BACKGROUND: A consistent approach to cervical spine injury (CSI) clearance for 
patients 65 and older remains a challenge. Clinical clearance algorithms like 
the National Emergency X-Radiography Utilisation Study (NEXUS) criteria have 
variable accuracy and the Canadian C-spine rule excludes older patients. Routine 
CT of the cervical spine is performed to rule out CSI but at an increased cost 
and low yield. Herein, we aimed to identify predictive clinical variables to 
selectively screen older patients for CSI.
METHODS: The University of Iowa's trauma registry was interrogated to 
retrospectively identify all patients 65 years and older who presented with 
trauma from a ground-level fall from January 2012 to July 2017. The relationship 
between predictive variables (demographics, NEXUS criteria and distracting 
injuries) and presence of CSI was examined using the generalised linear 
modelling (GLM) framework. A training set was used to build the statistical 
models to identify clinical variables that can be used to predict CSI and a 
validation set was used to assess the reliability and consistency of the model 
coefficients estimated from the training set.
RESULTS: Overall, 2312 patients ≥65 admitted for ground-level falls were 
identified; 253 (10.9%) patients had a CSI. Using the GLM framework, the best 
predictive model for CSI included midline tenderness, focal neurological deficit 
and signs of trauma to the head/face, with midline tenderness highly predictive 
of CSI (OR=22.961 (15.178-34.737); p<0.001). The negative predictive value (NPV) 
for this model was 95.1% (93.9%-96.3%). In the absence of midline tenderness, 
the best model included focal neurological deficit (OR=2.601 (1.340-5.049); 
p=0.005) and signs of trauma to the head/face (OR=3.024 (1.898-4.815); p<0.001). 
The NPV was 94.3% (93.1%-95.5%).
CONCLUSION: Midline tenderness, focal neurological deficit and signs of trauma 
to the head/face were significant in this older population. The absence of all 
three variables indicates lower likelihood of CSI for patients≥65. Future 
observational studies are warranted to prospectively validate this model.