NEXUS Criteria for C-Spine Imaging

Rules out cervical spine injury in stable trauma patients without radiographic imaging.

Refer to the text below the calculator for more information on the criteria and its use.


NEXUS criteria can be used in the evaluation of all alert and stable trauma patients where cervical spine injury is suspected and helps with clinical gestalt on whether radiographic images need to be obtained or not.

It has been prospectively validated in the largest cohort of patients ever studied for this indication and adopting it could decrease imaging by 12 to 36%.


  • If none of the NEXUS criteria are present, then C-Spine can be cleared clinically by these criteria. Further imaging is likely unnecessary.
  • If, however, at least one of the criteria are met, then C-Spine injury cannot be ruled out safely and imaging is required.

1Focal neurologic deficit present
2Midline spinal tenderness present
3Altered level of consciousness present
4Intoxication present
5Distracting injury present
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The Criteria Explained

This is a validated clinical decision tool that helps rule out cervical spine injury in alert, stable trauma patients without the need for radiographic images.

The NEXUS Criteria includes the following:

  • Focal neurologic deficit present;
  • Midline spinal tenderness present;
  • Altered level of consciousness present;
  • Intoxication present;
  • Distracting injury present.

If none of the NEXUS criteria are present, then C-Spine can be cleared clinically by these criteria. Further imaging is likely unnecessary. If, however, at least one of the criteria are met, then C-Spine injury cannot be ruled out safely and imaging is required.

Annually, more than one million people visit U.S. emergency departments due to blunt trauma with potential cervical spine injuries. Despite this high number, an overwhelming 98% of cervical spine imaging tests reveal no fractures. This suggests that much of this imaging may be unnecessary and incurs significant costs.

NEXUS Criteria have been prospectively validated in the largest cohort of patients ever studied for this indication and adopting it could decrease imaging by 12 to 36%.

 

About the Original Study and Validation

The National Emergency X-Radiography Utilization Study (NEXUS) was a multicenter, prospective study designed to define the sensitivity, for detecting significant cervical spine injury, of criteria previously shown to have high negative predictive value.

The original validation checked the performance of the decision rule in 34,069 patients who underwent radiography of the cervical spine after blunt trauma. The decision instrument identified all but 8 of the 818 patients who had CSI, yielding a sensitivity of 99%. The rule missed 2 of the 578 patients with a clinically significant CSI, yielding a sensitivity of 99.6%.

According to the results of the validation study, radiographic imaging could have been avoided in the cases of 4309 (12.6 percent) of the 34,069 evaluated patients.

 

Cervical Spine Assessment After Trauma

The incidence of cervical spine injuries in trauma patients is about 3.7%, with variations based on the patient’s alertness and the severity of the trauma. High-velocity or high-force impacts are typically associated with a higher risk of injury.

The clinical assessment of a trauma patient for cervical spine injuries involves a detailed history and a comprehensive physical examination, focusing on neurologic assessments and the detection of any focal deficits or abnormalities. Initial assessment should adhere to protocols like the Advanced Trauma Life Support (ATLS) guidelines in severe cases, while also incorporating thorough inspections and palpations of the cervical spine.

Two major decision-making protocols are used to determine the need for imaging: the NEXUS criteria and the Canadian C-spine rule. The criteria from these protocols provide a systematic approach to either clear a patient from cervical spine injury or prompt further imaging.

When imaging is deemed necessary, computed tomography (CT) is generally preferred for its accuracy, though five-view plain radiography is used if CT is unavailable.

Delayed presentation of symptoms such as neck pain or reduced mobility can occur, and these cases require careful reassessment as they may indicate missed injuries or gradual worsening of initially stable injuries. Long-term management includes physical therapy and early mobilization, aiming to restore function and manage pain.

 

Comparison to the Canadian C-Spine Rule

Similar to the NEXUS criteria, the Canadian C-Spine rule can be used in the evaluation of all alert (Glasgow Coma Score of 15) and stable trauma patients where cervical spine injury is suspected and can help with clinical gestalt on whether radiographic images need to be obtained or not.

The CCR has been shown to perform similarly to NEXUS in terms of sensitivity for cervical spine injury.

The NEXUS criteria does not have age cut-offs, in contrast to the CCR so can potentially be applied to all patients >1 year of age. However, there is further literature evidence to suggest caution applying NEXUS to patients >65 years of age, as the sensitivity may be as low as 66-84%. In these cases, clinicians may choose to consider further imaging despite the criteria result, where there are further concerns about the mechanism of the trauma or other patient health information.

There are concerns about the fact that the NEXUS criteria were developed and validated at a time when plain film radiography was the standard method for evaluating cervical spine injuries. Today, CT imaging is more frequently used, and there is some evidence suggesting that computed tomography could detect cervical spine injuries that might be overlooked by both NEXUS and the Canadian C-spine rule.

 

References

Original reference

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; 32(4):461-9.

Validation

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; 343(2):94-9.

Other references

Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, Worthington JR, Eisenhauer MA, Cass D, Greenberg G, MacPhail I, Dreyer J, Lee JS, Bandiera G, Reardon M, Holroyd B, Lesiuk H, Wells GA. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003; 349(26):2510-8.

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; 48(5):1020-1024.


Specialty: Traumatology

Type: Criteria

No. Of Items: 5

Year Of Study: 1998

Article By: Denise Nedea

Published On: May 20, 2024

Last Checked: May 20, 2024

Next Review: May 20, 2029