OBJECTIVE: The Canadian C-Spine Rule (CCR) and the National Emergency 
X-Radiography Utilization Study (NEXUS) criteria are two commonly used clinical 
decision rules which use midline cervical spine (c-spine) tenderness on 
palpation as an indication for c-spine imaging post-trauma. This study was 
undertaken to determine the prevalence and location of midline c-spine 
tenderness in the non-trauma population.
METHODS: We prospectively evaluated consenting adult patients presenting to an 
urban ED or university sport medicine clinic in Montreal, Canada between 2018 
and 2020 for atraumatic non-head and neck-related reports over a 20-month 
period. The presence and location of pain during midline c-spine palpation as 
assessed by two examiners during separate evaluations was recorded. Patient 
information such as age, neck length and circumference, gender, body mass index 
(BMI) and scaphoid tenderness was also collected.
RESULTS: Of 478 patients enrolled, 286 (59.8%) had midline c-spine tenderness on 
palpation with both examiners. The majority of those with tenderness were female 
(70.6%). When examining all patients, tenderness was present in the upper third 
of the c-spine in 128 (26.8%) patients, middle third in 270 (56.5%) patients and 
lower third in 6 (1.3%) patients. Factors associated with having increased odds 
of midline c-spine tenderness on palpation included a lower BMI and the presence 
of scaphoid tenderness on palpation.
CONCLUSIONS: There is a high prevalence of c-spine tenderness on palpation in 
patients who have not undergone head or neck trauma. This finding may help 
explain the low specificity in some of the validation studies examining the CCR 
and the NEXUS criteria.