Imaging in the NEXUS-negative patient: when we break the rule

In spite of general acceptance and validation of NEXUS (National Emergency X-Radiography Utilization Study) in the clearance of cervical spine (C-spine) immobilized patients, clinicians often elect to image NEXUS-negative patients in clinical practice.

We sought to determine which variables (patient age, mechanism of injury, provider level of training, provider self-reported motivation) contribute to the decision of emergency medicine providers to image NEXUS-negative patients.

This is a prospective observational study of patients with blunt trauma and risk for C-spine injury who did not meet "trauma team activation" criteria. Providers at one high-volume emergency department (ED) prospectively recorded NEXUS criteria, as well as rationale for imaging NEXUS-negative patients. Researchers then retrospectively queried the electronic medical record for patient age, mechanism of injury, and results of diagnostic imaging. Study data were analyzed with χ(2) and descriptive statistics.

Three hundred patients were enrolled; 169 patients received C-spine imaging, of whom 53 were NEXUS-negative. There was no difference in imaging of NEXUS-negative patients as a factor of medical provider level of training (P=0.42). Of NEXUS-negative patients receiving imaging, 51 (96%) were older than 65 years, and 52 were being evaluated for a fall on level ground. Imaging revealed 7 positive findings. Two of these injuries were in NEXUS-negative patients.

Regardless of level of training, providers in our ED often imaged patients who met NEXUS low-risk criteria. This was mot common in geriatric patients who presented after falls. This digression from NEXUS led to the diagnosis of significant injuries in 2 patients which would otherwise have been missed.