Retrospective analysis of efficacy of the National Emergency X-Radiography Utilization Study low-risk criteria and the Canadian cervical spine rules for cervical spine trauma

KM Pawan Kumar; P Madhuchandra; G Sunil Santhosh

doi:10.4103/jodp.jodp_96_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 6 | Issue : 2 | Page : 154-156

Retrospective analysis of efficacy of the National Emergency X-Radiography Utilization Study low-risk criteria and the Canadian cervical spine rules for cervical spine trauma

KM Pawan Kumar, P Madhuchandra, G Sunil Santhosh
Department of Orthopaedics, BGS Global Institute of Medical Sciences, Bengaluru, Karnataka, India

Date of Submission	12-Oct-2022
Date of Decision	22-Nov-2022
Date of Acceptance	27-Dec-2022
Date of Web Publication	3-May-2023

Correspondence Address:
K M Pawan Kumar
Department of Orthopaedics, BGS GIMS Under RGUHS, Kengeri, Bengaluru - 560 090, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.jodp_96_22

Abstract

Background: With increasing road traffic accidents, cervical spine injuries are a major health hazard in the developed as well as the developing world. Over the years, the National Emergency X-radiography Utilization Study (NEXUS) low-risk criteria and the Canadian cervical spine rules (CCRs) have acted as primary guidelines in emergency departments around the world to decide on the need for cervical spine X-ray in emergency settings. The aim of this study was to retrospectively analyze the efficiency of both the NEXUS low-risk criteria and CCR in confirming positive cervical spine injuries in emergency department settings. Aims and Objectives: The aim was to retrospectively analyze the efficiency of both the NEXUS low-risk criteria and CCR in confirming positive cervical spine injuries. Methods: A retrospective study involving 631 patients for 4 years aged above 18 years, who underwent a cervical spine X-ray from June 2018 to June 2022, were included in the study. From the eligible case records, the data pertaining to the NEXUS low-risk criteria and CCR were recorded. Along with this, the final diagnosis regarding the cervical spine injury, confirmed by subsequent computed tomography (CT) scan or magnetic resonance imaging (MRI), was also recorded. Results: The NEXUS low-risk criteria and CCR were met in 92.7% and 98.6% of the patients, respectively. The cervical spine X-rays were normal in 87.8% of the patients, fractures were recorded in 9.5% of the patients, and in 2.7% of the patients, doubtful lesions were present, which needed additional investigations in the form of CT scan or MRI or both. Conclusion: Both the Nexus and CCR guidelines act as a good guiding light in deciding about the need for the cervical spine X-ray in the emergency setup. Both guidelines are effective in ruling out cervical spine injuries in the majority of cases.

Keywords: Canadian cervical spine rules, cervical spine X-ray, National Emergency X-Radiography Utilization Study low-risk criteria

How to cite this article:
Pawan Kumar K M, Madhuchandra P, Santhosh G S. Retrospective analysis of efficacy of the National Emergency X-Radiography Utilization Study low-risk criteria and the Canadian cervical spine rules for cervical spine trauma. J Orthop Dis Traumatol 2023;6:154-6

How to cite this URL:
Pawan Kumar K M, Madhuchandra P, Santhosh G S. Retrospective analysis of efficacy of the National Emergency X-Radiography Utilization Study low-risk criteria and the Canadian cervical spine rules for cervical spine trauma. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jun 4];6:154-6. Available from: https://jodt.org/text.asp?2023/6/2/154/375556

Introduction

With increasing road traffic accidents, cervical spine injuries are a major health hazard in the developed as well as the developing world.^[1],[2] The fear of missing cervical spine injuries among orthopedicians and emergency medicine physicians leads to unnecessary multiple radiographs, which just increases the financial burden rather than contributing to the identification of the injury.^[3] In 1992, The National Emergency X-radiography Utilization Study (NEXUS) low-risk criteria (NLC) was developed as a simple tool based on five clinical criteria that can guide health-care workers to identify patients needing cervical spine X-ray in the emergency department with blunt trauma to the cervical spine.^[4] Over the years, this acted as a primary guideline in the emergency departments over the world to decide on the need for a cervical spine X-ray in emergency settings. However, by 2001, Canadians had developed the Canadian cervical spine rule (CCR).^[5] The CCR consisted of three high-risk criteria, five low-risk criteria, and the patient's ability to rotate the neck actively, which in combination helped the trauma physicians to decide on the need of a cervical spine X-ray. The aim of this study is to retrospectively analyse the efficiency of both the NEXUS-Low Risk Criteria, as shown in [Table 1] and Canadian Cervical-Spine Rule, as shown in [Figure 1] in confirming positive cervical spine injuries in emergency department setting.

Figure 1: The Canadian cervical spine criteria^[4]

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Table 1: The National Emergency X-radiography Utilization Study low-risk criteria^[5]

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Methods

We analyzed the case records of all patients aged above 18 years, who underwent a cervical spine X-ray from June 2018 to June 2022 retrospectively. The availability of medical records of data was mandatory for patients to be included in this study. The study was approved by the Institutional Ethics Committee at our hospital. Patients with incomplete data and the patients who needed or who underwent computed tomography (CT) scan prior to X-rays in view of associated head injury, chest trauma, or abdomen injury were excluded from the study. From the eligible case records, the data pertaining to the NLC and CCR were recorded. The data recorded in case sheets by multiple emergency doctors about information pertaining to the NLC and CCR before getting the X-ray were tabulated. Along with this, the final diagnosis regarding the cervical spine injury, confirmed by subsequent CT scan or magnetic resonance imaging (MRI), was also recorded.

[Table 1] NEXUS Low Risk Criteria^[5]

[Figure 1] Canadian Cervicle Spine Criteria^[6]

Statistical analysis

The data collected from the source documents for all patients were recorded in a master chart. SPSS Statistics is a statistical software suite developed by IBM for data management, advanced analytics, multivariate analysis, business intelligence, and criminal investigation. Long produced by SPSS Inc., it was acquired by IBM in 2009. Current versions (post 2015) have the brand name: (IBM SPSS Statistics. Somers, North Westchester County, New York, USA). Quantitative data were presented as mean ± standard deviation, and qualitative data were presented as counts and frequencies. The means were compared between the good and poor quality of radiography using the Student's t–test, while frequencies were compared using the Chi-squared test.

Results

In total, 631 patient's case records were included in the study. The mean age of the patients' included in the study was 32.8 years. The mechanism of injury was due to road traffic accidents in 64.4%, due to falls from height in 22.3%, and due to low-velocity injuries in 13.3%. 57.8% of the patients included in the study had localized pain in the cervical region. The NLC and CCR were met in 92.7% and 98.6% of the patients, respectively. The cervical spine X-rays were normal in 87.8% of the patients, fractures were recorded in 9.5% of the patients, and in 2.7% of the patients, doubtful lesions were present, which needed additional investigations in the form of CT scan or MRI or both. An open-mouth X-ray of the cervical spine was done in only 12.4% of the patients.

Discussion

The present study reveals that either the NEXUS or the CCR rules were applied in the emergency department of our institute. Weiner in their study demonstrated that 56% of the emergency physicians followed the NEXUS rules, whereas 10% of them followed the CCR rules in their daily practice.^[7] The study also recognized that the most common reason for not following the NEXUS guidelines is the patient or patient attender's insistence for an X-ray, even when the criteria are not met. Furthermore, the study states that the most common reason for not following the CCR guidelines by emergency physicians is because it is cumbersome and difficult to remember in daily practice.^[7] Some studies claim that the CCR guidelines are superior to the NEXUS guidelines.^[8] Michaleff et al., in 2012, demonstrated in their meta-analysis including 15 studies that these guidelines have a high sensitivity but a very low specificity.^[9] Another important finding of the study was that the open-mouth odontoid view was done only in 12.4% of the patients in the emergency department. However Tintinalli et al^[10] mentioned these as criteria for an ideal cervical spine x-ray 1) Xray must include all seven cervical vertebrae and C7-T1 junction 2) Two xray views have to be taken them being an anterior posterior view and an open mouth odontoid view.^[11] In the emergency department, it might be difficult to achieve these criteria as the patient may be unconscious, disoriented, or have restricted mobility of the neck due to immobilization devices. Many studies like that of Gale et al.,^[11] Holmes and Akkinepalli,^[12] Blackmore et al.,^[13] and Hanson et al.^[14] have proved beyond doubt that CT scans are superior to X-ray films in ruling out cervical spine injuries.

Because of concerns that the NEXUS criteria do not perform well among patients aged >65 years, clinicians may need to consider further imaging if there is concern about the mechanism or examination in elderly patients. Although more complicated to remember, the CCR appears to perform well or better than the NEXUS in terms of sensitivity for cervical spine injuries. In cases where a patient is not ruled out by the NEXUS criteria, it may be appropriate to apply the CCR. If the patient is negative for the CCR, then further imaging is probably unnecessary; for example, patients with midline cervical spine tenderness would need imaging according to the NEXUS criteria but potentially could be cleared by the CCR if they did not have any high-risk feature and could range their necks 45° to the left and right.^[15]

There is also concern that the NEXUS criteria were derived and validated in an era when plain films were much more commonly ordered to assess for cervical spine injuries. CT imaging of the cervical spine is now more common, and there is some evidence that CT may identify CSIs that would be missed by the NEXUS and/or the CCR.^[15] There is a weak support in the literature for applying the NEXUS criteria in determining the need for a cervical spine imaging in pediatric trauma patients.^[16] The study by Ghelichkhani et al.^[17] has shown that the modified Canadian C-spine rule has a fewer variables than the original Canadian C-spine rule and is entirely based on physical examination, which seems easier to use in the emergency departments.^[17] Chaudry et al.,^[18] in their study, showed that the NEXUS low-risk criteria is still a very reliable indicator regarding the need for the cervical spine X-ray, especially in the victims of blunt injury or assault.^[18]

Conclusion

Both the Nexus and CCR guidelines act as a good guiding light in deciding about the need for the cervical spine X-ray in the emergency setup, especially in the Indian context. Both guidelines are effective in ruling out cervical spine injuries in majority of cases. Since it is difficult to get an ideal cervical spine X-ray every time in the emergency department, CT scan becomes an effective alternate to an X-ray.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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