Table 1

Comparison of NEXUS, CCR and PECARN criteria: study type, ages, inclusion criteria and ‘rule’ features

Study typeProspective, observationalProspective, observationalRetrospective case–control
AgeAll ages≥16 years<16 years
Numbers3065 children (<18), median age 15 years
34 069 patients in total
No children
8924 enrolled
540 children with CSI matched against 1060, 1012 and 702 random, mechanism of injury and out of hospital emergency medical service controls
Inclusion criteriaRadiographic evaluation
Blunt trauma
GCS 15 and stable
Neck pain from any mechanism or visible injury above clavicles, non-ambulatory and dangerous mechanism of injury
Exclusion: penetrating trauma, known vertebral disease, acute paralysis, injury>48 hours, representation, pregnant
Received radiographic evaluation of the cervical spine.
Blunt trauma
Rule features: historyAge>65 years Predisposing condition*
Rule features: mechanism Dangerous mechanism:
Fall≥1 m or five stairs;
Axial load eg. diving
MVA>100 km/hour, rollover or ejection from vehicle; MVA involving recreational vehicle; bicycle collision
High-risk MVA
Head on collision, rollover, ejected from the vehicle, death in same crash, speed>55 miles/hour (>88 km/hour)
Rule features: examination Altered mental status
GCS<15, disorientated, impaired memory, inappropriate response to external stimuli
Focal neurology
Examiner elicited or patient reported
Painful distracting injury
Any condition thought by the clinician to be producing pain sufficient to distract the patient from a CSI, for example, any long bone fracture, a significant visceral injury, a large laceration, degloving injury or crush injury, extensive burns, any other injury producing acute functional impairment
Posterior midline neck tenderness
GCS<15 → exclusion criteria
Paraesthesias in extremities
Absence of low-risk factor enabling neck movement to be assessed.
Low-risk factors include:
No midline cervical spine tenderness
Delayed onset of neck pain
Sitting position in ED
Simple rear end MVA
Ambulatory at any time

Inability to actively rotate neck 45° left and right (providing able to be assessed—see above)
Altered mental status
GCS<15, AVPU (Alert, Voice, Pain, Unresponsive) Scale<A, evidence of intoxication or mental status descriptions deemed by consensus panel to represent altered level of consciousness)
Focal neurology
Paraesthesias, loss of sensation, motor weakness or other neurologic finding deemed consistent with spine injury
Neck pain
Child complaint if>2 years
Torticollis, limited range of motion or difficulty moving the neck
Substantial torso injury
Thorax including clavicles, abdomen, flanks, back including the spine and pelvis (eg rib fractures, visceral or solid organ injury, pelvic fracture)
Rule guidanceIf no criteria present, considered at very low probability of clinically significant CSI and imaging is not requiredProvides a flow chart with specific guidance on when imaging and no imaging is indicated. Imaging is not indicated if there are no high-risk factors, a low-risk factor enabling neck movement to be assessed is present and neck movement is assessed as normalIdentified an eight variable model of predictive factors for paediatric CSI after blunt trauma. Suggested these be considered in the development of a decision rule for the identification of children at negligible risk for CSI and for whom immobilisation and radiographic evaluation could be deferred
  • *Predisposing conditions include: Down Syndrome, Klippel-Feil syndrome, achondroplasia, mucopolysacchariodosis, Ehlers-Danlos syndrome, Marfan syndrome, osteogenesis imperfecta, Larsen syndrome, juvenile rheumatoid arthritis, juvenile ankylosing spondylitis, renal osteodystrophy, rickets and history of CSI.

  • CCR, Canadian C-spine rule; CSI, cervical spine injury; ED, emergency department; GCS, Glasgow Coma Scale Score; MVA, motor vehicle accident; NEXUS, National Emergency X-radiography Utilization Study; PECARN, Pediatric Emergency Care Applied Research Network.