Cervical spine fracture in geriatric blunt trauma: are the NEXUS criteria sensitive enough?
Keywords:Geriatric blunt trauma, Cervical fracture, NEXUS criteria
Background: The NEXUS criteria lack an age consideration. This study characterizes NEXUS sensitivity for significant cervical fracture (CF) in non-geriatric (18-64 years) and geriatric (≥65 years) patients.
Methods: This was a single-institution, retrospective review of blunt trauma patients (admitted between January 1, 2011 and December 31, 2016). Significant CF was an acute injury requiring surgery/orthosis. Propensity matching was used.
Results: Overall, 353 patients had significant CF and notably 101 (28.6%) denied neck pain and tenderness at presentation. There were 162 geriatric patients with 17 patients who failed to meet any NEXUS criterion (sensitivity: 89.5%). The remaining 191 patients were non-geriatric, only six failed to meet any NEXUS criterion (sensitivity: 96.8%). NEXUS sensitivity was reduced among geriatric patients (89.5% vs. 96.8%, p=0.01), even after propensity matching (n=73/group; 86.3% vs. 97.3%, p=0.02).
Conclusions: Alarmingly, 28.6% of patients with significant CF denied pain and tenderness. NEXUS demonstrated reduced sensitivity in the geriatric cohort, even after propensity matching. Liberal imaging is recommended for geriatric patients.
Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI, National Emergency X-Radiography Utilization Study Group. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343(2):94-9.
Touger M, Gennis P, Nathanson N, Lowery DW, Pollack CV Jr, Hoffman JR, et al. Validity of a decision rule to reduce cervical spine radiography in elderly patients with blunt trauma. Ann Emerg Med. 2002;40(3):287-93.
Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M. Low-risk criteria for cervical-spine radiography in blunt trauma: A prospective study. Ann Emerg Med. 1992;21(12):1454-60.
Como JJ, Diaz JJ, Dunham CM, Chiu WC, Duane TM, Capella JM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: Update from the eastern association for the surgery of trauma practice management guidelines committee. J Trauma Acute Care Surg. 2009;67(3):651-9.
Inaba K, Byerly S, Bush LD, Martin MJ, Martin DT, Peck KA, et al. Cervical spinal clearance: A prospective western trauma association multi-institutional trial. J Trauma Acute Care Surg. 2016;81(6):1122-30.
Griffen MM, Frykberg ER, Kerwin AJ, Schinco MA, Tepas JJ, Rowe K, et al. Radiographic clearance of blunt cervical spine injury: Plain radiograph or computed tomography scan? J Trauma. 2003;55(2):222-6.
Diaz JJ Jr, Gillman C, Morris JA, Jr, May AK, Carrillo YM, Guy J. Are five-view plain films of the cervical spine unreliable? A prospective evaluation in blunt trauma patients with altered mental status. J Trauma. 2003;55(4):658-63.
Gale SC, Gracias VH, Reilly PM, Schwab CW. The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. J Trauma. 2005;59(5):1121-5.
Brohi K, Healy M, Fotheringham T, Chan O, Aylwin C, Whitley S, et al. Helical computed tomographic scanning for the evaluation of the cervical spine in the unconscious, intubated trauma patient. J Trauma. 2005;58(5):897-901.
Mathen R, Inaba K, Munera F, Teixeira PG, Rivas L, McKenney M, et al. Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients. J Trauma. 2007;62(6):1427-31.
Rabb CH, Johnson JL, VanSickle D, Beauchamp K, Bolles G, Moore EE. Are upright lateral cervical radiographs in the obtunded trauma patient useful? A retrospective study. World J Emerg Surg. 2007;2:4-9.
Bailitz J, Starr F, Beecroft M, Bankoff J, Roberts R, Bokhari F, et al. CT should replace three-view radiographs as the initial screening test in patients at high, moderate, and low risk for blunt cervical spine injury: A prospective comparison. J Trauma. 2009;66(6):1605-9.
Schenarts PJ, Diaz J, Kaiser C, Carrillo Y, Eddy V, Morris JA,Jr. Prospective comparison of admission computed tomographic scan and plain films of the upper cervical spine in trauma patients with altered mental status. J Trauma. 2001;51(4):663-8.
Goode T, Young A, Wilson SP, Katzen J, Wolfe LG, Duane TM. Evaluation of cervical spine fracture in the elderly: Can we trust our physical examination? Am Surg. 2014;80(2):182-4.
Denver D, Shetty A, Unwin D. Falls and implementation of NEXUS in the elderly (the FINE study). J Emerg Med. 2015;49(3):294-300.
Paykin G, O'Reilly G, Ackland HM, Mitra B. The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients. Injury. 2017;48(5):1020-4.
Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: Methodology of the national emergency X-radiography utilization study (NEXUS). Ann Emerg Med. 1998;32(4):461-9.
Anderson LD, D'Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg. 1974;56(8):1663-74.
Platzer P, Hauswirth N, Jaindl M, Chatwani S, Vecsei V, Gaebler C. Delayed or missed diagnosis of cervical spine injuries. J Trauma. 2006;61(1):150-5.
Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries. J Trauma. 1993;34(3):342-6.
Reid DC, Henderson R, Saboe L, Miller JD. Etiology and clinical course of missed spine fractures. J Trauma. 1987;27(9):980-6.
Duane TM, Mayglothling J, Wilson SP, Wolfe LG, Aboutanos MB, Whelan JF, et al. National emergency X-radiography utilization study criteria is inadequate to rule out fracture after significant blunt trauma compared with computed tomography. J Trauma. 2011;70(4):829-31.
Healey CD, Spilman SK, King BD, Sherrill JE,2nd, Pelaez CA. Asymptomatic cervical spine fractures: Current guidelines can fail older patients. J Trauma Acute Care Surg. 2017;83(1):119-25.
Weller SJ, Malek AM, Rossitch E,Jr. Cervical spine fractures in the elderly. Surg Neurol. 1997;47(3):274-80.
Tran J, Jeanmonod D, Agresti D, Hamden K, Jeanmonod RK. Prospective validation of modified NEXUS cervical spine injury criteria in low-risk elderly fall patients. West J Emerg Med. 2016;17(3):252-7.
American College of Surgeons Committee on Trauma. ACS TQIP geriatric trauma management guidelines. Available at: https://www.facs.org/ ~/media/files/quality%20programs/trauma/tqip/geriatric%20guide%20tqip.ashx. Updated 2013. Accessed on 2 October 2017.