NEXUS Criteria for C-Spine Imaging
Clear patients from cervical spine fracture without imaging
Reference
Summary
Many blunt trauma patients undergo imaging of their cervical spine but most (98%) imaging studies come back negative for fracture. The NEXUS Criteria is a well-validated clinical decision aid that can be used to determine whether cervical imagining could be safely avoided in alert, stable trauma patients with concerns of possible cervical spine injury (CSI). Studies range in sensitive from 83-100% with majority finding 90-100% sensitivity for ruling out CSI.
The NEXUS Criteria does not have age cut-offs (unlike the Canadian C-spine Rule (CCR). However, caution is advised in applying NEXUS to patients > 65 years old, as the sensitivity may be as low as 66-84%. In a head-to-head trial comparing NEXUS to CCR, CCR had a higher sensitivity (99.4%) than NEXUS (90.7%). However, there are some concerns about the generalizability of the findings.
Additionally, there is controversy over x-rays versus CT as the most appropriate imaging modality. The question is, are X-rays of the c-spine sufficiently sensitive to rule out c-spine injuries in trauma patients or is CT more appropriate in this population (i.e. hospitals). Concern has been raised that NEXUS was derived and validated in an era when plain films were much more commonly ordered. CT imaging is more common now, and evidence suggests that CT may identify CSIs that would be missed by NEXUS and the CCR. Often providers will use both the NEXUS Criteria and the CCR to assist in decision-making.
.Summary
The NEXUS Criteria is a well-validated clinical decision aid that can be used to determine whether cervical imagining could be safely avoided in alert, stable trauma patients with concerns of possible cervical spine injury (CSI).
Recommendations and Criteria
| Recommendations | Criteria |
| Imaging is not required | All of the criteria false
|
| Consider imaging | Any of the criteria true
|
Management Considerations
If a c-spine injury is identified on imaging:
- Maintain cervical spine protection with appropriate collar.
- Consult neurosurgery.
- Keep patient NPO and non-ambulatory until treatment plan is complete.
- Patient may require emergent operative stabilization or admission to neurosurgical ICU.
Instructions
Inclusion Criteria
- Alert, stable trauma patient
- No age cut-offs, but evidence of lower sensitivity in ages > 65 years
Literature
- Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998 Oct;32(4):461-9. — Hoffman JR, Wolfson AB, Todd K, Mower WR.
- Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000 Jul 13;343(2):94-9. — Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI.
- The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003 Dec 25;349(26):2510-8. — Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, Worthington JR, Eisenhauer MA, Cass D, Greenberg G, MacPhail I, Dreyer J, Lee JS, Bandiera G, Reardon M, Holroyd B, Lesiuk H, Wells GA.
- Retrospective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments. Ann Emerg Med. 2004 Apr;43(4):507-14. — Dickinson G, Stiell IG, Schull M, Brison R, Clement CM, Vandemheen KL, Cass D, McKnight D, Greenberg G, Worthington JR, Reardon M, Morrison L, Eisenhauer MA, Dreyer J, Wells GA.
- Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ. 2012 Nov 6;184(16):E867-76. — Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CW.
- The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients. Injury. 2017 May;48(5):1020-1024. — Paykin G, O'Reilly G, Ackland HM, Mitra B.
- Jennifer Glen , DNP, FNP-BC — EVAL Health, Chief Medical Officer