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Suspected traumatic thoracic spinal cord injury with normal CT — MRCEM SBA MCQ

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EasyTraumaSuspected traumatic thoracic spinal cord injury with normal CTMRCEM SBA

A 35-year-old rider is brought to a major trauma centre after falling from a horse and landing on his back. He is alert and haemodynamically stable. He has mid-thoracic pain, bilateral leg power of 3/5 and reduced pinprick sensation below the umbilicus; arm examination is normal. Diagnostic-quality CT of the spine, including multiplanar reconstructions, shows no fracture or malalignment. In-line spinal immobilisation is maintained and the spinal surgical team has been contacted. He has no contraindication to MRI. What is the most appropriate next investigation?

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Correct answer: E — Obtain urgent MRI of the thoracic spine

The bilateral leg weakness and sensory level following a fall suggest a thoracic spinal cord injury. A normal, diagnostic-quality CT excludes neither cord injury nor the need for further imaging: NICE recommends MRI after CT whenever a neurological abnormality could be attributable to spinal cord injury, regardless of whether CT shows an abnormality. Urgent thoracic MRI is therefore the next investigation while spinal precautions and specialist involvement continue. ([nice.org.uk](https://www.nice.org.uk/guidance/ng41/chapter/Recommendations)) Repeating CT (A) might be reasonable if the first examination were technically inadequate, but it would not resolve the concern raised by persistent neurological deficits after an adequate scan. Radiographs (B) are a first-line option for suspected thoracic column injury *without* abnormal neurological signs; they add little after this CT. CT myelography (C) may be considered through specialist discussion when MRI cannot be performed, but this patient has no MRI contraindication. Serial examination (D) is important for detecting change, not a reason to defer indicated MRI. ([nice.org.uk](https://www.nice.org.uk/guidance/ng41/chapter/Recommendations))

Reference: Spinal injury: assessment and initial management — Recommendations, section 1.5 (2016; recommendation 1.5.7 clarified May 2021) — https://www.nice.org.uk/guidance/ng41/chapter/Recommendations Spinal injury: assessment and initial management — Recommendations, sections 1.4 and 1.5 (2016) — https://www.nice.org.uk/guidance/ng41/chapter/Recommendations