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NEXUS Criteria for C-Spine Imaging

Clears patients from cervical spine fracture clinically, without imaging.

Advice

The NEXUS Criteria have been prospectively validated in the largest cohort of patients ever studied for this indication. If a patient is NEXUS Criteria negative, further imaging is likely unnecessary.

Management

If a patient has a clinically significant c-spine injury identified on imaging:

  • Maintain cervical spine protection with an appropriate collar
  • Consult Neurosurgery
  • Keep patient non-ambulatory and NPO until treatment plan plan is complete
  • Patient may require emergent operative stabilization and/or admission to Neurosurgical ICU.

Critical Actions

The NEXUS Criteria have been prospectively validated in the largest cohort of patients ever studied for this indication. If a patient is NEXUS Criteria negative, further imaging is likely unnecessary.

  • Because of concerns that the NEXUS Criteria do not perform as well among patients > 65 years of age, providers may want to consider further imaging if they are concerned about the mechanism or exam in elderly patients.
  • Although more complicated to remember, the Canadian C-spine Rule appears to perform as well or better than NEXUS in terms of sensitivity for CSI. In cases where a patient does not rule out under the NEXUS Criteria, it may be appropriate to apply the CCR. If the patient is CCR negative then further imaging is probably unnecessary.
    • For example, a patient with midline C-spine tenderness would need imaging according to NEXUS, but could potentially be cleared by the CCR if they did not have any high risk features but could range their necks 45 degrees to the left and right.
  • There is also concern that NEXUS was derived and validated in an era when plain films were much more commonly ordered to assess for C-spine injuries. CT imaging of the C-spine is now much more common, and there is some evidence that computed tomography may identify CSIs that would be missed by NEXUS and/or the CCR.
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