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Suspected traumatic cervical spinal cord injury with ankylosing spondylitis — MRCEM SBA MCQ

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HardTraumaSuspected traumatic cervical spinal cord injury with ankylosing spondylitisMRCEM SBA

A 66-year-old man with ankylosing spondylitis falls from standing height. His neck is fixed in flexion, and he reports new tingling in both hands. Examination confirms reduced grip strength bilaterally and midline cervical tenderness. He is alert, breathing normally and haemodynamically stable. Gentle attempts to bring his neck towards neutral increase his pain. No imaging has been performed. Which plan is most appropriate now?

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

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Correct answer: B — Support the neck in its current position without a collar; arrange cervical CT followed by MRI.

The new bilateral sensory symptoms and objective hand weakness raise concern for cervical spinal cord injury despite the low-energy fall. His spine needs protection during urgent assessment and imaging. However, NICE advises against fitting a semi-rigid collar in a person with a known spinal deformity such as ankylosing spondylitis: the spine should be kept in its current position. Support should limit movement, not force his painful, fixed neck towards neutral. In an adult for whom cervical imaging is indicated, CT is the initial study. A neurological abnormality that could be attributable to spinal cord injury requires MRI **after CT**, even if CT shows no abnormality. Suspected cord injury also warrants prompt specialist spinal discussion. ([nice.org.uk](https://www.nice.org.uk/guidance/ng41/chapter/Recommendations)) **A** adds both forced repositioning and a contraindicated collar. **D** avoids repositioning but still uses that collar. **C** selects appropriate modalities in the wrong sequence. **E** selects the correct initial scan but substitutes observation for MRI despite new neurological abnormalities. The distinction is not whether a standing-height fall appears severe; it is the combination of a fixed deformity and findings concerning for cord injury.

Reference: NICE NG41, recommendations 1.1.2–1.1.4 and 1.1.11–1.1.13 (17 February 2016) — https://www.nice.org.uk/guidance/ng41/chapter/Recommendations NICE NG41, recommendations 1.5.6–1.5.7 (17 February 2016; recommendation 1.5.7 clarified May 2021) — https://www.nice.org.uk/guidance/ng41/chapter/Recommendations