EBQ:NEXUS cervical trauma rule

Under Review Journal Club Article

Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI.. "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. 2001. 343(2):94-9.
PubMed Full text PDF

Clinical Question

Can a clinical decision rule be used to evaluate the need for radiography of the cervical spine after blunt trauma?

Conclusion

The NEXUS C-spine rule is a highly sensitive decision rule used to determine the need for radiography in patients with blunt trauma.

Major Points

Five Main Questions:

Is a focal neurologic deficit present?
Is there midline spinal tenderness?
Does the patient have altered mental status?
Is the patient intoxicated?
Does the patient have an apparent distracting injury?

If the answer is "yes" to any of these questions, imaging in recommended.

Rule had 99% sensitivity and 12.9% specificity for identifying 810 patients with cervical spine injury.

Study Design

Multicenter, prospective, observational study of ED patients with blunt trauma for whom cervical spine imaging is ordered.^[1]
Completed in 21 centers across the United States (community and university hospitals)
Each center had a physician who served as liaison to the study (received 1 hour training), and a designated radiologist who ensured correct data collection
Physicians allowed to order images of patients at their own discretion
- Imaging was an X-ray series of 3 views of C-spine (cross table lateral, AP, open mouth odontoid) unless CT/MRI performed
All physicians submitted prospective data on all patients before imaging completed, unless patient was clinically unstable

Population

Patient Demographics

Mean age: 37 (range 1-101 years) Gender: 58.7% male

Inclusion Criteria

Patients with blunt trauma who underwent radiography of the C-spine in participating ED
Decision wheher to order radiography was made at discretion of the treating physician, according to the criteria he or she ordinarily used

Exclusion Criteria

Interventions

Outcomes

n=34,069 patient evaluated y imaging of cervical spine

Primary Outcome

818 (2.4%) had radiographically documented cervical-spine injury 578 (1.7%) had clinically significant cervical-spine injury

Not clinically significant cervical-spine injuries
- Spinous-process fracture
- Simple wedge-compression fracture with < 25% loss of vertebral-body heigt
- Isolated avulsion without associated ligamentous injury
- Type I odontoid fracture
- End-plate fracture
- Osteophyte fracture, not including corner fracture or teardrop fracture
- Injury to trabecular bone
- Tranverse-process fracture

Secondary Outcomes

Subgroup analysis

Criticisms & Further Discussion

External Links

Funding

References

↑ 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.

Authors:

[Methods-1] 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.

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