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NEXUS Criteria for C-Spine Imaging

Calculators  Musculoskeletal
The National Emergency X-Radiography Utilization Study (NEXUS) Criteria for cervical spine (C-Spine) Imaging helps safely rule out cervical spine fracture without imaging
Focal neurologic deficit present
No 0
Yes 1
Midline spinal tenderness present
No 0
Yes 1
Altered level of consciousness present
No 0
Yes 1
Intoxication present
No 0
Yes 1
Distracting injury present
No 0
Yes 1
Result:

Background

Measured Factor
The need for C-spine imaging because cervical spine fracture cannot be ruled out.
Measured Factor Disease
  • Cervical spine injury
Measured Factor Detail
The NEXUS Criteria for C-Spine Imaging determines if cervical spine injury can be ruled out without imaging in alert and stable trauma patients. It helps emergency physicians  identify the patients who really need radiography of the cervical spine after blunt trauma, based on clinical criteria. Application of this calculator reduces the use of unnecessary and costly  imaging. The C-Spine Imaging can be safely avoided when there was no focal neurologic deficit, midline spinal tenderness, altered level of consciousness, intoxication, or distracting and painful injury.
Speciality
Emergency Medicine Physician
Body System
Musculoskeletal
Measured Factor Low Impact
  • Cervical spine injury is ruled out. Imaging is likely unnecessary.
Measured Factor High Impact
  • High risk for cervical spine injury and imaging is recommended.

Result Interpretation

Ranges Ranges
  • Critical High: Scores ≥ 1: C-Spine imaging is recommended due to high risk for cervical spine injury.
  • Normal: Score 0: Cervical spine injury is ruled out. Imaging is likely unnecessary.
  • Normal Adult Male: Score 0: Cervical spine injury is ruled out. Imaging is likely unnecessary.
  • Normal Adult Female: Score 0: Cervical spine injury is ruled out. Imaging is likely unnecessary.
  • Normal Geriatric Male: Score 0: Cervical spine injury is ruled out. Imaging is likely unnecessary.
  • Normal Geriatric Female: Score 0: Cervical spine injury is ruled out. Imaging is likely unnecessary.
Result High Conditions
  • Cervical spine injury
Test Limitations
The NEXUS criteria are less sensitive in excluding cervical spine fractures in patients aged 65 years or older. Computed tomography should be used in these older patients regardless of whether they meet the NEXUS criteria.
References: 2

Studies

Study Validation 1
This systematic review of 15 studies evaluated the diagnostic accuracy of the Canadian C-spine rule and the National Emergency X-Radiography Utilization Study (NEXUS) criteria. The Canadian C-spine rule was found to have a sensitivity ranged from 0.90 to 1.00 and a specificity ranged from 0.01 to 0.77. The  NEXUS criteria was found to have a sensitivity ranged from 0.83 to 1.00 and a specificity ranged from 0.02 to 0.46. One study directly compared the accuracy of these 2 rules using the same cohort and found that the Canadian C-spine rule had better accuracy. The authors concluded that the Canadian C-spine rule may have better diagnostic accuracy than the NEXUS criteria.
References: 3
Study Validation 2
The purpose of this prospective study was to evaluate the NEXUS Criteria using computed tomography as the gold standard in patients with cervical spine fractures after blunt trauma. In the 1,361 patients with Glasgow Coma Scale score of 15 and without clinical evidence of intoxication or distracting injuries, 1,057 of them had no midline tenderness or neurologic deficits, and therefore would not require radiographic evaluation according to the NEXUS Criteria. However, 26 of them had fractures identified on computed tomography for a sensitivity of 59.4%, specificity of 79.5%, positive predictive value of 12.5%, and negative predictive value of 97.5%. The authors concluded that computed tomography is more accurate than NEXUS Criteria in diagnosing cervical spine fractures and should be used in all blunt trauma patients regardless of whether they meet the NEXUS Criteria.
References: 4
Study Validation 3
This study assessed the sensitivity of the NEXUS criteria in patients aged 65 years or older presenting with blunt trauma. Clinical examination findings were extracted from electronic medical records.  Among 468 patients aged ≥ 65years old and diagnosed with cervical spine fractures, 21 of them were determined to be NEXUS negative. The NEXUS criteria performed with a sensitivity of 94.8% (95% confidence interval: 92.1%-96.7%) on complete case analysis in older blunt trauma patients. One-way sensitivity analysis resulted in a maximum sensitivity limit of 95.5% (95% confidence interval: 93.2%-97.2%). The study concluded that the NEXUS criteria are less sensitive in excluding cervical spine fractures in older blunt trauma patients. The authors suggested that liberal imaging to be considered for patients aged 65 years or older, regardless of whether they meet the NEXUS Criteria.
References: 2
Study Additional 1
This prospective study compared the NEXUS criteria with computed tomography as the gold standard to evaluate cervical spine fractures in blunt trauma patients aged 65 years or older. A total of 320 patients aged 65 years or older (average age, 75 years) and 2465 patients younger than 65 years (average age, 36 years) were included in the study.  Incidence of cervical spine fracture was 12.8 % in the older group versus 7.4% in the younger group (P = 0.002). Age was an independent predictor of fracture (P = 0.01). The NEXUS criteria had a sensitivity of 65.9% and positive predictive value of 19.3% cent in the older group (P = 0.001) versus a sensitivity of 84.2% positive predictive value of 10.6% in the younger group (P < 0.0001). The specificity was 59.5% for the older group versus 42.6% for the younger group (negative predictive value, 92.2% in the older group versus 97.1% in the younger group). This study suggests that NEXUS criteria may not be adequate when applied to severe blunt trauma patients aged 65 years or older, because they might have more missed injures than their younger counterparts.
References: 5

Authors

Jerome Hoffman, MD, is a professor of Medicine and Emergency Medicine at University of California, Los Angeles (UCLA). He ia also the director of the UCLA Doctoring Program. His research focuses on health services research and clinical decision rules, as well as in areas related to medical education.
https://people.healthsciences.ucla.edu/institution/personnel?personnel_id=8185

References

  1. 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. 2000 Jul 13;343(2):94-9.
  2. Paykin G, O'Reilly G, Ackland HM, Mitra B. The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients. Injury. 2017 May;48(5):1020-1024.
  3. Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CW. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ. 2012 Nov 6;184(16):E867-76.
  4. Duane TM, Mayglothling J, Wilson SP, Wolfe LG, Aboutanos MB, Whelan JF, Malhotra AK, Ivatury RR. 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.
  5. Goode T, Young A, Wilson SP, Katzen J, Wolfe LG, Duane TM. Evaluation of cervical spine fracture in the elderly: can we trust our physical examination? Am Surg. 2014 Feb;80(2):182-4.