Clinical factors show promise for predicting fractures, but until they’re validated, all such patients should undergo C-spine computed tomography.

Both the National Emergency X-Radiography Utilization Study (NEXUS) and Canadian cervical spine (C-spine) rules have demonstrated that clinical exam is sufficient to clear the cervical spine for certain trauma patients. However, the sensitivity and specificity of these rules for patients with major trauma are not adequate, and many centers perform C-spine computed tomography (CT) for all patients with major trauma. In this prospective single-site study, investigators evaluated the correlation between findings on C-spine CT and presence of any of 18 combined NEXUS and Canadian C-spine criteria in 5812 trauma patients.

All patients met criteria for major trauma requiring trauma team activation, which included Glasgow Coma Scale (GCS) score <14, systolic blood pressure <90 mm Hg, respiratory rate <10 or >20 per minute, significant obvious anatomic injury (e.g., flail chest; two or more long-bone fractures; crushed, degloved, or mangled extremity; amputation; pelvic fractures; open or depressed skull fractures; paralysis), and significant mechanism of injury (e.g., falls >20 feet, high-risk motor vehicle collision).

Fracture incidence was 6.3%. Clinical exam had 100% sensitivity and 0.62% specificity for detecting fractures. Seven NEXUS/Canadian C-spine criteria were independent predictors of fracture: midline tenderness, GCS score <15, paresthesias, rollover motor vehicle collision, ejection from a motor vehicle, age 65, and not being able to sit up in the emergency department. Use of these seven factors increased specificity nearly 20-fold, to 11.6%.

Comment: Prospective multicenter validation of these factors is needed before practice changes. Until then, C-spine computed tomography should continue be the study of choice to evaluate patients with major trauma for possible cervical spine fracture.

Source: Journal Watch Emergency Medicine