When is a clinical examination reliable enough to clear the spine? In this first episode of our spinal series, James and David unpack clinical spinal clearance - stable and unstable injuries, challenge common assumptions about neurological deterioration, compare NEXUS with the Canadian C-Spine Rule, and work through the modified NEXUS approach used in Victoria. We also explain why low-energy falls, older age and bone-weakening conditions deserve particular caution.
Further resources
• Hoffman et al. (2000), Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. The landmark multicentre validation of the five NEXUS low-risk criteria.
• Stiell et al. (2001), The Canadian C-Spine Rule for radiography in alert and stable trauma patients. The derivation study describing the rule's three-step structure.
• Stiell et al. (2003), The Canadian C-Spine Rule versus the NEXUS low-risk criteria in patients with trauma. A prospective head-to-head comparison of the two decision rules.
• Vaillancourt et al. (2009), The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Prospective evidence on paramedic application of the Canadian C-Spine Rule.
• Domeier et al. (2005), Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. A four-year prospective EMS study of 13,357 patients evaluating a NEXUS-like selective immobilisation protocol; sensitivity was 92% for any spine injury, and no non-immobilised patient had a spinal cord injury.
• Paykin et al. (2017), The NEXUS criteria are insufficient to exclude cervical spine fractures in older blunt trauma patients. In patients aged 65 years and older with cervical spine fractures, NEXUS had 94.8% sensitivity, supporting caution when applying the rule to older adults.
• Denver et al. (2015), Falls and Implementation of NEXUS in the Elderly (The FINE Study). A prospective study of patients older than 65 years after low-level falls; NEXUS sensitivity was 88.9% for clinically significant cervical spine injury.
• Delaney et al. (2022), Prevalence of midline cervical spine tenderness in the non-trauma population. Useful context for interpreting midline tenderness and its limited specificity.
• Oto et al. (2015), Early Secondary Neurologic Deterioration After Blunt Spinal Trauma: A Review of the Literature. A systematic review examining the incidence, timing and causes of secondary neurological deterioration after blunt spinal trauma, including deterioration associated with unstable injuries, delayed diagnosis and subsequent patient movement.
Get in touch
clinicalguidelines@ambulance.vic.gov.au
Socials
David: @expensivecare |@expensivecare.bsky.social | LinkedIn
James: https://linktr.ee/ClinicalConversations
