Cervical spine clearance — the NEXUS criteria

The five NEXUS criteria for the clinical clearance of the cervical spine are: (1) no midline cervical tenderness, (2) no focal neurological deficit, (3) a normal level of alertness (a fully awake and oriented patient, not intoxicated), (4) no intoxication (no alcohol, no drugs, no metabolic), and (5) no painful distracting injury (no long-bone fracture, no large laceration, no thermal injury that would distract the patient from the cervical-spine pain). All five must be met to clear the cervical spine clinically; the failure of any one mandates the imaging.^[2] The limitations are that the NEXUS criteria have a high sensitivity but a lower specificity (the derivation specificity 12.9 per cent, so many patients are imaged unnecessarily). In the geriatric subgroup analysis (2,943 patients aged 65 and over), the injury rate was doubled (4.59 per cent versus 2.19 per cent) with the odontoid fractures over-represented (20 per cent versus 5 per cent), and the instrument was 100 per cent sensitive (95 per cent CI 97.1–100 per cent) for the clinically significant injury with a comparable imaging reduction — so the rule can be applied safely, but the threshold for the CT remains low. The Canadian C-Spine Rule is an alternative that was more sensitive (99.4 per cent versus 90.7 per cent) and more specific (45.1 per cent versus 36.8 per cent) head-to-head, missing 1 versus 16 important injuries. The CT is now the standard imaging for the high-risk patient, replacing the plain radiographs.^[2][1][3][4]