NEXUS – National Emergency X-Radiography Utilisation Study

Short Citation: N Engl J Med 2000;343(2):94-9.

PubMed PMID: 10891516

Full Citation: Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. 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):94-9. Erratum in: N Engl J Med 2001;344(6):464.

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Study Size: 34,069 (21 centres across USA)

Findings: The decision instrument required patients to meet five criteria in order to be classified as having a low probability of injury:

  1. no midline cervical tenderness,
  2. no focal neurologic deficit,
  3. normal alertness,
  4. no intoxication,
  5. and no painful, distracting injury.

The decision instrument identified all but 8 of the 818 patients who had C-spine injury (sensitivity 99.0%). The negative predictive value was 99.8%, specificity was 12.9%, and the positive predictive value was 2.7%.
Only two of the patients classified as unlikely to have an injury according to the decision instrument met the preset definition of a clinically significant injury (sensitivity, 99.6%); negative predictive value, 99.9%; specificity, 12.9%; positive predictive value, 1.9%, and only one of these two patients received surgical treatment.
According to the results of assessment with the decision instrument, radiographic imaging could have been avoided in the cases of 4309 (12.6 percent) of the 34,069 evaluated patients.

Authors' Conclusions: A simple decision instrument based on clinical criteria can help physicians to identify reliably the patients who need radiography of the cervical spine after blunt trauma. Application of this instrument could reduce the use of imaging in such patients.

Additional comments from Journal Gems contributors: Helpful acronym:

  • Neurological deficit (focal signs or symptoms)
  • Ethanol (intoxication)
  • X-line tenderness (midline cervical spinous process tenderness)
  • Unconcious / altered level of consciousness
  • Some other painful or distracting injury (apart from the neck)

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