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Suspected traumatic cervical spinal cord injury with fixed cervical deformity — MRCEM SBA MCQ

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HardProcedures, imaging and diagnosticsSuspected traumatic cervical spinal cord injury with fixed cervical deformityMRCEM SBA

A 63-year-old man with axial spondyloarthritis and a fixed, markedly flexed cervical posture falls forwards from standing. He is alert and haemodynamically stable. His neck has been supported in its usual position without a collar. He has new bilateral hand weakness (MRC grade 3/5) and reduced pinprick sensation below C6. An adequately performed cervical spine CT is reported as showing no acute fracture or malalignment. MRI is available immediately, and he has no MRI contraindication. What is the most appropriate next diagnostic and management plan?

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

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Correct answer: C — Maintain his usual spinal alignment without a collar; request urgent cervical MRI and seek urgent spinal surgical review.

The new bilateral weakness and sensory level after trauma are neurological abnormalities that could reflect cervical spinal cord injury. A normal CT does not settle that question: NICE recommends MRI after CT when a neurological abnormality could be attributable to cord injury, regardless of whether CT shows an abnormality. Imaging should be urgent, with prompt spinal surgical involvement. ([nice.org.uk](https://www.nice.org.uk/guidance/ng41/chapter/Recommendations)) His fixed deformity changes how spinal protection is provided. Maintain support in his existing alignment rather than forcing his neck into a semi-rigid collar or a neutral position. NICE identifies known deformity, including ankylosing spondylitis, as a contraindication to that collar approach. ([nice.org.uk](https://www.nice.org.uk/guidance/ng41/chapter/Recommendations)) **A** repeats a scan that was adequate instead of investigating the persistent neurological deficit with MRI. **B** selects the right investigation but risks harmful repositioning of his fixed neck. **D** selects the right investigation but prematurely removes spinal support while cord injury remains possible. **E** proposes an alternative investigation despite MRI being available and not contraindicated. Thus C is the plan that addresses both the unresolved diagnostic question and safe spinal protection.

Reference: NICE NG41: Spinal injury—assessment and initial management, recommendation 1.5.7 (Published 17 February 2016; recommendation clarified May 2021) — https://www.nice.org.uk/guidance/ng41/chapter/Recommendations NICE NG41: Spinal injury—assessment and initial management, recommendation 1.1.13 (17 February 2016) — https://www.nice.org.uk/guidance/ng41/chapter/Recommendations NICE NG41: Spinal injury—assessment and initial management, recommendations 1.4.4, 1.5.1 and 1.6.1–1.6.2 (17 February 2016) — https://www.nice.org.uk/guidance/ng41/chapter/Recommendations