Why use it

Safely reduces unnecessary c-spine imaging in low-risk trauma patients. Saves time, cost, and radiation exposure. Validated in > 34,000 patients.

About

The NEXUS (National Emergency X-Radiography Utilization Study) criteria identify alert, stable trauma patients who do not require cervical spine imaging. If ALL five criteria are met (absent), the c-spine can be clinically cleared without radiography. Sensitivity > 99% for clinically significant c-spine injury.

When to use

Blunt trauma patients presenting to the ED
Decision on c-spine imaging after trauma
Clinical c-spine clearance

Formula

C-spine imaging NOT needed if ALL absent: 1. No posterior midline cervical tenderness 2. No focal neurological deficit 3. Normal alertness 4. No intoxication 5. No painful distracting injury

Pearls & pitfalls

ALL five criteria must be ABSENT to clear the c-spine.
NEXUS applies to blunt trauma only — not penetrating trauma.
Intoxicated patients cannot have midline tenderness reliably assessed — image them.
Canadian C-Spine Rule has slightly higher sensitivity and specificity in ambulatory patients.
NEXUS may miss injuries in the elderly — consider lower threshold for imaging in patients > 65.
Distracting injury is subjective — err on the side of imaging if uncertain.

Next steps

All criteria absent (NEXUS negative): C-spine can be cleared clinically — no imaging needed. Any criterion present: C-spine imaging required (CT preferred over plain films in most settings).

Evidence

Hoffman et al. (N Engl J Med, 2000). Prospective study of 34,069 patients. Sensitivity 99.6% (missed 8 of 818 injuries; only 2 clinically significant). NPV 99.9%.

References

Hoffman JR et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343(2):94-99. — link

NEXUS C-Spine Rule

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