The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients

Paykin, Gabriel; O’Reilly, Gerard; Ackland, Helen M; Mitra, Biswadev

doi:10.1016/j.injury.2017.02.013

Cited by 29 publications

(19 citation statements)

References 33 publications

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“…13 Recently, it has been suggested that the NEXUS criteria may not maintain the same validity for excluding injury in certain population subgroups such as the elderly. 10,15,16 Older blunt trauma patients constitute a unique subset of the general trauma population and must be assessed independently. Previous reviews have not evaluated the sensitivity of the NEXUS criteria in this population.…”

Section: Introductionmentioning

confidence: 99%

Review article: NEXUS criteria to rule out cervical spine injury among older patients: A systematic review

Paykin

O’Reilly

Ackland

et al. 2017

Emerg Medicine Australasia

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The National Emergency X-Radiography Utilization Study (NEXUS) criteria were derived from a heterogeneous group of adult blunt trauma patients, with the outcome measure assessed most commonly using plain X-ray radiographs. Recent observations have suggested inadequacy of these criteria for excluding injury in population subgroups such as the elderly. The aim of this systematic review was to determine the sensitivity of the NEXUS criteria in excluding cervical spine injury among older patients aged ≥65 years. A systematic review of the literature published prior to 1 January 2017 that reported on the performance of the NEXUS criteria among older patients was conducted. The databases OVID Embase and OVID Medline were searched. The sensitivity of the NEXUS criteria was recalculated for each study among older patients. There were seven studies included in this review. All studies were considered to be at risk of bias and rated down for quality of evidence. Emergency physicians were assessors in all included studies. Sensitivity of the NEXUS criteria among older patients ranged from 66% to 100%. Variable sensitivity was demonstrated when the NEXUS criteria were applied to older blunt trauma patients. This questions the applicability of the NEXUS criteria in this subgroup.

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Section: Introductionmentioning

confidence: 99%

Review article: NEXUS criteria to rule out cervical spine injury among older patients: A systematic review

Paykin

O’Reilly

Ackland

et al. 2017

Emerg Medicine Australasia

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“…It is also possible that demographic characteristics, such as age, injury characteristics, mechanism of injury and associated injuries can be added to refine the tool to increase specificity. For example, age has been suggested as a limitation to the National Emergency X‐Radiography Utilization Study criteria for cervical spine assessment . However, perceived benefits of the current tool are its simplicity and similarities to commonly utilized assessment tools for the cervical spine.…”

Section: Discussionmentioning

confidence: 99%

Clinical clearance of the thoracic and lumbar spine: a pilot study

Mitra

El‐Menyar

Mercier

et al. 2019

ANZ Journal of Surgery

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Background: In patients who are awake with normal mental and neurologic status, it has been suggested that the thoracolumbar (TL) spine may be cleared by clinical examination, irrespective of the mechanism of injury. The aim of this pilot study was to test the feasibility and accuracy of a clinical decision tool focused towards clearance of the TL spine during assessment of patients in the emergency department after trauma. Methods: A prospective interventional study was conducted at two major trauma centres. The intervention of a clinical decision tool for assessment of the TL spine was applied prospectively to all patients with subsequent imaging results acting as the comparator. The primary outcome variable was fracture of the thoracic or lumbar vertebra(e). The clinical decision tool was assessed using sensitivity and specificity for detecting a TL fracture and reported with 95% confidence intervals (CIs). Results: There were 188 cases included for analysis that all underwent imaging of the thoracic and/or lumbar vertebrae. There were 34 (18%) patients diagnosed with fractures of the thoracic and/or lumbar vertebrae. In this pilot study, sensitivity of the clinical decision tool was 100% (95% CI 87.3-100%) and specificity was 37.0% (95% CI 29.5-45.2%) for the detection of a thoracic or lumbar vertebral fracture. Conclusions: Feasibility of clinical clearance of the TL spine in two major trauma centres was demonstrated in a clinical study setting. Evaluation of this clinical decision tool in patients following blunt trauma, particularly in reducing imaging rates, is indicated using a larger prospective study.

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“…[1][2][3] The paradigm shift to computed tomography (CT) as the standard imaging modality warrants reassessment of the NEXUS criteria secondary to the enhanced cervical spine injury detection provided by CT. [4][5][6][7][8][9][10][11][12][13] Recent external validations have raised concern regarding the use of the NEXUS criteria in geriatric trauma, though the existing literature offers little consensus with NEXUS sensitivity ranging from 65.9% to 94.8%. [14][15][16] One considerable confound in this literature, however, is the frequent exclusion of non-geriatric patients. 15,16 Without the appropriate population of younger counterparts, it is difficult to ascertain whether the findings in the geriatric population are truly age-specific.…”

Section: Introductionmentioning

confidence: 99%

“…[14][15][16] One considerable confound in this literature, however, is the frequent exclusion of non-geriatric patients. 15,16 Without the appropriate population of younger counterparts, it is difficult to ascertain whether the findings in the geriatric population are truly age-specific. The existing literature is also limited by an inconsistent consideration for whether missed injuries were clinically significant.…”

Section: Introductionmentioning

confidence: 99%

“…The existing literature is also limited by an inconsistent consideration for whether missed injuries were clinically significant. 14,16 Additionally, some investigations restricted the scope to low-or high-energy mechanisms of injury. 14,15 To enhance the current understanding of the relationship between the NEXUS criteria and patient age, the present study aimed to compare the NEXUS criteria's sensitivity in identifying individuals with significant cervical spine fracture (CF) between non-geriatric (age <65 years) and geriatric (age ≥65 years) patients sustaining injury from any blunt trauma mechanism.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2019

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Background: The NEXUS criteria lack an age consideration. This study characterizes NEXUS sensitivity for significant cervical fracture (CF) in non-geriatric (18-64 years) and geriatric (≥65 years) patients.Methods: This was a single-institution, retrospective review of blunt trauma patients (admitted between January 1, 2011 and December 31, 2016). Significant CF was an acute injury requiring surgery/orthosis. Propensity matching was used.Results: Overall, 353 patients had significant CF and notably 101 (28.6%) denied neck pain and tenderness at presentation. There were 162 geriatric patients with 17 patients who failed to meet any NEXUS criterion (sensitivity: 89.5%). The remaining 191 patients were non-geriatric, only six failed to meet any NEXUS criterion (sensitivity: 96.8%). NEXUS sensitivity was reduced among geriatric patients (89.5% vs. 96.8%, p=0.01), even after propensity matching (n=73/group; 86.3% vs. 97.3%, p=0.02).Conclusions: Alarmingly, 28.6% of patients with significant CF denied pain and tenderness. NEXUS demonstrated reduced sensitivity in the geriatric cohort, even after propensity matching. Liberal imaging is recommended for geriatric patients.

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The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients

Cited by 29 publications

References 33 publications

Review article: NEXUS criteria to rule out cervical spine injury among older patients: A systematic review

Review article: NEXUS criteria to rule out cervical spine injury among older patients: A systematic review

Clinical clearance of the thoracic and lumbar spine: a pilot study

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

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