Journal Club: NEXUS C-Spine

Overview:

In this inaugural Journal Club episode, we discuss the over-utilization of cervical spine imaging in traumatic patients via landmark papers from the NEXUS group.

X-radiography of the C-spine has been widely replaced by CT-radiography, but the principles remain the same. Patient with low mechanism injuries are often over-irradiated due to physician fears of a statistically small percentage of true clinically significant C-spine injuries. Physicians often neglect to recognize the number needed to harm during diagnostic studies. This is particularly important in C-spine imaging as the anatomic target is directly adjacent to the radiosensitive thyroid gland.

With the Assistance of Dr. Hoffman (Primary Author), we will delve into the overall study with some advanced pearls.

Key Resources / References:

• Initial Paper: Hoffman JR, Wolfson AB, Todd KH, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med 1998;32:461-469. PMID:9774931 https://www.ncbi.nlm.nih.gov/pubmed/9774931
• Hoffman JR, , Mower WR, Todd KH. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343(2):94-1. PMID: 10891516 https://www.nejm.org/doi/10.1056/NEJM200007133430203?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov
• https://www.mdcalc.com/nexus-criteria-c-spine-imaging#evidence

Key Points:

• NEXUS C-Spine is an INSTRUMENT designed to augment clinical judgement. It was designed to support common-sense practices.
• Criteria – 99.6% Sensitive (If all negative, reassured no significant fracture)
  • No Focal Neurologic Deficit
  • No Altered Consciousness
  • No Intoxication – Requires Judgement (common sense)
  • No Distracting Injury – Requires Judgement (common sense)
    • Is a finger fracture? Is a corneal ulceration?
  • No Midline Tenderness
• Study Highlights
  • >34,000 Patients over 21 hospitals in 4 geographic US regions
  • >800 true positive C-spine injuries identified
  • Sensitivity reported at 99.6%
  • Two clinically significant “misses” identified
    • One likely chronic injury. No change in outcome at follow-up. Patient asymptomatic.
    • One patient underwent surgical intervention
      • Of note authors suggest patient actually did not meet NEXUS criteria as he had paresthesias
• NEXUS C-spine: Overall 12.6% reduction in C-spine imaging