-C6	Bodies of C3-T3 and transverse processes of C3-C5	Ventral rami of C2-C6 spinal nerves	Neck flexion, ipsilateral side-bending, and rotation
Rectus capitis anterior	Base of skull anterior to occipital condyle	Anterior aspect of lateral mass of C1	Branches from loop between C1 and C2 spinal nerves	Flexes head on neck
Rectus capitis lateralis	Jugular process of occipital bone	Transverse process of C1	Branches from loop between C1 and C2 spinal nerves	Flexes head and assists in stabilizing head on neck

Posterior Muscles of the Neck

Muscle	Proximal Attachment	Distal Attachment	Nerve and Segmental Level	Action
Upper trapezius	Superior nuchal line, occipital protuberance, nuchal ligament, spinous processes of C7-T12	Lateral clavicle, acromion, and spine of scapula	Spinal root of accessory nerve	Elevates scapula
Levator scapulae	Transverse processes of C1-C4	Superomedial border of scapula	Dorsal scapular nerve (C3, C4, C5)	Elevates scapula and inferiorly rotates glenoid fossa
Semispinalis capitis and cervicis	Cervical and thoracic spinous processes	Superior spinous processes and occipital bone	Dorsal rami of spinal nerves	Bilaterally: extends neck Unilaterally: ipsilateral side-bending
Splenius capitis and cervicis	Spinous processes of T1-T6 and ligamentum nuchae	Mastoid process and lateral superior nuchal line	Dorsal rami of middle cervical spinal nerves	Bilaterally: head and neck extension Unilaterally: ipsilateral rotation
Longissimus capitis and cervicis	Superior thoracic transverse processes and cervical transverse processes	Mastoid process of temporal bone and cervical transverse processes	Dorsal rami of cervical spinal nerves	Head extension, ipsilateral side-bending, and rotation of head and neck
Spinalis cervicis	Lower cervical spinous processes of vertebrae	Upper cervical spinous processes of vertebrae	Dorsal rami of spinal nerves	Bilaterally: extends neck Unilaterally: ipsilateral side-bending of neck
Suboccipital Muscles
Rectus capitis posterior major	Spinous process of C2	Lateral inferior nuchal line of occipital bone	Suboccipital nerve (C1)	Head extension and ipsilateral rotation
Rectus capitis posterior minor	Posterior arch of C1	Medial inferior nuchal line	Suboccipital nerve (C1)	Head extension and ipsilateral rotation
Obliquus capitis superior	Transverse process of C1	Occipital bone	Suboccipital nerve (C1)	Head extension and side-bending
Obliquus capitis inferior	Spinous process of C2	Transverse process of C1	Suboccipital nerve (C1)	Ipsilateral neck rotation

Nerves

Nerves	Segmental Levels	Sensory	Motor
Dorsal scapular	C4, C5	No sensory	Rhomboids, levator scapulae
Suprascapular	C4, C5, C6	No sensory	Supraspinatus, infraspinatus
Nerve to subclavius	C5, C6	No sensory	Subclavius
Lateral pectoral	C5, C6, C7	No sensory	Pectoralis major
Medial pectoral	C8, T1	No sensory	Pectoralis major Pectoralis minor
Long thoracic	C5, C6, C7	No sensory	Serratus anterior
Medial cutaneous of arm	C8, T1	Medial aspect of arm	No motor
Medial cutaneous of forearm	C8, T1	Medial aspect of forearm	No motor
Upper subscapular	C5, C6	No sensory	Subscapularis
Lower subscapular	C5, C6, C7	No sensory	Subscapularis, teres major
Thoracodorsal	C6, C7, C8	No sensory	Latissimus dorsi
Axillary	C5, C6	Lateral shoulder	Deltoid, teres minor
Radial	C5, C6, C7, C8, T1	Dorsal lateral aspect of hand, including the thumb and up to the base of digits 2 and 3	Triceps brachii, brachioradialis, anconeus, extensor carpi radialis longus, extensor carpi radialis brevis
Median	C5, C6, C7, C8, T1	Palmar aspect of lateral hand, including lateral half of digit 4, dorsal distal half of digits 1-3, and lateral border of digit 4	Pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor pollicis longus, flexor digitorum profundus (lateral half), pronator quadratus, lumbricals to digits 2 and 3, thenar muscles
Ulnar	C8, T1	Medial border of both palmar and dorsal hand, including medial half of digit 4	Flexor carpi ulnaris, flexor digitorum profundus (medial half), palmar interossei, adductor pollicis, palmaris brevis, dorsal interossei, lumbricals to digits 4 and 5, hypothenar muscles
Musculocutaneous	C5, C6, C7	Lateral forearm	Coracobrachialis, biceps brachii, brachialis

Patient History

Initial Hypotheses Based on Patient History

History	Initial Hypotheses
Patient reports diffuse nonspecific neck pain that is exacerbated by neck movements	Mechanical neck pain Cervical facet syndrome Cervical muscle strain or sprain
Patient reports pain in certain postures that is alleviated by positional changes	Upper crossed postural syndrome
Traumatic mechanism of injury with complaint of nonspecific cervical symptoms that are exacerbated in the vertical positions and relieved with the head supported in the supine position	Cervical instability, especially if patient reports dysesthesias of the face occurring with neck movement
Reports of nonspecific neck pain with numbness and tingling into one upper extremity	Cervical radiculopathy
Reports of neck pain with bilateral upper extremity symptoms with occasional reports of loss of balance or lack of coordination of the lower extremities	Cervical myelopathy

Cervical Zygapophyseal Pain Syndromes

Figure 3-11, Pain referral patterns. Distribution of zygapophyseal pain referral patterns as described by Dwyer and colleagues. 4

Figure 3-12, Pain referral patterns. Probability of zygapophyseal joints at the segments indicated being the source of pain, as described by Cooper and colleagues. 5

Reliability of the Cervical Spine Historical Examination

Historical Question and Study Quality	Possible Responses	Population	Interexaminer Reliability
Mode of onset	Gradual, sudden, or traumatic	22 patients with mechanical neck pain	κ = .72 (.47, .96)
Nature of neck symptoms	Constant or intermittent		κ = .81 (.56, 1.0)
Prior episode of neck pain	Yes or No		κ = .90 (.70, 1.0)
Turning the head aggravates symptoms	Yes or No		(Right) κ = −.04 (2.11, .02) ∗ (Left) κ = 1.0 (1.0, 1.0)
Looking up and down aggravates symptoms	Yes or No		(Down) κ = .79 (.51, 1.0) (Up) κ = .80 (.55, 1.0)
Driving aggravates symptoms	Yes or No		κ = −.06 (−.39, .26) ∗
Sleeping aggravates symptoms	Yes or No		κ = .90 (.72, 1.0)
Which of the following symptoms are most bothersome for you?	Pain Numbness and tingling Loss of feeling	50 patients with suspected cervical radiculopathy or carpal tunnel syndrome	κ = .74 (.55, .93)
Where are your symptoms most bothersome?	Neck Shoulder or shoulder blade Arm above elbow Arm below elbow Hands and/or fingers		κ = .83 (.68, .96)
Which of the following best describes the behavior of your symptoms?	Constant Intermittent Variable		κ = .57 (.35, .79)
Does your entire affected limb and/or hand feel numb?	Yes or No		κ = .53 (.26, .81)
Do your symptoms keep you from falling asleep?	Yes or No		κ = .70 (.48, .92)
Do your symptoms improve with moving your neck?	Yes or No		κ = .67 (.44, .90)

∗ Question had a high percentage of agreement but a low κ because 95% of participants answered “yes.”

Diagnostic Utility of Patient Complaints for Cervical Radiculopathy

Complaint and Study Quality	Description and Positive Findings	Population	Reference Standard	Sens	Spec	+LR	−LR
Weakness	Not specifically described	183 patients referred to electrodiagnostic laboratories	Cervical radiculopathy via electrodiagnostics	.65	.39	1.07	.90
Numbness				.79	.25	1.05	.84
Arm pain				.65	.26	.88	1.35
Neck pain				.62	.35	.95	1.09
Tingling				.72	.25	.96	1.92
Burning				.33	.63	.89	1.06

Complaint and Study Quality	Description and Positive Findings	Population	Reference Standard	Sens	Spec	+LR	−LR ∗
Which of the following symptoms are most bothersome for you?	Pain	82 consecutive patients referred to electrophysiologic laboratory with suspected diagnosis of cervical radiculopathy or carpal tunnel syndrome	Cervical radiculopathy via needle electromyography and nerve conduction studies	.47 (.23, .71)	.52 (.41, .65)	.99 (.56, 1.7)	1.02
	Numbness and tingling			.47 (.23, .71)	.56 (.42, .68)	1.1 (.6, 1.9)	.95
	Loss of feeling			.06 (.00, .17)	.92 (.85, .99)	.74 (.09, 5.9)	1.02
Where are your symptoms most bothersome?	Neck			.19 (.00, .35)	.90 (.83, .98)	1.9 (.54, 6.9)	.90
	Shoulder or scapula			.38 (.19, .73)	.84 (.75, .93)	2.3 (1.0, 5.4)	.74
	Arm above elbow			.03 (.14, .61)	.93 (.86, .99)	.41 (.02, 7.3)	1.04
	Arm below elbow			.06 (.00, .11)	.84 (.75, .93)	.39 (.05, 2.8)	1.12
	Hands and/or fingers			.38 (.14, .48)	.48 (.36, .61)	.73 (.37, 1.4)	1.29
Which of the following best describes the behavior of your symptoms?	Constant			.12 (.00, .27)	.84 (.75, .93)	.74 (.18, 3.1)	1.05
	Intermittent			.35 (.13, .58)	.62 (.50, .74)	.93 (.45, 1.9)	1.05
	Variable			.53 (.29, .77)	.54 (.42, .66)	1.2 (.68, 1.9)	.87
Does your entire affected limb and/or hand feel numb?	Yes or No			.24 (.03, .44)	.73 (.62, .84)	.87 (.34, 2.3)	1.04
Do your symptoms keep you from falling asleep?				.47 (.23, .71)	.60 (.48, .72)	1.19 (.66, 2.1)	.88
Do your symptoms improve with moving your neck?				.65 (.42, .87)	.71 (.60, .82)	2.23 (1.3, 3.8)	.49

∗ −LR in this table has been calculated by the authors.

Physical Examination Tests

Neurologic Examination

Reliability of Sensation Testing

Figure 3-14, Dermatomes of the upper limb.

Test and Study Quality	Description and Positive Findings	Population	Reliability
Identifying sensory deficits in extremities	No details given	8924 adult patients who presented to emergency department after blunt trauma to head/neck and had Glasgow Coma Score of 15	Interexaminer κ = .60

Diagnostic Utility of Pinprick Sensation Testing for Cervical Radiculopathy

Test and Study Quality	Description and Positive Findings	Population	Reference Standard	Sens	Spec	+LR	−LR
C5 Dermatome	Pinprick sensation testing. Graded as “normal” or “abnormal”	82 consecutive patients referred to electrophysiologic laboratory with suspected diagnosis of cervical radiculopathy or carpal tunnel syndrome	Cervical radiculopathy via needle electromyography and nerve conduction studies	.29 (.08, .51)	.86 (.77, .94)	2.1 (.79, 5.3)	.82 (.60, 1.1)
C6 Dermatome				.24 (.03, .44)	.66 (.54, .78)	.69 (.28, 1.8)	1.16 (.84, 1.6)
C7 Dermatome				.18 (.00, .36)	.77 (.66, .87)	.76 (.25, 2.3)	1.07 (.83, 1.4)
C8 Dermatome				.12 (.00, .27)	.81 (.71, .90)	.61 (.15, 2.5)	1.09 (.88, 1.4)
T1 Dermatome				.18 (.00, .36)	.79 (.68, .89)	.83 (.27, 2.6)	1.05 (.81, 1.4)
Decreased sensation to pinprick	Not specifically described	183 patients referred to electrodiagnostic laboratories	Cervical radiculopathy via electrodiagnostics	.49	.64	1.36	.80

Reliability of Manual Muscle Testing

Figure 3-15, Manual muscle testing of the upper limb.

Test and Study Quality	Description and Positive Findings	Population	Reliability
Identifying motor deficits in the extremities	No details given	8924 adult patients who presented to emergency department after blunt trauma to head/neck and had Glasgow Coma Score of 15	Interexaminer κ = .93

Diagnostic Utility of Manual Muscle Testing for Cervical Radiculopathy

Test and Study Quality	Description and Positive Findings	Population	Reference Standard	Sens	Spec	+LR	−LR
MMT deltoid	Standard strength testing using methods of Kendall and McCreary. Graded as “normal” or “abnormal”	82 consecutive patients referred to electrophysiologic laboratory with suspected diagnosis of cervical radiculopathy or carpal tunnel syndrome	Cervical radiculopathy via needle electromyography and nerve conduction studies	.24 (.03, .44)	.89 (.81, .97)	2.1 (.70, 6.4)	.86 (.65, 1.1)
MMT biceps brachii				.24 (.03, .44)	.94 (.88, 1.0)	3.7 (1.0, 13.3)	.82 (.62, 1.1)
MMT extensor carpi radialis longus/brevis				.12 (.00, .27)	.90 (.83, .98)	1.2 (.27, 5.6)	.98 (.81, 1.2)
MMT triceps brachii				.12 (.00, .27)	.94 (.88, 1.0)	1.9 (.37, 9.3)	.94 (.78, 1.1)
MMT flexor carpi radialis				.06 (.00, .17)	.89 (.82, .97)	.55 (.07, 4.2)	1.05 (.91, 1.2)
MMT abductor pollicis brevis				.06 (.00, .17)	.84 (.75, .93)	.37 (.05, 2.7)	1.12 (.95, 1.3)
MMT first dorsal interosseus				.03 (.00, .10)	.93 (.87, .99)	.40 (.02, 7.0)	1.05 (.94, 1.2)

Diagnostic Utility of Muscle Stretch Reflex Testing for Cervical Radiculopathy

Test and Study Quality	Description and Positive Findings	Population	Reference Standard	Sens	Spec	+LR	−LR
Biceps brachii MSR	Tested bilaterally using standard reflex hammer. Graded as “normal” or “abnormal”	82 consecutive patients referred to electrophysiologic laboratory with suspected diagnosis of cervical radiculopathy or carpal tunnel syndrome	Cervical radiculopathy via needle electromyography and nerve conduction studies	.24 (.3, .44)	.95 (.90, 1.0)	4.9 (1.2, 20.0)	.80 (.61, 1.1)
Brachioradialis MSR				.06 (.00, .17)	.95 (.90, 1.9)	1.2 (.14, 11.1)	.99 (.87, 1.1)
Triceps MSR				.03 (.00, .10)	.93 (.87, .99)	.40 (.02, 7.0)	1.05 (.94, 1.2)
Biceps	Not specifically described	183 patients referred to electrodiagnostic laboratories	Cervical radiculopathy via electrodiagnostics	.10	.99	10.0	.91
Triceps				.10	.95	2.0	.95
Brachioradialis				.08	.99	8.0	.93

Screening for Cervical Spine Injury

$Figure 3-17, Compression fracture of the cervical spine.$

NEXUS Low-Risk Criteria

Cervical spine radiography is indicated for patients with trauma unless they meet all of the following criteria:	1. No posterior midline cervical spine tenderness
	2. No evidence of intoxication
	3. Normal level of alertness
	4. No focal neurologic deficit
	5. No painful distracting injuries

Diagnostic Utility of the Clinical Examination for Identifying Cervical Spine Injury

Test and Study Quality	Description and Positive Findings	Population	Reference Standard	Sens	Spec	+LR	−LR
NEXUS Low-Risk Criteria	See Figure 3-18	34,069 patients who presented to emergency department after blunt trauma and had cervical spine radiography	Clinically important cervical spine injury demonstrated by radiography, computed tomography (CT), or magnetic resonance imaging (MRI)	.99 (.98, 1.0)	.13 (.13, .13)	1.14	.08
NEXUS Low-Risk Criteria	See Figure 3-18	320 elderly patients (65 years or older) who presented to emergency department after blunt trauma	Clinically important cervical spine injury demonstrated by CT	.66	.60	1.65	.57
NEXUS Low-Risk Criteria	See Figure 3-18	8924 alert adult patients who presented to emergency department after blunt trauma to head/neck	Clinically important cervical spine injury defined as any fracture, dislocation, or ligamentous instability demonstrated by radiography, CT, and/or a telephone follow-up	.93 (.87, .96)	.38 (.37, .39)	1.50	.18
NEXUS Low-Risk Criteria	See Figure 3-18	7438 alert adult patients who presented to emergency department after blunt trauma to head/neck		.91 (.85, .94)	.37 (.36, .38)	1.44	.24
Canadian C-Spine Rule	See Figure 3-18			.99 (.96, 1.0)	.45 (.44, .46)	1.80	.02
Canadian C-Spine Rule		8924 alert adult patients who presented to emergency department after blunt trauma to head/neck		1.0 (.98, 1.0)	.43 (.40, .44)	1.75	.00
Canadian C-Spine Rule				1.0 (.94, 1.0)	.44 (.43, .45)	1.79	.00
Physician judgment	Physicians were asked to estimate the probability that the patient would have a clinically important cervical spine injury by circling one of the following: 0%, 1%, 2%, 3%, 4%, 5%, 10%, 20%, 30%, 40%, 50%, 75%, or 100%	6265 alert adult patients who presented to emergency department after trauma to head/neck	Clinically important cervical spine injury demonstrated by radiography, CT, and/or a telephone follow-up	.92 (.82, .96)	.54 (.53, .55)	2.00	.15
Clinical examination	Patient history, including mechanism of injury and subjective complaints of neck pain and/or neurologic deficits, followed by physical examination of tenderness to palpation, abnormalities to palpation, and neurologic deficits	534 patients consulting a level I trauma center after blunt trauma to head/neck	Cervical fracture via CT	.77	.55	1.70	.42
Clinical examination	Among subset of patients with a Glasgow Coma Score of 15 (i.e., alert), who were not intoxicated, and who did not have a distracting injury		Cervical fracture via CT	.67	.62	1.76	.54

Range-of-Motion Measurements

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