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Suspected traumatic cervical spinal cord injury — MSRA MCQ

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HardMRISuspected traumatic cervical spinal cord injuryMSRA

A 42-year-old man presents to general practice 40 minutes after diving into a shallow swimming pool and striking his forehead on the pool floor. He did not lose consciousness and walked from the pool with assistance. He has midline cervical pain, burning paraesthesia in both hands and difficulty gripping his car keys. He is alert (GCS 15), haemodynamically stable and has no vomiting or seizure. Examination shows cervical midline tenderness, bilateral reduced handgrip strength (4/5) and reduced pinprick sensation in both hands. Lower-limb power and sensation are normal. There is no facial weakness, dysarthria, visual disturbance or headache. He has no contraindication to MRI. Which is the most appropriate next management and imaging plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Apply spinal precautions, arrange emergency transfer for CT cervical spine within 1 hour, followed by MRI because of the neurological abnormality regardless of the CT result

Explanation lettering: C = shown as A · A = shown as B · B = shown as C

This is high-risk suspected cervical spine injury. Diving with impact to the head is an axial-load mechanism specifically classed by NICE as dangerous. In addition, he has cervical tenderness, upper-limb paraesthesia and objective focal peripheral neurological abnormality (bilateral hand weakness and sensory loss). He therefore requires emergency transfer with CT cervical spine imaging within 1 hour of the risk factor being identified. The decisive further step is MRI after CT. His bilateral upper-limb signs could represent cervical spinal cord injury, including cord contusion, traumatic disc injury or ligamentous injury, which may not be apparent on CT. NICE recommends MRI after CT where a neurological abnormality could be attributable to spinal cord injury, irrespective of whether CT demonstrates the abnormality. A is inappropriate because plain radiographs are not first-line imaging in this high-risk adult presentation. B is plausible because CT defines fractures and alignment, but incorrectly makes MRI conditional on an abnormal CT. C correctly recognises the value of MRI for cord assessment but omits the required initial CT. E incorrectly delays MRI despite an objective neurological deficit potentially attributable to spinal cord injury.

Reference: NICE NG232: Head injury: assessment and early management — recommendation 1.6.2, Criteria for doing a CT cervical spine scan in people 16 and over (2023) — https://www.nice.org.uk/guidance/NG232/chapter/recommendations NICE NG41: Spinal injury: assessment and initial management — recommendations 1.5.6 and 1.5.7, Diagnostic imaging (2016; clarified May 2021) — https://www.nice.org.uk/guidance/ng41/chapter/Recommendations