Normal neurology does not prove spinal stability

An older patient falls from standing height, is fully alert and moves all four limbs. It is tempting to regard the cervical spine as safe, particularly when there is no obvious injury. Yet an intact neurological examination tells us about spinal cord function without necessarily establishing the stability of the bones and ligaments surrounding it.

An unstable spinal column injury can be present before any neurological deficit develops. Cord damage may follow hours or even days later. Watching someone move their arms and legs is therefore a poor substitute for a deliberate cervical spine assessment.

Clinical clearance requires confidence in both the patient's eligibility and the reliability of the examination. The five NEXUS criteria require no focal neurological deficit, no posterior cervical midline tenderness, normal alertness, no intoxication and no distracting injury. Each addresses a different reason why an important injury might be overlooked.

The neurological baseline should be explicit. Assess strength and sensation on both sides, ask directly about numbness or pins and needles, and document the findings. Spontaneous movement observed during an assessment does not replace that examination.

The posterior cervical midline also needs careful examination, from the base of the skull to the first thoracic vertebra. Firm, steady fingertip pressure is used to identify tenderness. If midline tenderness is present, clinical clearance stops, regardless of the neurological findings.

Reliability is another potential weakness. A Glasgow Coma Scale score of 15 is necessary but does not guarantee meaningful participation. Intoxication, analgesia, distracting pain or intense emotional distress may make responses difficult to trust. Nor should a rule developed in stable trauma patients be transferred uncritically into major trauma.

Age complicates the decision further. Older adults, particularly those with osteoporosis, metastatic bone disease or ankylosing spinal conditions, may sustain significant injuries after relatively minor mechanisms.

The Victorian approach described adds exclusions for age over 65 and significant bone-weakening disease. It also places a controlled assessment of active neck rotation through 45 degrees in each direction at the end of the clearance process for eligible patients. These additions have a clinical rationale, but the modified rule has not been formally validated. They should not be presented as original NEXUS criteria or as evidence of improved safety.

Clinical clearance can avoid unnecessary transport or imaging. The potential consequences of overlooking an unstable injury are considerably greater. Before declaring the cervical spine clear, the clinician must be satisfied that the patient can be assessed reliably and that the complete examination supports that decision.