What is the recommended management for a 22-year-old female with a cervical computed tomography (CT) scan showing a small well-corticated calcific density with subtle irregularity and depression at C5 following a fall?

Management of Incidental C5 Vertebral Finding in Young Trauma Patient

This well-corticated calcific density with subtle irregularity at C5 most likely represents a chronic, incidental finding rather than an acute traumatic injury, and in the absence of neurological deficits or significant neck pain, no specific intervention beyond clinical correlation and possible short-term cervical collar immobilization is warranted. 1

Initial Assessment and Clinical Correlation

The key to management is determining whether this represents an acute traumatic injury versus a chronic/incidental finding:

• Well-corticated margins strongly suggest a chronic process rather than acute trauma, as acute fractures demonstrate sharp, non-corticated edges 2
• The "subtle irregularity and depression" could represent:
  • A chronic compression deformity
  • An old healed fracture
  • A developmental variant
  • An incidental bone island or osteophyte

Assess for neurological deficits immediately - any focal neurological findings, paresthesias, or motor weakness would mandate additional imaging regardless of the CT appearance 3, 1

Role of MRI in This Clinical Scenario

MRI is NOT routinely indicated when CT shows only chronic-appearing findings without neurological deficits. 1

The 2025 ACR guidelines are clear that:

• MRI following normal CT in obtunded patients without traumatic injury identified does not provide additional benefit 1
• The false-positive rate of MRI for clinically significant ligamentous injury is 20-40%, leading to unnecessary prolonged immobilization 1
• Studies demonstrate that CT alone (without MRI) leads to shorter ICU stays and reduced morbidity from rigid cervical collars, without missing unstable injuries 1

However, MRI should be obtained if:

• Neurological deficits are present that are unexplained by CT findings 1
• There is persistent, significant neck pain despite the benign-appearing CT 4
• The patient cannot be adequately examined clinically (obtunded) AND there are soft tissue abnormalities or non-bony findings on CT 5

In this 22-year-old with what appears to be a chronic finding, MRI would likely only detect incidental degenerative changes or soft tissue edema from the acute fall, not requiring intervention 6

Recommended Management Algorithm

For this specific patient:

1. Perform thorough neurological examination - document motor strength, sensation, reflexes, and any radicular symptoms 3

2. Assess neck pain severity - mild tenderness at the injury site is expected; severe midline tenderness or inability to rotate neck 45° bilaterally warrants closer evaluation 3

3. If neurologically intact with minimal pain:

   • Remove cervical collar once clinically cleared 1
   • Provide reassurance that well-corticated findings are typically chronic/benign
   • Discharge with return precautions for new neurological symptoms
   • Consider outpatient spine clinic follow-up if patient remains symptomatic 1

4. If significant neck pain persists (uncommon with chronic findings):

   • Maintain cervical collar for comfort (typically 48-72 hours maximum) 4
   • Consider MRI only if pain persists beyond 1-2 weeks or new symptoms develop 1

5. If any neurological deficits present:

   • Obtain MRI cervical spine without contrast emergently 1
   • Consult spine surgery if MRI demonstrates cord compression or unstable ligamentous injury 1

Critical Pitfalls to Avoid

• Do not obtain routine MRI for well-corticated, chronic-appearing CT findings - this leads to false-positive soft tissue findings, prolonged immobilization, and increased morbidity without improving outcomes 1, 6

• Do not maintain cervical collar indefinitely awaiting MRI - prolonged immobilization causes skin breakdown, dysphagia, and increased ICU length of stay 1

• Do not dismiss new or progressive neurological symptoms - even with benign-appearing CT, cord injury can occur from ligamentous instability requiring MRI 4

• Do not confuse chronic degenerative changes with acute trauma - well-corticated margins indicate chronicity; acute fractures have sharp, non-corticated edges 2

Evidence Quality Considerations

The 2025 ACR Appropriateness Criteria provide the strongest guidance here, explicitly stating that MRI adds no benefit after normal CT in trauma patients without neurological deficits 1. This is supported by multiple studies showing that routine MRI after normal CT does not alter management and increases healthcare costs and patient morbidity 6. The French guidelines similarly recommend MRI only when neurological deficits are unexplained by CT or when surgical planning requires soft tissue detail 1.

In this 22-year-old with a chronic-appearing finding and presumably normal neurological examination, clinical clearance without MRI is the evidence-based approach. 1, 5