More Accurate Screening Tool for Serious Neck Injuries

To screen for serious neck (cervical spine) injuries such as fractures in the emergency department, the Canadian Cervical Spine rule (C-Spine) appears to be more accurate compared with the National Emergency X-Radiography Utilisation Study (NEXUS) criteria, according to a review published today in the Canadian Medical Association Journal.

A serious neck injury can result from blunt trauma like a car accident and have disastrous consequences including spinal cord injury and death if the diagnosis is delayed or missed.

The traditional course of action in emergency for diagnosing a neck fracture is costly and potentially distressing for people with neck injuries despite only 2% of people having a fracture.

Researchers from Australia and The Netherlands looked at 15 research studies evaluating the use of the C-Spine and NEXUS rules in diagnosing serious neck injuries and found that the C-Spine rule has better diagnostic accuracy and a lower rate of false negatives compared with NEXUS.

Professor Chris Maher from The George Institute for Global Health said a negative test helps exclude an important neck injury and thus the need for diagnostic imaging.

“Our review highlights that the C-Spine rule is more effective than the NEXUS criteria in clearing the cervical spine without the need for imaging, while maintaining patient safety,” Professor Maher said.

“There is uncertainty about the optimal approach to screen for clinically important neck injury following blunt trauma,” he said.

“We conducted a systematic review to investigate the diagnostic accuracy of screening tools available to emergency physicians, C-Spine Rule and the NEXUS criteria.

“Screening tools such as these are useful because they can reduce the need for unnecessary diagnostic imaging, which can expose patients to radiation, psychological distress and is also costly.”

The C-Spine rule has been designed to have a high pick-up rate for detection of serious neck injuries and is simple and easy for use by GPs, ambulance officers and emergency physicians.

Professor Maher said that studies in Australia and overseas have shown that implementing the C-Spine rule in emergency reduces the rate of imaging without increasing the rate of missed fractures.

“Both the C-Spine rule and NEXUS are recommended in many international guidelines to help exclude important neck injuries,” Prof Maher said.

“Assessing someone’s risk of a serious neck injury using the C-Spine rule is simple as it is based around easily assessed features such as a person’s age and the mechanism of injury, for example, the type of accident,” he said

"Despite these findings, in Australia and around the world many patients with blunt trauma are immediately sent for x-ray.

“This may be because of patient preference, physicians' fear of litigation or missing a fracture, or uncertainty of the application or accuracy of the screening tools.”

Through better education and with easy to use tools like The British Medical Journal’s Doctor’s Toolbag iPhone App, GPs and emergency physicians can become more confident about using the C-Spine rule.

“It is also important to educate patients that these tools are effective and that imaging is not necessary if there are no signs of neck injury,” Dr Maher said.

“Follow-up strategies for patients discharged without imaging could be used to ease patient anxiety.”