From the Guidelines
The NEXUS criteria is a clinical decision tool used to determine whether a patient with cervical spine trauma needs imaging, consisting of five criteria: no midline cervical tenderness, no focal neurological deficit, normal alertness, no intoxication, and no painful distracting injury. To apply this tool, clinicians should perform a thorough physical examination, checking for neck pain with palpation, assessing neurological function, evaluating mental status, determining if the patient is under the influence of substances, and identifying any injuries that might distract from neck pain. The criteria are as follows:
- No midline cervical tenderness
- No focal neurological deficit
- Normal alertness
- No intoxication
- No painful distracting injury If all five criteria are met (all negative), the patient has a very low risk of clinically significant cervical spine injury, and imaging can be safely avoided, as shown by the high sensitivity (99.6%) and negative predictive value (99.9%) of the NEXUS criteria 1. This approach is based on extensive validation studies, including the study by the Journal of the American College of Radiology 1, which highlights the importance of the NEXUS criteria in reducing unnecessary radiation exposure and healthcare costs while maintaining patient safety. Other studies, such as the PECARN criteria 1, also support the use of clinical decision tools in evaluating cervical spine trauma, but the NEXUS criteria remain a widely accepted and validated tool for this purpose. The NEXUS criteria is particularly valuable in emergency settings, where rapid and accurate assessment of cervical spine trauma is crucial, and the tool has been shown to be effective in reducing unnecessary imaging and improving patient outcomes 1.
From the Research
National Emergency X-Radiography Utilization Study (NEXUS) Criteria
The NEXUS criteria are a set of clinical decision rules used to identify patients with a low probability of cervical spine injury who do not require cervical spine imaging. The criteria include:
- Posterior midline cervical tenderness
- Focal neurologic deficit
- Level of alertness (altered mental status)
- Evidence of intoxication
- Clinically apparent distracting injury
Application of NEXUS Criteria
Studies have shown that the strict application of the NEXUS low-risk criteria could potentially reduce the number of screening cervical spine CT examinations in the setting of trauma by more than 20% 2. However, some studies have also highlighted the importance of considering other factors, such as patient age and mechanism of injury, when applying the NEXUS criteria 3, 4.
Limitations of NEXUS Criteria
The NEXUS criteria have been found to be less sensitive than previously reported in some studies, with a sensitivity of 92.7% for identifying important cervical spine injury 5. Additionally, some studies have suggested that the NEXUS criteria may not be suitable for use in certain patient populations, such as the elderly 3.
Clinical Decision-Making
The decision to image patients who are NEXUS-negative is often influenced by factors such as patient age, mechanism of injury, and provider level of training 4. However, studies have shown that imaging NEXUS-negative patients can lead to the diagnosis of significant injuries that would otherwise have been missed 4. The use of NEXUS criteria, excluding femur fracture as an indication for imaging, has been found to detect all significant injuries with a sensitivity of 96.2% and a negative predictive value of 99.4% 6.