Is cervical spine X-ray necessary if there is a distracting injury?

Clinical Scenario
 A 40 yo lady arrives in ED by ambulance with neck and spinal immobilization because she fell down a staircare.

 The patient’s vital signs are within normal physiological parameters, she is alert, no deficit, remembers all, denies head contusion and neck pain. She complains for a sharp shoulder pain (NRS 10/10), it seems broken.

If I perform the Nexus C-Spine criteria  X Ray is indicated: a distracting injury mandates cervical spine imaging.

How much the presence of distracting injury reduces my sensibility in rule out cervical spine (c-spine) injury?

Conclusion

 Once upon a time nearly all patients who presented in ED with blunt trauma received a cervical spine X-Ray. The clinicians feared to undiagnosed a cervical fracture, with catastrophic consequences for the patients and than for the same doctor, so there were a large number of unnecessary films. The Nexus five criteria simplified our work: it’s easy and speedy and especially is high sensitive to rule out a cervical spine injury. The presence of a distracting injury has a negligible impact. 

Is it time to define the Nexus four criteria? 

Bibliography

MK Rose

Clinical clearance of the cervical spine in patients with distracting injuries: it is time to dispel the myth.

J Trauma 2012 vol 73 n 2 pag 498-502.

A Kostantininidis

The presence of a nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study.

J Trauma Sept 2011 vol 71 n 3.

Paucis Verbis: distracting injuries in c-spine injuries from Academic Life In Emergency Medicine Sept 2011.



                                                                                                                                            Ciro Paolillo