EBQ:NEXUS cervical trauma rule
Can a clinical decision rule be used to evaluate the need for radiography of the cervical spine after blunt trauma?
The NEXUS C-spine rule is a highly sensitive decision rule used to guide the use of cervical-spine radiography in patients with blunt trauma.
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.
- The rule had 99% sensitivity and 12.9% specificity for identifying 810 patients with cervical spine injury.
- The Canadian C-spine Rule is also useful for risk stratifying patients into low risk groups that can foregoe cervical spine radiographs. While the NEXUS criteria uses 5 items, the Canadian cervical spine rule uses 3 high risk, 5 low risk and pain free rotation of the neck to stratify trauma patients.
- Multicenter, prospective, observational study of ED patients with blunt trauma for whom cervical spine imaging is ordered.
- 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
Mean age: 37 (range 1-101 years) Sex: 58.7% male
- 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
- Patients with penetrating trauma
- Those who underwent cervical-spine imaging for any other reason, unrelated to trauma
The NEXUS study was an observational trial
n=34,069 patient evaluated y imaging of cervical spine
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
|Any Cervical Spine Injury||Value (95% CI)|
|Negative Predictive Value||99.8 (99.6-100)|
|Positive Predictive Value||2.7 (2.6-2.8)|
|Clinically Significant Cervical Spine Injury||Value (95% CI)|
|Negative Predictive Value||99.9 (99.8-100)|
|Positive Predictive Value||1.9 (1.8-2.0)|
- Good-to-excellent interobserver reliability (kappa, 0.58-0.86)
- Excellent interobserver agreement (kappa, 0.73)
Criticisms & Further Discussion
- Decision rule requires clinical gestault
- Individual criteria such as "distracting injury" not explicitly defined
- The resultant decrease in ordering of radiographs was small than the reduction of almost 30% in previous NEXUS study 
- May reflect an influence of the previous study on participating institutions
- At the time some considered a five views c-spine series to be the standard and thus a false sense of security could be found using less views as was done in this study (cross-table lateral, anteroposterior, open-mouth, and right and left obliques)
- Prospective evaluation of NEXUS in the setting of CT scanning rather than plain films did identify a 0.9% miss rate
- The Canadian cervical spine rule in a single study has been shown to be more sensitive than NEXUS (99.4 percent vs. 90.7 percent, P<0.001) and more specific (45.1 percent vs. 36.8 percent, P<0.001) for injury, and its may result in lower radiography rates
Grant from the Agency for Healthcare Research and Quality
- 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.
- Hoffman JR, SChringer DL, Mower WR, Luo JS, Zucker M. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med 1992;12:1454-60.
- Duane TM. et al. National Emergency X-Radiography Utilization Study criteria is inadequate to rule out fracture after significant blunt trauma compared with computed tomography. J Trauma. 2011 Apr;70(4):829-31
- Stiell, Ian et al. The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. N Engl J Med 2003; 349:2510-2518