NEXUS Criteria for C-Spine Imaging

Introduction

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.

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

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.

Hoffman JR, Wolfson AB, Todd K, Mower WR. 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. doi: 10.1016/s0196-0644(98)70176-3. PMID: 9774931.