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Falls and Implementation of NEXUS in the Elderly (The FINE Study)

      Abstract

      Background

      The incidence of cervical spine injuries (CSI) in people over 65 years of age from low-energy mechanisms is far greater than in younger populations. Algorithms and decision rules exist for selection of trauma patients requiring cervical spine imaging.

      Objectives

      To determine the validity of the NEXUS criteria in the elderly population with low-mechanism injuries.

      Methods

      We prospectively conducted computed tomography (CT) imaging in patients > 65 years of age presenting with fall from standing height or less to rule out predefined clinically significant CSI. Eligible patients were prospectively categorized into NEXUS positive or negative.

      Results

      There were 169 patients included in the final analyses. One hundred twenty (71%) patients in the cohort were classified as “NEXUS positive.” Eleven patients (6.5% of the cohort) had CSI detected on CT imaging of the cervical spine. Nine patients had clinically significant CSI. The NEXUS decision instrument demonstrated 88.9% sensitivity (50.7–99.4%) and 98% negative predictive value (NPV) (87.8–99.9%) in detecting clinically significant CSI. The NEXUS decision instrument demonstrated 81.8% sensitivity (47.8–96.8%) and 95.9% NPV (84.9–99.3%) in detecting any CSI.

      Conclusion

      In our study, the NEXUS decision instrument was not a valid tool to rule out imaging for patients > 65 years of age presenting after a fall from standing height or less. We advocate the liberal use of CT imaging of the cervical spine in this cohort of patients to rule out cervical spine injury.

      Keywords

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      References

        • Herman M.
        • Gallagher E.
        • Scott V.
        The evolution of seniors' falls prevention in British Columbia.
        British Columbia Ministry of Health, Victoria, BC, Canada2006
        • Blake A.J.
        • Morgan K.
        • Bendall M.J.
        • et al.
        Falls by elderly people at home: prevalence and associated factors.
        Age Ageing. 1988; 17: 365-372
        • Prudham D.
        • Evans J.G.
        Factors associated with falls in the elderly: a community study.
        Age Ageing. 1981; 10: 141-146
        • Campbell A.J.
        • Reinken J.
        • Allan B.C.
        • Martinez G.S.
        Falls in old age: a study of frequency and related clinical factors.
        Age Ageing. 1981; 10: 264-270
        • Tinetti M.E.
        • Speechley M.
        • Ginter S.F.
        Risk factors for falls among elderly persons living in the community.
        N Engl J Med. 1988; 319: 1701-1707
        • Downton J.H.
        • Andrews K.
        Prevalence, characteristics and factors associated with falls among the elderly living at home.
        Aging (Milano). 1991; 3: 219-228
        • Stalenhoef P.A.
        • Diederiks J.P.
        • Knottnerus J.A.
        • Kester A.D.
        • Crebolder H.F.
        A risk model for the prediction of recurrent falls in community-dwelling elderly: a prospective cohort study.
        J Clin Epidemiol. 2002; 55: 1088-1094
        • World Health Organization (WHO)
        WHO global report on falls prevention in older age.
        World Health Organization, Geneva, Switzerland2008
        • Stevens J.A.
        • Ryan G.
        • Kresnow M.
        Fatalities and injuries from falls among older adults—United States, 1993–2003 and 2001–2005.
        MMWR Morb Mortal Wkly Rep. 2006; 55: 1221-1224
        • Division of Aging and Seniors, Public Health Agency of Canada
        Report on seniors' falls in Canada.
        Public Health Agency of Canada, Ottawa, ON, Canada2005
        • Hendrie D.
        • Hall S.E.
        • Legge M.
        • Arena G.
        • Injury Research Centre, University of Western Australia; Department of Health, Injury Prevention Unit
        Injury in Western Australia: the health system costs of falls in older adults in Western Australia: report prepared by Injury Research Centre, School of Population Health, The University of Western Australia.
        Injury Prevention Unit; Department of Health, Crawley, WA, Australia2003
        • Roudsari B.S.
        • Ebel B.E.
        • Corso P.S.
        • Molinari N.A.
        • Koepsell T.D.
        The acute medical care costs of fall-related injuries among the U.S. older adults.
        Injury. 2005; 36: 1316-1322
        • Cummings S.R.
        • Rubin S.M.
        • Black D.
        The future of hip fractures in the United States. Numbers, costs, and potential effects of postmenopausal estrogen.
        Clin Orthop Relat Res. 1990; : 163-166
        • Bub L.D.
        • Blackmore C.C.
        • Mann F.A.
        • Lomoschitz F.M.
        Cervical spine fractures in patients 65 years and older: a clinical prediction rule for blunt trauma.
        Radiology. 2005; 234: 143-149
        • Harris M.B.
        • Reichmann W.M.
        • Bono C.M.
        • et al.
        Mortality in elderly patients after cervical spine fractures.
        J Bone Joint Surg Am. 2010; 92: 567-574
        • Spaniolas K.
        • Cheng J.D.
        • Gestring M.L.
        • Sangosanya A.
        • Stassen N.A.
        • Bankey P.E.
        Ground level falls are associated with significant mortality in elderly patients.
        J Trauma. 2010; 69: 821-825
        • Walid M.S.
        • Zaytseva N.V.
        Upper cervical spine injuries in elderly patients.
        Aust Fam Physician. 2009; 38: 43-45
        • Morisod J.
        • Coutaz M.
        Falls in the elderly: think about cervical fracture! [French].
        Rev Med Suisse. 2009; 5 (2198–9): 2195-2196
        • Hoffman J.R.
        • Wolfson A.B.
        • Todd K.
        • Mower W.R.
        Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS).
        Ann Emerg Med. 1998; 32: 461-469
        • Hoffman J.R.
        • Mower W.R.
        • Wolfson A.B.
        • Todd K.H.
        • Zucker M.I.
        Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.
        N Engl J Med. 2000; 343: 94-99
        • Lieberman I.H.
        • Webb J.K.
        Cervical spine injuries in the elderly.
        J Bone Joint Surg Br. 1994; 76: 877-881
        • Stiell I.G.
        • Wells G.A.
        • Vandemheen K.L.
        • et al.
        The Canadian C-spine rule for radiography in alert and stable trauma patients.
        JAMA. 2001; 286: 1841-1848
        • Theocharopoulos N.
        • Chatzakis G.
        • Damilakis J.
        Is radiography justified for the evaluation of patients presenting with cervical spine trauma?.
        Med Phys. 2009; 36: 4461-4470
        • Mathen R.
        • Inaba K.
        • Munera F.
        • et al.
        Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients.
        J Trauma. 2007; 62: 1427-1431
        • Looby S.
        • Flanders A.
        Spine trauma.
        Radiol Clin North Am. 2011; 49: 129-163
        • Platzer P.
        • Jaindl M.
        • Thalhammer G.
        • et al.
        Clearing the cervical spine in critically injured patients: a comprehensive C-spine protocol to avoid unnecessary delays in diagnosis.
        Eur Spine J. 2006; 15: 1801-1810
        • Menaker J.
        • Philp A.
        • Boswell S.
        • Scalea T.M.
        Computed tomography alone for cervical spine clearance in the unreliable patient—are we there yet?.
        J Trauma. 2008; 64 (discussion 903–4): 898-903
        • Lomoschitz F.M.
        • Blackmore C.C.
        • Mirza S.K.
        • Mann F.A.
        Cervical spine injuries in patients 65 years old and older: epidemiologic analysis regarding the effects of age and injury mechanism on distribution, type, and stability of injuries.
        AJR Am J Roentgenol. 2002; 178: 573-577
        • Panacek E.A.
        • Mower W.R.
        • Holmes J.F.
        • Hoffman J.R.
        Test performance of the individual NEXUS low-risk clinical screening criteria for cervical spine injury.
        Ann Emerg Med. 2001; 38: 22-25
        • Schoenfeld A.J.
        • Bono C.M.
        • McGuire K.J.
        • Warholic N.
        • Harris M.B.
        Computed tomography alone versus computed tomography and magnetic resonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis.
        J Trauma. 2010; 68 (discussion 113–4): 109-113