This document discusses guidelines for cervical spine immobilization and imaging in trauma patients. It describes the NEXUS criteria, a clinical decision tool that can safely rule out cervical spine fractures without imaging in alert, stable trauma patients. Validation studies found the NEXUS criteria have a sensitivity of 99.6% in adults and 83-100% in pediatric patients older than 8. While it can reduce unnecessary imaging by 12.6%, caution is advised in older adults and children under 8, where sensitivity may be lower. The document provides indications for when cervical spine imaging is recommended in pediatric trauma based on mechanism of injury and clinical findings.

1. By Yana Puckett MD, MS, MPH, MBA

3. Our Aspen Collars

4. When to Place C-Collar
 AANS
 • “all trauma patients with...mechanism
of injury having the potential to cause
cervical spinal injury should be
immobilized”

5. NEXUS Criteria
 Clears patients from cervical spine
fracture clinically, without imaging.
 Well-validated clinical decision aid.
 Can be used to safely rule out cervical
spine injury in alert, stable trauma
patients without the need to obtain
radiographic images.
 If positive, xray of cervical spine is
indicated.

7. Validity of NEXUS Criteria
 Validation study included prospective,
observational sample of 34,069 patients
aged 1 to 101 from 21 US trauma centers.
 Sensitivity of 99.6% for ruling out cervical
spine injury.
 Adopting rule decreases imaging by 12.6%
 Subsequent studies: 83-100% sensitivity
for CSI with majority between 90-100%
sensitivity.

8. NEXUS Criteria
 Theoretically doe not have an age cutoff
 All patients >1 year of age
 Caution in patients >65 years, sensitivity
lower 66-84%
 NEXUS Criteria prospectively validated
in the largest cohort of patients ever
studied.

9. Why Use?
 Over 1 million visits to US ED annually
for blunt trauma.
 Most undergo imaging of c-spine with
overwhelming majority (98%) that come
back negative for a fracture.
 Extremely costly >$180,000,000
annually.
 Excess radiation exposure.

10. Pneumonic: NSAID
 Neurological Deficit
 Spinal Tenderness
 Altered Mental Status/Level of
Consciousness
 Intoxication
 Distracting Injury

11. Pediatric Criteria NEXUS
 In toddlers and infants with minor
trauma and normal neurological exam;
palpate C-spine and assess ROM. If
normal, clinically cleared.
 3,065 children were involved, 30 had C-
spine injuries.
 Sensitivity 100% , Specificity 19.9%.
 None of the children studied were
younger than 2 years, and only 817
(27%) were younger than age 8 years .

12. Further Studies on NEXUS in
Pediatric Patients
 Single-center, 20-year review applied the
NEXUS criteria to 190 children with significant
cervical spine injury found that the criteria
were 94% sensitive among children aged less
than 8 years and 100% sensitive in those
greater than age 8 years.
 A Pediatric Emergency Care Applied Research
Network (PECARN) study found that the
NEXUS criteria were 83% sensitive among
539 children with spinal injury who presented
to the emergency department. Of the 90
children missed by the NEXUS criteria, 58
(64%) were younger than 8 years of age.

14. CCR vs NEXUS

15. Indications for Imaging in
Pediatric Trauma
 High risk-mechanism:
 High speed motor vehicle collision, bicycle
injury, diving or other activity with
hyperextension or hyperflexion of neck, falls
greater than body height, and other
acceleration-deceleration injuries of the head.
 Multiple system with severe injuries
 Distracting pain
 Injury above clavicle
 Altered mental status
 Neck pain, tenderness or limitation of movement
 Acute neurological deficit

16. Indication for CT C-Spine in
Pediatric Trauma
 Lower or upper C-spines not visualized
on plain films
 Abnormal or suspicious C-spine on plain
films
 Suspicion of injury despite normal plain
cervical radiographs
 As part of initial evaluation of severe
head trauma (GCS ≤12) instead of plain
films