Unfortunately, these studies suffer from great variability in design and none could be considered methodologically robust [67]. Of note are the U.S. based NEXUS Criteria which have received prominent attention after the publication of a huge validation study incorporating more than 34,000 patients [26,68,69]. Clinicians in Canada, Inhibitors,research,lifescience,medical however, have found several of the criteria to be poorly reproducible, namely “presence of intoxication” and “distracting painful injuries”. Moreover, we recently attempted a retrospective

validation of the NEXUS criteria based upon an existing database of 8,924 patients and found that the criteria missed Inhibitors,research,lifescience,medical ten of 148 clinically important injuries, yielding a sensitivity of only 93% [46]. We also found poor performance of the NEXUS criteria in our phase II prospective validation study [70]. We

believe that the NEXUS criteria lack the accuracy and reliability to be useful for widespread clinical use. Previous guideline studies for use by paramedics The necessity to immobilize all victims Inhibitors,research,lifescience,medical of blunt traumatic injuries during ambulance transport remains controversial. Despite the absence of difference in the neurological outcomes of 454 patients with blunt spinal injuries Luminespib clinical trial transported by a U.S. EMS system with full immobilization and Kuala Lumpur, Malaysia with no Inhibitors,research,lifescience,medical immobilization [71], most EMS systems continue to use back board, collar, and head immobilization during transport. We have been able to identify three original research papers that assessed the potential for paramedics to evaluate the c-spine in the field. Domeier conducted a large prospective cohort study evaluating selective immobilization by paramedics in 13,357 patients, 415 of which had cervical spine injuries [72]. Paramedics did not immobilize Inhibitors,research,lifescience,medical 33 of the 415 patients with

spine injuries, none of which sustained a spinal cord lesion. Stroh retrospectively reviewed the health records of 861 patients transported to a trauma-receiving Linifanib (ABT-869) hospital using a selective immobilization strategy, and subsequently discharged with the diagnosis of cervical spine injury [73]. Five injuries were missed by their c-spine clearance protocol, one of which resulted in an adverse outcome. Muhr compared the immobilization rate in 293 patients before and 281 patients after the implementation of a selective spinal immobilization strategy, and found a 33% reduction in the rate of immobilization [74]. All three papers used the selective immobilization strategy described in the NEXUS studies. In Canada, the Canadian C-Spine Rule (CCR) is currently used in the city of Calgary and the province of Nova Scotia (without formal safety evaluation). Most other Canadian EMS are awaiting further safety evaluation studies before implementing such a program.