Blunt trauma · C-spine clearance
NEXUS — the National Emergency X-Radiography Utilization Study rule — is a five-item clinical decision instrument used after blunt trauma. In the right low-risk, examinable patient, it helps identify when the cervical spine may be cleared clinically without imaging.
Rule anatomy
05
binary criteria
one clearance threshold
How to read the rule
NEXUS is intended for the stable, cooperative adult after blunt trauma whose neck can be examined. All five criteria must be absent for a NEXUS-negative, low-risk result. When that threshold is met in the appropriate validated context, clinical clearance without cervical-spine imaging may be considered.
One or more positive criteria means the patient should not be clinically cleared by NEXUS. Maintain the institution’s trauma precautions and move to the next evaluation and imaging pathway rather than treating a negative count as a diagnosis or a substitute for examination.
NEXUS-negative
Clinical clearance without imaging may be considered when the patient is stable, cooperative, and otherwise appropriate for the rule.
NEXUS-positive
Follow immobilization, examination, and imaging steps in the local trauma pathway; a positive NEXUS criterion is not itself a prescription for one modality.
The five findings
Each item is binary: present or absent. The distinctions matter — posterior midline tenderness is not the same as paraspinal soreness, and a focal neurologic deficit is an examination finding rather than a vague symptom label.
Palpation of the posterior midline neck is positive. Paraspinal or off-midline tenderness does not satisfy this specific NEXUS criterion.
Look for an actual motor or sensory deficit referable to the cervical spine on examination, rather than treating nonspecific symptoms as a focal finding.
A patient who is disoriented, slow to respond, has a GCS below 15, or cannot participate normally in the examination does not meet the low-risk threshold.
Clinical or biochemical evidence of alcohol or drug effect is positive. Intoxication is assessed separately even when alertness is otherwise documented.
A long-bone fracture, severe laceration, crush injury, burn, or another painful injury could occupy attention and mask cervical pain during the examination.
Evidence base
Hoffman and colleagues reported the prospective, multicenter NEXUS validation in the New England Journal of Medicine in 2000. Among 34,069 patients who underwent cervical-spine imaging after blunt trauma, 818 had a radiographic injury.
The rule showed 99.0% sensitivity for radiographic injury and 99.6% sensitivity for clinically significant injury. The study reported a 99.9% negative predictive value for clinically significant injury and identified 12.6% of imaging as potentially avoidable in that population.
Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343:94–99. doi:10.1056/NEJM200007133430203
Hoffman et al. · NEJM 2000
Imaging threshold
“All five absent” is the NEXUS-negative threshold for clinical clearance without imaging in the appropriate validated context. “Any one present” is the threshold to stop clinical clearance and proceed with immobilization, further evaluation, and imaging according to the local trauma protocol.
Rule-out threshold
NEXUS-negative / low risk. In a stable, cooperative patient who fits the validated context, the cervical spine may be cleared clinically without imaging.
Evaluation threshold
NEXUS-positive. Do not clinically clear by this rule; continue the patient’s immobilization, examination, and institution-specific imaging pathway.
NEXUS does not mandate CT, MRI, or a specific radiograph series. Modality selection depends on the patient, the examination, mechanism, available resources, and local trauma protocol. It is also distinct from the Canadian C-Spine Rule; the Stiell 2001 paper describes a different decision rule.
Open the calculator
The in-app NEXUS calculator lets you tick the five criteria and see the binary result, then copy or print a clean clinical summary. It uses the existing account and subscriber access flow when you continue.
Open the NEXUS calculator →Informational only. Not a substitute for clinical judgement. Not a patient record — NEXUS results are not persisted; a refresh clears the result. Applicable to stable, cooperative adults after blunt trauma; not validated for children, penetrating trauma, or acute paralysis. Always follow your institution’s c-spine clearance pathway and clinical gestalt.