Background. Because clinicians fear missing occult cervical-spine injuries, they obtain cervical radiographs for nearly all patients who present with blunt trauma. Previous research suggests that a set of clinical criteria (decision instrument) can identify patients who have an extremely low probability of injury and who consequently have no need for imaging studies.
Methods. We conducted a prospective, observational study of such a decision instrument at 21 centers across the United States. The decision instrument required patients to meet five criteria in order to be classified as having a low probability of injury: no midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no painful, distracting injury. We examined the performance of the decision instrument in 34,069 patients who underwent radiography of the cervical spine after blunt trauma.
Results. The decision instrument identified all but 8 of the 818 patients who had cervical-spine injury (sensitivity, 99.0 percent [95 percent confidence interval, 98.0 to 99.6 percent]). The negative predictive value was 99.8 percent (95 percent confidence interval, 99.6 to 100 percent), the specificity was 12.9 percent, and the positive predictive value was 2.7 percent. 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 percent [95 percent confidence interval, 98.6 to 100 percent]; negative predictive value, 99.9 percent [95 percent confidence interval, 99.8 to 100 percent]; specificity, 12.9 percent; positive predictive value, 1.9 percent), 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.
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. (N Engl J Med 2000;343:94-9.)
From the Emergency Medicine Center and the Departments of Medicine (J.R.H., W.R.M., M.I.Z.) and Radiology (M.I.Z.), University of California, Los Angeles, School of Medicine, Los Angeles; the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (A.B.W.); and the Division of Emergency Medicine, Department of Surgery, Emory University School of Medicine, Atlanta (K.H.T.). Address reprint requests to Dr. Mower at the UCLA Emergency Medicine Center, 924 Westwood Blvd., Suite 300, Los Angeles, CA 90024, or at [log in to unmask].
The centers and investigators participating in the National Emergency X-Radiography Utilization Study (NEXUS) are listed in the Appendix.
The following centers and investigators collaborated in the NEXUS study: Principal investigator -- W. Mower; Co-investigator -- J. Hoffman; Steering Committee -- J. Hoffman, W. Mower, K. Todd, A. Wolfson, and M. Zucker; Site investigators -- Antelope Valley Medical Center (Los Angeles): M. Brown and R. Sisson; Bellevue Hospital (New York): W. Goldberg and R. Siegmann; Cedars-Sinai Medical Center (Los Angeles): J. Geiderman and B. Pressman; Crawford Long Hospital (Atlanta): S. Pitts and W. Davis; Egleston Children's Hospital (Atlanta): H. Simon and T. Ball; Emory University Medical Center (Atlanta): D. Lowery and S. Tigges; Grady Hospital (Atlanta): C. Finney and S. Tigges; Hennepin County Medical Center (Minneapolis): B. Mahoney and J. Hollerman; Jacobi Medical Center (Bronx, N.Y.): M. Touger, P. Gennis, and N. Nathanson; Maricopa Medical Center (Phoenix, Ariz.): C. Pollack and M. Connell; Mercy Hospital of Pittsburgh (Pittsburgh): M. Turturro and B. Carlin; Midway Hospital (Los Angeles): D. Kalmanson and G. Berman; Ohio State University Medical Center (Columbus): D. Martin and C. Mueller; Southern Regional Hospital (Decatur, Ga.): W. Watkins and E. Hadley; State University of New York at Stony Brook (Stony Brook): P. Viccellio and S. Fuchs; University of California, Davis, Medical Center (Sacramento): E. Panacek and J. Holmes; University of California, Los Angeles, Center for the Health Sciences (Los Angeles); J. Hoffman and M. Zucker; University of California, San Francisco, Fresno University Medical Center (Fresno, Calif.): G. Hendey and R. Lesperance; University of Maryland Medical Center (Baltimore): B. Browne and S. Mirvis; University of Pittsburgh Medical Center (Pittsburgh): A. Wolfson and J. Towers; Hermann Hospital, University of Texas Health Sciences Center (Houston): N. Adame, Jr., and J. Harris, Jr.