RadiologyValidity of a decision rule to reduce cervical spine radiography in elderly patients with blunt trauma*,**,★
Introduction
Cervical spine injury (CSI) in blunt trauma represents a classic example of the frequent use of low-yield testing to detect a high-stakes diagnosis. Physicians obtain an estimated 800,000 cervical spine radiographs for victims of blunt trauma annually, of which approximately 2.4% are positive for CSI.1 The selective criteria proposed in the National Emergency X-radiography Utilization Study (NEXUS) were developed to safely improve the yield of cervical spine radiography. In a large, prospective, observational study involving 34,069 patients, these criteria were shown to offer a potential 12.6% reduction in cervical spine radiographs, while maintaining a sensitivity of 99.6% (95% confidence interval [CI] 98.6% to 100%) for clinically significant CSI.1
The NEXUS decision instrument was derived and validated in a sample including patients of all ages. It is unclear whether these criteria retain their safety and efficacy in each age group. For example, geriatric patients, because of osteopenia, physical debility, and other age-related comorbid conditions, might be more vulnerable to CSI than their younger counterparts. Simultaneously, pain perception might be diminished in the elderly, which might diminish the effectiveness of individual criteria in identifying injuries. Other age-related neurologic conditions, such as dementia, could further confound interpretation of the NEXUS criteria in the elderly and significantly alter their operator characteristics and subsequent clinical utility.
This article examines the operator characteristics of the NEXUS decision instrument in the subset of geriatric patients in the NEXUS database. It also explores some of the common features of CSI found in this group.
Section snippets
Materials and methods
NEXUS was a multicenter, prospective, observational study of emergency department patients with blunt trauma for whom cervical spine imaging was requested. The NEXUS methodology has previously been described in detail2 and will be summarized here. The study was designed to test the validity of a previously derived set of low-risk criteria for CSI that included the absence of the following 5 findings: (1) evidence of intoxication, (2) posterior midline neck tenderness, (3) distracting painful
Results
There were 34,069 patients with suspected CSI enrolled in the study. The study sample had a mean age of 37 years (interquartile range 23 to 47 years) and included 19,700 (58%) male and 13,866 (42%) female patients. Sex was not recorded for 503 patients.
The study sample included 31,126 (91.4%) nongeriatric patients and 2,943 (8.6%) geriatric patients. In the nongeriatric group, a majority of patients (59%) were male, whereas there were more female (53%) than male patients among the geriatric
Discussion
The NEXUS study validated previously derived criteria that allow physicians to be selective in the use of radiographs in the evaluation of patients with blunt trauma. The decision instrument, applied to 34,069 patients undergoing cervical spine imaging, including 818 with CSI, had an overall sensitivity of 99.0% (95% CI 98% to 99.6%) for identifying any CSI and a sensitivity of 99.6% (95% CI 98.6% to 100%) for identifying clinically significant injury.1
Several features of geriatric trauma
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2023, Emergency Medicine Clinics of North AmericaCitation Excerpt :The Canadian C-Spine Rule considers patients older than 65 years of age as a high-risk criterion and therefore recommends imaging for all older adults.90 For the NEXUS criteria, studies have shown variable sensitivity in older adults, ranging from 65.9% to 100%.91–93 Multiple studies have questioned the validity of this tool to rule out the need for imaging for older adults.91,93
Geriatric Trauma
2021, Emergency Medicine Clinics of North AmericaManaging the Elderly Emergency Department Patient
2019, Annals of Emergency MedicineHead and Neck Injuries: Special Considerations in the Elderly Patient
2018, Neuroimaging Clinics of North America
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Author contributions: MT and PG analyzed the data and drafted the manuscript. WRM provided statistical advice. All authors contributed significantly to the manuscript's revision. MT takes responsibility for the paper for a whole.
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Supported by grant R01 HS08239 from the Agency for Healthcare Research and Quality, formerly the Agency for Health Care Research and Policy.
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Address for reprints: Michael Touger, MD, Department of Emergency Medicine, Albert Einstein College of Medicine, 1W20 Jacobi Medical Center, 1400 Pelham Parkway South, Bronx, NY 10461;,718-918-5852, fax 718-918-7459; E-mail [email protected]