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Likelihood Ratio (LR) in Emergency Medicine


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 patients 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?


 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: its 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


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


  1. One must not forget to mention the consultation fee of the doctor, expenses on the tests and medicines, cost of medical equipment, fee of medical attendant, and the financial losses due to loss of earnings, while filing the papers for the spinal injury claim.

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