NEXUS Criteria for C-Spine Imaging
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.