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    NEXUS Criteria for C-Spine Imaging

    Clears patients from cervical spine fracture clinically, without imaging.
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    When to Use
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    Why Use

    The NEXUS Criteria represent a well-validated clinical decision aid that can be used to safely rule out cervical spine injury in alert, stable trauma patients without the need to obtain radiographic images.

    The NEXUS Criteria were developed to help physicians determine whether cervical spine imaging could be safely avoided in appropriate patients.

    • Validation study included a prospective, observational sample of 34,069 patients, aged 1 to 101 years, presenting to 21 US trauma centers. 1.7% of those studied had clinically significant c-spine injuries (CSI). NEXUS Criteria found to have sensitivity of 99.6% for ruling out CSI (2/578).
    • Also detected 99.0% (8/818) of ALL c-spine injuries (6 of which were injuries that didn’t require stabilization or specialized treatment).
    • Adopting this rule could decrease imaging in the these patients by 12.6%.
    • Subsequent studies have found a sensitivity of 83-100% for CSI with majority finding 90-100% sensitivity.

    Points to keep in mind:

    • Unlike the Canadian C-spine Rule (CCR), NEXUS Criteria does not have age cut-offs and is theoretically applicable to all patients > 1 year of age. However, there is literature to suggest caution applying NEXUS to patients > 65 years of age, as the sensitivity may be as low as 66-84%. In a large retrospective trauma registry study of 231,018 patients by Paykin et al in 2017, sensitivity was still only 94.8% (95% CI: 92.1%-96.7%).
    • In the only trial to undertake a prospective head to head comparison of NEXUS to the CCR, the CCR was found to have superior sensitivity (99.4 vs 90.7%). However the trial was performed by the creators of the CCR at hospitals that were involved in the initial CCR validation study. There were also post-hoc “clarifications” added by the authors to the original NEXUS Criteria, leading to some concerns about the generalizability of the study findings.
    • There is also debate about whether x-rays of the c-spine are sufficiently sensitive to rule out c-spine injuries in trauma patients and whether CT is a more appropriate imaging modality in this patient population.
    • There are over 1 million visits to US emergency departments annually for blunt trauma patients who present with a concern for possible cervical spine imaging. Many of these patients undergo imaging of their c-spine, with the overwhelming majority (98%) of the studies coming back negative for a fracture. This imaging is both largely unnecessary, and extremely costly (>$180,000,000 annually).
    • Applying the NEXUS Criteria would allow physicians to safely reduce imaging between 12-36% in patients presenting with concern for possible cervical spine imaging, avoiding unnecessary radiographic studies and saving significant cost.
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    Next Steps
    Evidence
    Creator Insights

    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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