Canadian C-spine Rule versus NEXUS in Screening of Clinically Important Traumatic Cervical Spine Injuries; a systematic review and meta-analysis
Archives of Academic Emergency Medicine,
Vol. 11 No. 1 (2023),
15 November 2022
,
Page e5
https://doi.org/10.22037/aaem.v11i1.1833
Abstract
Introduction: The Canadian C-spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) are two criteria designed to rule-out clinically important traumatic cervical Spinal Cord Injury (SCI). In this systematic review and meta-analysis, we reviewed the articles comparing the performance of these two models.
Methods: Search was done in Medline, Embase, Scopus and Web of Science until June 2022. Observational studies with direct comparison of CCR and NEXUS criteria in detection of clinically important cervical SCI were included. Two independent reviewers screened the relevant articles and summarized the data. Certainty of evidence was assessed based on QUADAS-2. Data were recorded as true positive, true negative, false positive, and false negative. Then, using “diagma” package and applying weighted random effect model, area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity, negative likelihood ratio, positive likelihood ratio, and diagnostic odds ratio (DOR) were calculated with 95% confidence interval (95% CI).
Results: We included 5 studies with direct comparison. Area under the ROC curve of NEXUS in screening of patients with clinically important cervical SCI was 0.708 (95% CI: 0.647 to 0.762). Pooled sensitivity and specificity of NEXUS criteria in screening of patients with clinically important cervical SCI were 0.899 (95% CI: 0.845 to 0.936) and 0.398 (95% CI: 0.315 to 0.488). The positive and negative likelihood ratios of NEXUS were 1.494 (95% CI: 1.146 to 1.949) and 0.254 (95% CI: 1.155 to 1.414), respectively. Diagnostic odds ratio of NEXUS was 5.894 (95% CI: 3.372 to 10.305). Furthermore, area under the ROC curve of CCR in screening of clinically important cervical SCI was 0.793 (95% CI: 0.657 to 0.884). Meta-analysis results showed that pooled sensitivity of CCR criteria in screening of patients with clinically important cervical SCI was 0.987 (95% CI: 0.957 to 0.996) and specificity was 0.167 (95% CI: 0.073 to 0.336). The positive and negative likelihood ratios of CCR were 1.184 (95% CI: 0.837 to 1.675) and 0.081 (95% CI: 0.021 to 0.308), respectively. Diagnostic odds ratio of CCR was 14.647 (95% CI: 3.678 to 58.336).
Conclusion: Based on studies, both CCR and NEXUS were sensitive rules that have the potential to reduce unnecessary imaging in cervical spine trauma patients. However, the low specificity and false-positive results of both of these tools indicate that many people will continue to undergo unnecessary imaging after screening of cervical SCI using these tools. In this meta-analysis, CCR appeared to have better screening accuracy.
- Spinal cord injuries
- cervical cord
- wounds and injuries
- diagnosis
- clinical decision rules
- sensitivity and specificity
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References
Spinal cord injury facts and figures at a glance. J Spinal Cord Med. 2013;36(1):1-2.
Ropper AE, Neal MT, Theodore N. Acute management of traumatic cervical spinal cord injury. Pract Neurol. 2015;15(4):266-72.
Nordin M, Carragee EJ, Hogg-Johnson S, Weiner SS, Hurwitz EL, Peloso PM, et al. Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). 2008;33(4 Suppl):S101-22.
Pimentel L, Diegelmann L. Evaluation and management of acute cervical spine trauma. Emerg Med Clin North Am. 2010;28(4):719-38.
Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries. J Trauma. 1993;34(3):342-6.
Griffith B, Bolton C, Goyal N, Brown ML, Jain R. Screening cervical spine CT in a level I trauma center: overutilization? AJR Am J Roentgenol. 2011;197(2):463-7.
Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-8.
Stiell IG, Wells GA, Hoag RH, Sivilotti ML, Cacciotti TF, Verbeek PR, et al. Implementation of the Ottawa Knee Rule for the use of radiography in acute knee injuries. Jama. 1997;278(23):2075-9.
Como JJ, Diaz JJ, Dunham CM, Chiu WC, Duane TM, Capella JM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. J Trauma. 2009;67(3):651-9.
National Clinical Guideline C. National Institute for Health and Care Excellence: Guidelines. Spinal Injury: Assessment and Initial Management. London: National Institute for Health and Care Excellence (NICE)
Copyright © National Clinical Guideline Centre, 2016.; 2016.
Laupacis A, Sekar N, Stiell IG. Clinical prediction rules. A review and suggested modifications of methodological standards. Jama. 1997;277(6):488-94.
Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. Jama. 2001;286(15):1841-8.
Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998;32(4):461-9.
Trauma T, Recovery I, Sterling M, editors. Clinical guidelines for best practice management of acute and chronic whiplash-associated disorders2008.
de Jager JP, Ahern MJ. Improved evidence-based management of acute musculoskeletal pain: guidelines from the National Health and Medical Research Council are now available. Med J Aust. 2004;181(10):527-8.
Wootton-Gorges SL, Soares BP, Alazraki AL, Anupindi SA, Blount JP, Booth TN, et al. ACR Appropriateness Criteria(®) Suspected Physical Abuse-Child. J Am Coll Radiol. 2017;14(5s):S338-s49.
Ala A, Shams Vahdati S, Ghaffarzad A, Mousavi H, Mirza-Aghazadeh-Attari M. National emergency X-radiography utilization study guidelines versus Canadian C-Spine guidelines on trauma patients, a prospective analytical study. PLoS One. 2018;13(11):e0206283.
Benayoun MD, Allen JW, Lovasik BP, Uriell ML, Spandorfer RM, Holder CA. Utility of computed tomographic imaging of the cervical spine in trauma evaluation of ground-level fall. J Trauma Acute Care Surg. 2016;81(2):339-44.
Duane TM, Young A, Mayglothling J, Wilson SP, Weber WF, Wolfe LG, et al. CT for all or selective approach? Who really needs a cervical spine CT after blunt trauma. J Trauma Acute Care Surg. 2013;74(4):1098-101.
Ghelichkhani P, Shahsavarinia K, Gharekhani A, Taghizadieh A, Baratloo A, Fattah FHR, et al. Value of Canadian C-spine rule versus the NEXUS criteria in ruling out clinically important cervical spine injuries: derivation of modified Canadian C-spine rule. Radiol Med. 2021;126(3):414-20.
Jeanmonod R, Varacallo M. Geriatric Cervical Spine Injury. StatPearls. Treasure Island (FL): StatPearls Publishing
Copyright © 2022, StatPearls Publishing LLC.; 2022.
Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin CW. 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;184(16):E867-76.
Paykin G, O'Reilly G, Ackland H, Mitra B. Review article: NEXUS criteria to rule out cervical spine injury among older patients: A systematic review. Emerg Med Australas. 2018;30(4):450-5.
Mower WR, Gupta M, Rodriguez R, Hendey GW. Validation of the sensitivity of the National Emergency X-Radiography Utilization Study (NEXUS) Head computed tomographic (CT) decision instrument for selective imaging of blunt head injury patients: An observational study. PLoS Med. 2017;14(7):e1002313.
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