Selective Cervical Spine Radiography in Blunt Trauma: Methodology of the National Emergency X-Radiography Utilization Study (NEXUS)☆,☆☆,★,★★

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Abstract

Fear of failure to identify cervical spine injury has led to extremely liberal use of radiography in patients with blunt trauma and remotely possible neck injury. A number of previous retrospective and small prospective studies have tried to address the question of whether any clinical criteria can identify patients, from among this group, at sufficiently low risk that cervical spine radiography is unnecessary. The National Emergency X-Radiography Utilization Study (NEXUS) is a very large, federally supported, multicenter, prospective study designed to define the sensitivity, for detecting significant cervical spine injury, of criteria previously shown to have high negative predictive value. Done at 23 different emergency departments across the United States and projected to enroll more than 20 times as many patients with cervical spine injury than any previous study, NEXUS should be able to answer definitively questions about the validity and reliability of clinical criteria used as a preliminary screen for cervical spine injury. [Hoffman JR, Wolfson AB, Todd K, Mower WR, for the NEXUS Group: Selective cervical spine radiography in blunt trauma: Methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med October 1998;32:461-469.]

Section snippets

INTRODUCTION

Unrecognized cervical spine injury can produce catastrophic neurologic disability. Fear of failing to diagnose such injuries has led to the use of radiographic spine imaging in virtually all cases of multiple blunt trauma.1, 2 This practice exposes large numbers of patients to x-ray imaging, at considerable expense, while detecting injuries in a small minority.1, 2, 3, 4, 5, 6, 7 It is estimated that each year in the United States approximately 800,000 people undergo cervical spine radiography,

MATERIALS AND METHODS

NEXUS is a multicenter, prospective, observational study of ED patients with blunt trauma for whom cervical spine imaging is ordered. Participating centers represent a wide variety of facilities, including university hospitals, community teaching hospitals, and community hospitals without teaching programs; public hospitals and private hospitals; and hospitals with all levels of trauma categorization. In this prospective study, the presence or absence of the 4 low-risk criteria will be

DISCUSSION

Sporadic case reports have described rare patients with occult or even asymptomatic cervical spine injuries after blunt trauma.3, 4, 5, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 Careful review of these cases indicates that most of them involved patients who were inadequately evaluated or who actually met at least 1 of the low-risk criteria considered in the NEXUS study. Nevertheless, fear of missing cervical spine injuries, with their potential to produce severe neurologic disability, has led to

Acknowledgements

The following centers and investigators collaborated in this study.

Principal Investigator: W Mower.

Coinvestigator: J Hoffman. Steering Committee: J Hoffman, W Mower, K Todd, A Wolfson, M Zucker.

Site Investigators: Antelope Valley Medical Center (Los Angeles): M Brown, R Sisson; Bellevue Hospital (New York): W Goldberg, R Siegmann; Cedars-Sinai Medical Center (Los Angeles): J Geiderman, B Pressman; Crawford Long Hospital (Atlanta): S Pitts, W Davis; Egleston Children’s Hospital (Atlanta): H

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    ☆

    From The UCLA Emergency Medicine Center and Department of Medicine, UCLA School of Medicine, Los Angeles, CA, the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, and the Division of Emergency Medicine, Department of Surgery, Emory University School of Medicine, Atlanta, GA.

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    This project was supported by grant number R01 HS08239 from the Agency for Health Care Policy and Research.

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    Reprint no. 47/1/93129

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    Address for reprints:William R Mower, MD, PhD, 924 Westwood Boulevard, Suite 300, Los Angeles, CA 90024, 310-794-0582, Fax 310-794-9747, E-mail [email protected]

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    Copyright © 1998 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.