Prospective Validation of Modified NEXUS Cervical Spine Injury Criteria in Low-risk Elderly Fall Patients

Abstract

IntroductionThe National Emergency X-radiography Utilization Study (NEXUS) criteria are used extensively in emergency departments to rule out C-spine injuries (CSI) in the general population. Although the NEXUS validation set included 2,943 elderly patients, multiple case reports and the Canadian C-Spine Rules question the validity of applying NEXUS to geriatric populations. The objective of this study was to validate a modified NEXUS criteria in a low-risk elderly fall population with two changes: a modified definition for distracting injury and the definition of normal mentation.MethodsThis is a prospective, observational cohort study of geriatric fall patients who presented to a Level I trauma center and were not triaged to the trauma bay. Providers enrolled non-intoxicated patients at baseline mental status with no lateralizing neurologic deficits. They recorded midline neck tenderness, signs of trauma, and presence of other distracting injury.ResultsWe enrolled 800 patients. One patient fall event was excluded due to duplicate enrollment, and four were lost to follow up, leaving 795 for analysis. Average age was 83.6 (range 65–101). The numbers in parenthesis after the negative predictive value represent confidence interval. There were 11 (1.4%) cervical spine injuries. One hundred seventeen patients had midline tenderness and seven of these had CSI; 366 patients had signs of trauma to the face/neck, and 10 of these patients had CSI. Using signs of trauma to the head/neck as the only distracting injury and baseline mental status as normal alertness, the modified NEXUS criteria was 100% sensitive (CI [67.9–100]) with a negative predictive value of 100 (98.7–100).ConclusionOur study suggests that a modified NEXUS criteria can be safely applied to low-risk elderly falls.

Cervical spine fracture in geriatric blunt trauma: are the NEXUS criteria sensitive enough?

“…16 Recently, a modified version of NEXUS (distracting injury limited to any external head/neck trauma, baseline rather than normal mentation) was applied to geriatric ground level falls not triaged to the trauma bay and reported 100% sensitivity for CF, though the clinical significance of the injury was not considered. 25 In the present population, 11 of the 17 NEXUS-negative geriatric patients presented with a minor sign of trauma (small and superficial laceration, small ecchymosis) to the face or head, which the admitting clinician did not assess to be a painful or distracting injury. Though encouraging, the modified criteria still require dedicated validation of sensitivity and specificity before implementation in this highly specific subset of patients.…”

Appropriate CT cervical spine utilisation in the emergency department

“…16 This study has been validated many times and remains one of the two primary clinical decision tools regarding blunt cervical spine trauma. [24][25][26][27] The Canadian C-Spine Rule is another validated clinical decision support tool. 24 28 The American College of Radiology (ACR) recommendations also support the statement that it would be medically inappropriate to order a CT C-spine on a patient that is determined to be low risk by NEXUS criteria.…”

Early Management of Acute Spinal Cord Injury—Part I: Initial Injury to Surgery

“…35 In alert, unintoxicated patients with no midline tenderness, no distracting injuries, and no neurologic deficits, spinal imaging is not needed according to the NEXUS (National Emergency X-ray Utilization Study) criteria. 36,37 The use and timing of magnetic resonance imaging (MRI) in acute SCI is controversial and depends on clinical circumstances and institutional resources. In high-resource SCI centers, MRI is typically obtained within 48 to 72 hours of injury after cardiopulmonary stabilization to fully assess the neural elements, soft tissues, and ligamentous structures.…”