The National Emergency X-Radiography Utilization Study (NEXUS) Criteria provide a validated, evidence-based approach to clearing the cervical spine clinically in trauma patients.
Clinical Context
Prior to the validation of the NEXUS criteria, standard trauma protocols often dictated that nearly all patients presenting with blunt trauma, especially those arriving on a backboard and wearing a cervical collar, undergo cervical spine radiography. This led to massive resource utilization and radiation exposure, despite a very low incidence of actual cervical spine fractures.
The Five Criteria
According to the NEXUS rule, cervical spine imaging is unnecessary if the patient meets all of the following criteria:
- Absence of Midline Cervical Tenderness: No pain is elicited upon palpation of the posterior midline of the neck.
- No Focal Neurologic Deficit: No sensory or motor deficits are present on neurological examination.
- Normal Level of Alertness: The patient is fully alert and oriented (GCS 15).
- No Evidence of Intoxication: The patient does not appear to be under the influence of alcohol or illicit drugs.
- No Painful Distracting Injury: There are no other significant injuries that might distract the patient from perceiving neck pain.
Clinical Decision Rule: Imaging indicated UNLESS all 5 low-risk criteria are met: No focal deficit, no midline tenderness, normal alertness, no intoxication, no distracting injury.
Application and Efficacy
If a patient fails even one of these criteria, cervical spine imaging (typically a CT scan in modern trauma centers) is indicated. When applied correctly, the NEXUS criteria have a sensitivity of nearly 99.6% for detecting significant cervical spine injuries, making it an exceptionally safe rule-out tool.