NEXUS C-Spine Criteria
The NEXUS (National Emergency X-Radiography Utilization Study) criteria identify blunt trauma patients at very low risk of cervical spine injury who do not require imaging. All 5 low-risk criteria must be met to clear the c-spine clinically.
inputs
✓ when to use
Use in alert, stable adults after blunt trauma to determine whether cervical spine imaging is required. If all 5 criteria are met, the c-spine can be cleared without radiography. Applicable in ED and pre-hospital settings.
✗ when not to use
Not validated for penetrating trauma. Limited in paediatric populations (use with caution in children <8). The 'distracting injury' criterion is subjective and has been criticised for poor inter-rater reliability. The Canadian C-Spine Rule has been shown to be more sensitive and specific in direct comparison (Stiell et al., NEJM 2003) — consider using it preferentially.
clinical pearls
- The Canadian C-Spine Rule is generally preferred over NEXUS in direct comparisons — it is more sensitive (99.4% vs 90.7%) and more specific (45.1% vs 36.8%) in the Stiell 2003 head-to-head study. Consider using the Canadian C-Spine Rule when both are applicable.
- The 'distracting injury' criterion is the weakest link in NEXUS. There is no consensus definition, and inter-rater agreement is poor. Use clinical judgement — a long bone fracture clearly qualifies, but a minor laceration probably does not.
- NEXUS is simpler than the Canadian C-Spine Rule (5 criteria vs a branching algorithm), which may make it more practical in high-volume or resource-limited settings.
- A patient who is intoxicated cannot have their c-spine cleared by NEXUS. The standard approach is to image or maintain immobilisation until the patient can be reliably reassessed.
- NEXUS does not specify the type of imaging. In modern practice, CT is preferred over plain radiography for suspected cervical spine injury, particularly in high-risk mechanisms or patients with positive NEXUS/Canadian C-Spine criteria.