EBM Consult

C-Spine Clearance Using NEXUS vs Canadian C-Spine Rule in Adult Trauma


  • P = Adult blunt trauma patients
  • I = Clearance of C-spine based off clinical exam
  • C = Clearance of C-spine based off imaging
  • O = Clinically significant c-spine injury
  • T = Acute setting
  • S = Emergency department

Note: PICOTS stands for (P) for patient, (I) for intervention of interest, (C) for comparison, (O) for outcome of interest, (T) for timing, & (S) for setting.

Take Home Point(s):

  • In adult blunt trauma patients with concern for C-spine injury, the NEXUS criteria is an effective clinical tool to screen for those that would require imaging out of concern for clinically significant C-spine injury (sens 99.6%, NPV 99.9%)
  • In adult blunt trauma patients with concern for C-spine injury, the Canadian C-spine Rule (CCR) is an effective clinical tool to screen for those that would require imaging out of concern for clinically significant C-spine injury (sens 100%, NPV 100%)
  • When compared, the CCR is superior to the NEXUS criteria in terms of sensitivity (99.4% vs 90.7%) and specificity (45.1% vs 36.8%)


Adult blunt trauma patients with concern for C-spine injury is a common occurrence in trauma centers/emergency departments. Due to the fact that unrecognized injury to the cervical spine has potential to be catastrophic, many clinicians may feel inclined to err on the side of caution and order imaging—however, there are two caveats. First is that imaging is not without its own risks and expenses. Second, prolonged immobilization in a cervical collar is associated with its own deleterious effects and patient discomfort. The NEXUS criteria and CCR were designed to assist physicians in utilizing clinical exam to decide if the probability of clinically significant injury was low enough that imaging would not be required. Although both NEXUS and CCR are effective clinical tools, the CCR outperforms NEXUS for detection of clinically significant injury.

It should be noted that although the NEXUS and CCR studies utilized "radiographs" which included plain films and CT C-spine, the standard of care has evolved to C-spine CT over plain films for imaging of the C-spine. Lastly, clinicians should approach elderly patients (>age 65) with caution—the CCR has a hard stop for patients >65 years, and the NEXUS criteria, while not specifically including age, have been shown in multiple studies to not be effective in screening this patient population.

Author(s): Joshua Trebach, MD (Johns Hopkins School of Medicine)
Reviewers:  Ameen Jamali, MD and Jeremiah Hinson, MD, PhD (Johns Hopkins School of Medicine)
Editor-in-Chief:  Anthony J. Busti, MD, PharmD, FNLA, FAHA
Date Last Reviewed:  August 2018

Guideline Statements

  • Eastern Association for the Surgery of Trauma
    "In awake, alert patients with trauma without neurological deficit or distracting injury who have no neck pain or tenderness with full range of motion of the CS: CS imaging is not necessary and cervical collar may be removed. All other patients in whom CS injury is suspected must have radiographic evaluation. This applies to patients with pain or tenderness, patients with neurologic deficit, patients with altered mental status, and patients with distracting injury. The primary screening modality is axial CT from the occiput to T1 with sagittal and coronary reconstructions. Plain radiographs contribute no additional information and should not be obtained."

Cochrane Reviews

  • No known publications available.

Systematic Reviews / Meta-Analyses

  • Moser N et al. Validity and reliability of clinical prediction rules used to screen for cervical spine injury in alert low-risk patients with blunt trauma to the neck: part 2. A systematic review from the Cervical Assessment and Diagnosis Research Evaluation (CADRE) Collaboration. Eur Spine J. 2018 Jun;27(6):1219-1233. PubMed

  • Michaleff ZA et al. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ. 2012 Nov 6;184(16):E867-76. PubMed

Original Studies

  • Hoffman JR et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. NE Engl J Med 200; 343:94-99.PubMed

  • Stiell IG et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286(15):1841-8. PubMed

  • Stiell et al. The Canadian C Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. N Engl J Med 2003; 349:2510-2518. PubMed

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