Section V

The diagnosis of cervical spine injuries presents a challenge in emergency practice. The anatomy of the cervical spine is complex, the spectrum of injuries is broad, and the consequences of injury, particularly spinal cord injury, can be devastating. Most serious cervical spine injuries are caused by high-energy forces. However, unstable injuries can occur following relatively minor trauma, such as a fall from a standing position, particularly in the elderly.

Although most cervical spine fractures are radiographically obvious, 10% have subtle radiographic manifestations or even normal radiographs (Mower et al. 2001). Patients at high risk of injury (e.g., severe trauma victims) and those with signs of neurologic injury require imaging with CT and possibly MRI (see Appendix).

Because of the potentially serious consequences of a missed injury, cervical spine radiographs are ordered whenever there is a chance of an injury, even if the risk is small. In fact, fewer than 3% of cervical spine radiographs will reveal injuries.

Two groups of investigators have developed clinical decision rules with the aim of reducing the number of cervical spine radiographs ordered, as well as to objectively validate clinical criteria useful in the decision to order radiographs.

### Nexus Low-Risk Criteria

The National Emergency X-Radiography Utilization Study Group developed the NEXUS Low-Risk Criteria to guide the clinician in “clearing” the cervical spine without radiography (Table 1) (Hoffman et al. 2000). In prior empirically derived clinical practice, the “absence of neck pain” was the major criterion used to clinically clear the cervical spine. With the NEXUS rule, the more selective criterion “no midline cervical tenderness” is employed instead.

Table 1 NEXUS Low-Risk Criteria

The concept of the NEXUS criteria is that in the absence of factors that interfere with pain perception, patients without midline cervical tenderness do not need radiography. This holds true irrespective of the mechanism of injury or the age of the patient.

The NEXUS criteria are not explicitly defined, but instead depend on the judgment of the clinician. Although this creates imprecision, it avoids the complexity of a list of items defining each criterion. Because of the lack of exact definitions, the NEXUS criteria could be applied differently by different clinicians. The reduction in radiography could thereby vary considerably.

The safety of using the NEXUS rule was prospectively validated in a large multicenter trial that included 34,069 patients. A total of 818 patients had injuries (2.4%), of which 578 (71%) were clinically significant. The decision rule identified all but ...

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