Journal Club: NEXUS C-Spine

Journal Club: Nexus C-Spine
October 1, 2019
In this episode, Dr. Alex Kaminsky delves into cervical spine imaging with NEXUS author Dr. Jerry Hoffman, in this inaugural episode of Journal Club.
Host
Alexander Kaminsky, MD
University of California San Francisco – Fresno
PGY4
@Alex_KamskyEM
EMRA*Cast Episodes
Guests
Jerome (Jerry) Hoffman, MD
Professor Emeritus UCLA School of Medicine.
Co-Founder EM Abstracts
Hospital Affiliation: UCLA
Twitter: @emabstracts
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
Related Content

Oct 14, 2020
Resident Unions Part 1: How Can They Help?
When you received your employment contract after matching into residency, did you read it? Was there any question you would sign it, no matter what it said? The structure of medical training and board certification creates an unequivocal power differential in that employment setting. Can resident unions help? Part 1 of this series gets into the pros and cons of unionization.

Oct 14, 2020
What Would MacGuyver Do? Medical Excellence in Austere Settings
Your patient has an arterial bleed and a tenuous airway. You've got 1 unit of blood, no vent, and no hospital within hours. Welcome to the world of austere medicine. Host Kate Joyce, MD, MPH (@sceneisnotsafe) and USAF Lt Col Regan Lyon, MD, FACEP, discuss the challenges of treating patients in the most extreme scenarios.

Oct 14, 2020
Learning: The Chapter After Residency
Learning is the entire point of residency. But how do you keep building your knowledge base after the structured life of residency gives way to attending or community medicine? Turns out there's a special magic to it. EMRA*Cast host Shreyans Sanghvi, DO, takes notes from accomplished educator, speaker, and street illusionist Salil Bhandari, MD (@salilbhandarimd).