C-Spine: NEXUS Criteria vs. Canadian C-Spine Rule

Clinical Scenario

A 45 year old man presents with neck pain after being rear-ended at 30 MPH. He was a restrained driver, airbags deployed, and he walked at the scene.

He denies head injury, focal weakness, or paresthesias, and reports having one beer an hour ago.

Exam: GCS 15, mild midline tenderness at C6–C7, full strength, non-focal neurological exam including normal speech and decision-making capacity, no other injuries. He asks, “Do I really need a CT Scan?”

Summary

CCR and NEXUS are effective at ruling out c-spine fractures. CCR contains more steps, but can be applied to patients who have midline tenderness on physical exam.

Tool Comparison

	Nexus	CCR
Purpose	Clinically clears cervical spine fracture without imaging in alert, stable trauma patients.
Ease of Use	Fewer inputs than CCR. “Distracting injury” and “intoxication” are at the discretion of the clinician.	Difficult to memorize (three-step process).
Midline Tenderness	Cannot clinically rule out c-spine fx if pt has midline tenderness.	Able to rule out c-spine fx in pts with midline tenderness.
Age	No age cutoffs, but sensitivity may decrease in pts >65y.	Should not be applied to patients <16 or >65.
Intoxication	Cannot clinically rule out c-spine injury for intoxicated patients.	Can be used in intoxicated patients if alert and cooperative.
Mechanism of Injury (MOI)	Does not consider MOI.	Considers MOI.
Performance	NEXUS and CCR both rule out >99% of clinically-significant injuries. CCR may result in lower imaging rates than NEXUS. CCR may be more accurate and is more extensively validated.

Case Resolution:

You explain to your patient that the Canadian C-Spine Rule is highly reliable, catching >99% of serious injuries - though it might miss the tiniest ones. Satisfied, he asks to be discharged so he can make it to happy hour.