What are the nexus criteria for cervical spine (c-spine) injuries?

NEXUS Criteria for C-Spine Injury Assessment

The NEXUS criteria identify five clinical factors that, when all absent, allow safe clearance of the cervical spine without imaging in trauma patients with 99.6% sensitivity for detecting significant cervical spine injuries. 1

The Five NEXUS Criteria

When ANY of these criteria are present, cervical spine imaging is indicated:

1. Midline spinal tenderness - Pain on palpation of the posterior cervical spine
2. Focal neurologic deficit - Any new neurological finding or complaint
3. Altered level of consciousness - GCS <15 or disorientation
4. Intoxication - Clinical evidence of intoxication with drugs or alcohol
5. Distracting injury - Injury severe enough to distract the patient from cervical spine pain

Clinical Application Algorithm

1. Assess all five NEXUS criteria in alert trauma patients

2. If ALL criteria are NEGATIVE (absent):

   • Patient can be cleared clinically without imaging
   • Cervical collar can be safely removed

3. If ANY criterion is POSITIVE (present):

   • Proceed with appropriate cervical spine imaging
   • CT is now preferred over plain radiographs due to significantly higher sensitivity 2

Important Considerations and Limitations

• Elderly patients: Exercise caution when using NEXUS criteria in elderly patients (>65 years), as significant C-spine injuries have been documented in elderly patients who would have been cleared by NEXUS 3

• High sensitivity, low specificity: While NEXUS has excellent sensitivity (99.6%) and negative predictive value (99.9%), it has very low specificity (12.9%), meaning many patients without injury will still undergo imaging 1

• Canadian C-Spine Rule comparison: The Canadian C-Spine Rule has demonstrated higher sensitivity (98.7% vs 89.9%) and specificity compared to NEXUS in direct comparisons 4, and may be more accurate for screening cervical spine injuries

• Paramedic application: Studies show excellent agreement between paramedics and physicians when evaluating patients using these clinical criteria, suggesting potential for prehospital application 5

Modified Approaches

Some recent research suggests a modified Canadian C-Spine Rule (removing dangerous mechanism and simple rear-end motor vehicle collision criteria) may maintain 100% sensitivity while being easier to use in emergency settings 6

Bottom Line

The NEXUS criteria provide a simple, validated approach to determine which trauma patients require cervical spine imaging. When all five criteria are absent, the cervical spine can be safely cleared without imaging. However, in elderly patients or when in doubt, imaging is recommended, with CT being the preferred modality.