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Perfect, great. So last week, we talked about head injuries this week, we're going to talk about spinal injuries. Um Now, when we think about spinal injuries, we are referring to both the bony spinal column and also the neurological structures that it's protected. So the spinal cord and all the nerve roots, the spinal cord side of things is actually very similar to the head injuries because it is essentially an extension of your central nervous system. So a lot of the things you have to do to kind of protect the spinal cord to um improve kind of repair and healing within the spinal cord after an injury is very similar to the neurop protection that we talked about last week. So I'll touch on that a little bit again. Um But what's very different is obviously the spine itself um in terms of the bony structure of the spine, and that's much more common commonly, the problem in that people will have fractures and the majority of fractures that we see are actually not associated with a neurological deficit. So I think on a daily basis, maybe every 24 hours, we probably referred somewhere between 12 to 15 fractures of some form, but probably only one of those will have some form of neurological deficit. And in terms of actual spinal cord injury, you're probably looking at about two or three cases a week. Um So it is still common. Um, but certainly bony knee fractures are much more common than uh spinal cord injury, which is a good thing. Now, in terms of spinal fractures, there are a few things to think about. Um So I'm going to go through kind of looking at the spine, uh the the bony spine of all the different ages and also some special considerations that you have to give and how you can decide if something is stable or unstable. And like I said, we'll touch on spinal cord injury towards the end. Um Now look at the spine itself, the spine changes from the top to the bottom and from young to old. Uh for obvious reasons, we start at the top. So we're looking at the cervical spine at the moment. This is a ct scan of an 11 year old, um cervical spine, it's completely normal, just, just so, you know, it's not very common that you'll see a CT scan of a child's spine mainly because we try not to irradiate Children, especially the thyroid gland. Um you know, is quite sensitive to irradiation. So you try not to irradiate the neck if you can avoid it. Um So certainly below the age of nine or 10 Children are so unlikely to have a bony injury. CT scan is probably not very useful. Uh, you know, let's say a five year old came in after falling from a high height. Um, and they've got a lot of neck pain and you get a CT scan, which is completely normal. That doesn't tell you that the ligaments are fine. It just tells you the bones are not fractured. And as you can see here, you can't see the ligaments, you can't really see the muscles, you can't even see the spinal cord, you're just seeing the bones. So the CT is very good at telling you what's happening with the bones. And like I said, in a child, they are unlikely to have a bony injury, they tend to have ligamentous injuries. So, ultimately, they're gonna need an MRI scan. So most of the time we don't CT them, we will get an x-ray. If the suspicion is low. If the suspicion is high, then we'll go straight for an MRI scan. Um But in this particular case, the thing to really remember about um Children and this is not just a spine, this any kind of bone, I guess is that they have growth plates and they have primary and secondary ossification centers, as you probably remember from the 1st and 2nd year of medical school and they don't always fuse um early on and then at what point they fuse depends on exactly which bone you're looking at. And if you don't know the answer to these things, then it's very easy to look the bone and think there is a fracture where that may actually be just, you know, normal for that age because the growth plates have been fused together. So in this particular case, if you look at the C two bone, you can see the C two vertebral body, here's my arrow, see two vertebral body down here and then the finger like projection is the odontoid process or what we call the peg. And you can see a white line between the two. Now, if this was an adult spine and that white line would, would suggest that there is a fracture across the base of the peg. Um but in the child, this is completely normal. The other thing is the gap between the C one, anterior C one arch, which is this little circle thing here and between the peg. So this gap in between the two in an adult, you allow anything up to about three millimeters in the child. Some especially in a very young child, sometimes that can be anything up to about five millimeters and that can still be within normal limit. Similarly, between the C two and the C three brings some Children have a little step. So the C two bring is actually sitting about 23 more anterior to the C three bone. It's called an enterolith isis. Once again, in an adult, if you see something like that, you would have to have a high index of suspicion that there might be some form of subluxation or even dislocation um in a child, it could be completely physiological and normal. But just a few things to think about when you look at the CT scans as they get a little bit older, what you notice is that the bones become a lot more kind of square in shape rather than the rectangles with the rounded edges that you get in a child. And also you start to develop these little sharp bits at the back corners at the posterior aspect of the vertebra. So these are little osteophytes that are starting to form. This is a 50 odd year old. So you can see little osteophytes forming and as they get a bit older and this 81 year old, you can see this huge osteophyte. It's almost like a bit of bone that bridging between these two vertebrae has formed. And that's very normal from degenerative disease. And the thing to worry about here is that because these bones are now much more formed and much more brittle, they will fracture easier than in a child. So adults, if they injure the neck, they are much more likely to have bony injuries. And it's very unlikely to see a ligamentous only injury in an adult. There's always a fracture somewhere in the child. As I said, you can have a ligamentous injury without any fracture. So just be very wary of that. And also the other thing is because of this changing kind of anatomy of the spine. They also stent in slightly different ways. So we said in a child, they can get neck pain, they can get some neurological deficits because of the ligament that's ruptured. Maybe there's a little bit of bleeding from the ligaments, giving them a small epidural hematoma. Something along those lines in a 50 year old, year old, you know, they're likely to have some form of fracture of the spine. Um So that could be a fracture of the retinal body, that could be a fracture of the posterior elements. Combination of the two could be a subluxation, dislocation, et cetera. We'll come on to those later in an elderly person. What's likely to happen is rather than having an actual fracture. This big osteophyte, which even at the best of time is already squishing the spinal cord as you can tell because the canal it's very narrow there as they fall over and most elderly people, they fall forward and because their reaction is slow, maybe a bit of dementia, maybe a bit of Parkinson's, um they don't put their arms out to protect themselves. So they hit the forehead, they have a sudden hyperextension injury. And as they extend the neck, what happens is that the ligamentum flavum, which is the back of the spinal cord between the lamina that buckles into the spinal canal. So if you look up right now, your ligamentum flavum buckles into your spinal cord. And as you look down, it straightens out. Now, if you do it in a controlled manner, then it doesn't matter. And you've got lots of space in your spinal canal when your spinal cord is already slightly pinched before the accident and you suddenly have a hyperextension because of the fall And the ligamentum flavum suddenly buckles inward. That will all of a sudden pinch your spinal cord really really tightly and keep the spinal cord um a really bad contusion. Now by the time they come into hospital and you get them a CT and an MRI scan, that ligamental flavum is no longer buckle in, it's now straightened out again because the patient is not in the hyperextended position, you know, they're back in a neutral position. So sometimes you get MRI scan for an elderly person, you can see the what we call high signal within the spinal cord, which is indicative of bruising of the spinal cord, but you can't see anything obvious, compressing it. And you're wondering, oh, where the hell did this come from? And that's because at the time of the accident, the ligament has buckled in. So these people get spinal cord injury sometimes without any obvious bone or ligamentous injury at all. So, so they all present in a slightly different way, which is what makes spines quite interesting actually. Now, moving down the spine, um, you can see that I've skipped the thoracic spine and this is because the thoracic spine does relatively little in that. It's not the weight bearing part of your spine. It is very well supported by the rib cage and the sternum and it really only does rotation. It doesn't really do any flexion extension. So you are actually quite likely to fracture your thoracic spine unless it's really, really high energy impact, um such as, you know, a high speed car accident or something along those lines. Um So we'll skip through the thoracic spine and come down to the lumbar spine once again in a child lumbar spine, you can see very, you know, nice square shaped vertebrae from the side, rounded corners, you know, a capacious canal. As you get a little bit older, you can start to see these corners start to form little spikes. So you can see the degenerative changes starting to kick in but still not too bad in this particular patient. I mean, in fact, the 61 year old has a very healthy time, but as they get older and older, you can start seeing some fractures that are old. These are old osteoporotic fractures. So these fractures have happened at some point. And often we get that we have an elderly person, they've fallen over, they've come up to the hospital because they've got back pain, we scan them and we see something like this. And then the next question is, well, are these new fractures from the current fall or are these fractures from some time ago? Because actually this patient has been having recurrent falls over a period of time. Sometimes it's really obvious because you can't see a fracture line. Everything is corticated or the patient of the family can give you a history that they've had multiple falls or they've had previous fractures, sometimes not so obvious. Um But once again, we'll come on to that in a minute. The other thing to say uh and something I always say is if there is more calcium, which is the white lining, your aorta than there is in the bone itself, that patient must be at least osteopenic if not osteoporotic. Um So if you see a lot of white in the aorta in front of the bone, um That's a sign this patient really should be on treatment for osteoporosis, especially when they've got lots of collapses like this. So these are some of the more normal looking spines for these different ages. Uh There are a few other specific things to think about. So the first is degenerative disease, which we've already eluded to. Um So mainly happens in elderly people, although you can get degeneration at any age, I have once done a decompression on a 12 year old um because of degenerative changes. Uh So it can happen in anybody. Um So it's just something to think about really. Um, now, the problem with degenerative disease is that as you can see here, sometimes it makes it really difficult to interpret what's going on. You know, can you tell how many vertebrae are there within this kind of chunk of bone? There could be two, there could be three. It's really hard to tell they all kind of fused to one another. You know, the disc space looks like it's opened up at the front, but it's really narrow at the back. You know, is this normal from the degeneration or is this because the patients actually ruptured the disc and the anterior longitudinal ligament and this is actually an unstable injury. It's really hard to know because sometimes in elderly people with severe degeneration, you're better off getting an MRI scan than not just to help you work out what is normal and what isn't Axon? Uh probably it's worth a separate lecture altogether. Now, I'm not going to talk about a lot of Axon um from uh you all know about ankylosing spondylosis, I hope. Um yeah, this is the main mean in uh male, but also it can happen in females. Um It's uh mainly affecting your si joint. In fact, the first things they get is sacral ileitis. Um and obviously they get a lot of back pain and neck pain because the whole spine is actually fused into one long chunk of bone. And it's what we call bamboo spine because it looks a bit like a bamboo from the side. Now, the problem with a bone is that because everything is fused into this one long chunk of bone. If they fall over and injure the spine, it's really hard to fracture the spine just at the front or just at the back without the fracture going all the way through from front to back. Um And almost every a spun fracture is going through from front to back, which makes all aon fractures unstable until proven otherwise. Um In fact, I don't really remember the last a spun fracture that was successfully treated conservatively. Um unless they are so frail that you can't operate on them, otherwise, they should all be fixed. So all a bone fractures are unstable until proven otherwise, and they can be really difficult to see. Um So in this case, I point it out now, there is a fracture just there in that corner, that little corner looks like it's chipped off. Now, it looks very subtle and it looks very minor, but actually that fracture comes across here into the disc space which you can't see. But remember the disc space is now actually bone because it's actually fused and it actually comes all the way across to the back here. Oops, sorry. Um So this gap between these two spinous processes is actually part of the fracture. Once again, it's very hard to pick these things up unless you've seen lots of them. Um So anyone with back pain or neck pain having had a fall with a background history of ankylosing spondylosis, you have to assume they have an unstable injury until proven otherwise. So keep these patients bed rested and get them CT scanned as soon as possible and get an opinion from a spine surgeon. Um Now, the other thing to quickly mention about a bo is that when I say keep them bed rested, I don't mean to keep them flat in bed. And you may have heard this before that often say, you know, keep a patient with an unstable spinal injury, uh flat in bed and lo road until their injury is fixed. Um Now with a bon because the spine is already fused into one long chunk of bone and most of the time in a very kyphotic deformity. So most of them have, have this big of Buffalo hump um or a bit like a Buffalo hump. Um just in the upper thoracic spine because of the severe kyphosis, then it's fused naturally into that angle. If you make them lie flat, it's well, it's not possible because it's fused. So the only way they will flatten out is either because you've now massively opened up the fracture. So you've displaced the fracture to make them flat or you've created a new fracture at the point of the kyphosis in order to straighten out the spine. But either way you are actually causing more injury to the patient. Um And certainly there was one case where a patient without a lung diagnosis of a bo but came into the trauma co went down to CT for a scan. And the radiographer asked the patient to lie flat for the scan. The patient said he couldn't. And the radiographer thought that the patient was confused or whatever and actually put her hands on the shoulders and pushed the patient down onto the scanner to lie flat and everybody the room could hear this loud crack and almost immediately the patient could not move um his his legs. Um and the and the scan and showed this massive fracture that's completely dislocated and displaced across the kyphosis. So just be very careful with. Thanks a lot. Finally, to talk about something called dish dish is diffuse. I um idiopathic sle to hypertrophy uh which is mainly happening in elderly people. This is where as you can see the ligaments are ossified, sorry the dry throat. Um So you can see the calcium within the posterior and anterior longitudinal ligament, fusing everything together. This is not aon, it's from really severe degenerative disease. However, it works like aon because everything is fused into one long segment. So once again, if you see a fracture of the ligament here, this actually is an unstable injury. So just be wary when you see these. The other thing to mention is if you imagine that this black thing here, that's air. So this is your pharynx. You can see this osteopor is th into the pharynx, in fact, and very much narrowing the pharynx here. So this patient may well also present with some swallowing difficulties. Um So, so that's something else to think about. So, you know, if you were to take this patient to theater, you're planning to fix this. Um you know, should you remove some of this osteophyte at the same time just to flatten everything down, um to increase the amount of space for the esophagus, allowing it to open up and improving the swallowing um for the patient. Um So extra things to think about. Uh even though this is not um uh AAA swallowing problem, this is mainly a spinal problem, but they are all linked, right? So why are we so worried about all these people with spinal fractures? Um I kind of alluded to this earlier on already. The problem is there is an increasing elderly population across the whole world and an increasing number of elderly people falling over causing injuries. Lots of studies showing this kind of epidemiology. I've picked this one out just because it's got a really nice graph. Um but loads of studies across the world showing exactly the same trend everywhere really. Um and elderly people, as you can imagine are much more tricky than the young people because not only do you have to deal with the spine, they may well have other injuries. They also have a lot of comorbidities. They may be on anticoagulation. Um They will have a lot, well, they will have less physiological surf. So overall, they're much more likely to have complications from either conservative or surgical management. So you can't really win either way. And such, I've had patients who are really elderly and frail, they've got an injury that is very unstable and I made it very clear to the geriatrician that if we did not operate on this, um there is absolutely no chance this patient would be able to walk off hospital um with normal function or even alive. At the same time, the geriatrician said to me, if you operate on this patient, there's absolutely no chance this patient will come out of theater alive. So you're then stuck in this rock and a hard place, you know, you can't operate because they might die from your surgery. But at the same time, you can't not operate because they're clearly going to be paralyzed. And if you're elderly and frail and paralyzed and stuck in bed, you are gonna die. So, you know, what do you do? Um So, so we are faced with really difficult situations sometimes. Oh, so lots of things to think about when someone comes in with the spine injury. And um that picture just so, you know, is not a flow chart for spine injury. If you manage to zoom in, it's actually a random flow chart, but just to show you the potential complexity of um spinal injuries, you know, are we thinking about putting a collar on the patient? Are we thinking about more than just a CT scan or x-rays? Do they need surgery if they've got spinal cord injury? Remember about neuroprotection, you're trying to fused the central nerve system, you want to match the perfusion pressure. So you think about some form of new arterial pressure target, you know, all the comorbidities and anticoagulants. What are you going to do about those nursing care is a big deal in spinal injury because these patients may not be moving and you can't leave them lying on the back forever because they'll get um pressure sores. So every few hours, they're gonna have to be rolled from one side to the next and they may well need a lot of help with various things as well. Um So, so there's a lot of things to think about in a spinal injury patient. So just to put all of that into practice, the first patient is an elderly patient. As you can see, um he fell from a standing height. Um he normally lives in a nursing home because of dementia and normally walks around with a ZMA frame. His clinical frailty score is six. This is the rock put scale. If you joined my top last week, you would have seen the diaphragm of that. Uh But essentially they're moderately fail is what that means um so after the fall, he's complaining of some back pain, but there's no radiation into the legs. There's no neurological deficits. There's a bit of tenderness when you palpate the spine. Um So this is all the information you've got. Now, it's very unlikely a patient will come through a without some form of x-ray or scan nowadays. Um So this patient gets an x-ray. Now, remember the x-ray and also CT and MRI scans are all done with the patient lying down. So sometimes it doesn't show you the full extent of the injury because if you're lying down and you're not putting weight through the vertebrae, they may not look very collapsed down the moment you're standing up, it may actually look a lot worse. It's good to see what the spine looks like without the stress of the weight before you put weight through it, obviously. So this is the x-ray of this elderly person. Um So if you count 54321 12, so the T 12 bone is a bit is a bit shorter than the next bones. But this is a simple compression fracture of the T 12 bone where the roof of the bone if you like has been pushed down a little bit. So this is a very standard osteoporotic compression fracture. You get AC T scan and it shows you exactly the same thing. Here's the T 12 thing you can see on the CT scan much more clearly. The white line being the fracture, the reduction in the height of the vertebrae at the front. Um So this is a very typical osteoporotic fracture. Now, you can treat this completely conservatively. Um So from my point of view, you know, this does not look unstable at all. You know, the posterior elements are not in involved. He's got no neurological deficits. You, the fracture has compressed down but there's no fragments going to the canal. So it all looks fine. Do I need an MRI scan to show me that the nerves look fine? The spinal cord looks fine, the ligaments look fine. Probably not because you know the the bone looks like a very standard compression fracture. So if the patient is not in too much pain, I'd be quite keen to just give them some painkillers and I mobilize the patient. The problem is if you ask for an MRI scan, firstly, the scan is not gonna happen straight away because there is no real urgency to this patient getting a scan. And are you going to mobilize the patient whilst waiting for the scan? Because if you say yes, the patient can walk around whilst waiting for the scan. But then what's the point of the scan? Because you've already made the decision, the patient can walk around. If you say no, the patient must remain in bed until the scan is done. And let's say the scan can't be done for another two or three days and then you can keep an 87 year old lying flat in bed for two or three days. By which point, they'll have a chest infection, urine infection, DVT and PE So you do have to be very careful when you think about whether the patient needs a scan or not. So I'm gonna give them analgesia, immobilize them. The other question is, should we put a brace on a brace as something that looks like this? It kind of holds your spine and you know, the idea is that it will prevent the patient from flexing um and therefore stopping any potential kyphosis um of the spine. Uh it doesn't stop the vertebral body collapsing down further, cause the brace acts in the kind of anterior posterior direction. It doesn't act in an axial flame. So, you know, the patient's body weight is still going through the vertebra and it can still collapse down further. But potentially, it could reduce the amount of kyphosis because it stops the patient flexing forward. Although if you look at all the studies, it shows that it doesn't really work very well. If the patient is trying to lean forward, they probably still can. And if they really can't, then you've probably done this really tight. And in an 87 year old and putting this thing on really tight, probably cause more harm than good. So I don't like using braces, especially not in elderly people if you've got really young patients, they've got T 12 or L1 fracture. And the thoracolumbar junction is particularly a problem because you've gone from a non mobile part, which is the thoracic spine to a very mobile part and also very dependent parts of the spine, which is the lumbar spine. Then actually, there's a lot of stress across the T 12 L1 junction. So young people with T 12 1 fracture, they are at higher risk of having a kyphotic deformity over time. Um And you could argue, putting them in the brace for a short period of time. Um But remember when you put a brace on because it does help take some of the body weight off the spine. The spinal muscles will start to waste away because they're not using the muscles as much. So by the time you take the brace off, although the spine itself may look fine, the muscles are actually very weak and the patient will end up with quite a lot of back pain for quite some time until these muscles strengthen up and balance across the two sides in a young person. Less of a problem because they can go to the gym, they can do Pilates, they can, you know, do swimming, they can work around it if you're 87. And you've already come from a nursing home, walking with a Zimmer frame, that muscle is never gonna come back and they are now left with long term back pain, which is why I don't like braces in elderly people and obviously don't forget osteoporosis um treatment as we already mentioned. Now, if you were to do an MRI scan, what would be the indication in an osteoporotic patient? Um But if you really can't decide whether the fracture is stable or not, then yes, you do need an MRI scan very unlikely in an osteoporotic situation. Like I said, the other thing is you might want an MRI scan to see whether the fracture is new or old. So the scan I've put up here is called stir sequence, which is essentially a fat suppression sequence. So on T one imaging and T two imaging. So T one is where water is black and T two is where water is white. On both of these imaging fat is also white. However, on a stir sequence, the water remains white but the fat signal becomes black. And what that means is that anything that's still showing up as white on the stir sequence is now water rather than fat. So this tells you there is water content in this particular case within the L4 and L5 vertebrae. So that's edema or inflammation, which means there is something acute going on in these two banks. And in the context of trauma, obviously, that's a fracture. And similarly, you can see a lot of white just behind the spine. So that on the normal T two sequence, you might say this is all just fat. But because on the ST sequence fat is black, this is actually all water, which means all the paraspinal muscles are also bruised and injured. So this is actually a lot more significant than initially would have been um thought. So sometimes MRI scan can be useful to distinguish if there is acute fracture or if this is an old fracture. In which case, this will not show up as white. The last reason to do an MRI scan in an osteoporotic fracture is to see whether they may benefit from injection of some cement into the bone. So there are procedures called vertebroplasty and kyphoplasty. Vertebral plasty is literally putting two big needles into vertebral body and injecting some cement. Kyphoplasty is the same thing. But what you do is you put a balloon into your vertebral body, you inflate the balloon in an attempt to firstly lift the roof of the vertebra back up to try and restore the lost height from the compression fracture and also to create this cavity within the balloon where you then inject um the cement um which potentially means you can get more cement in. Um And if you do this kind of cement, injection into an acute fracture, then the patient gets very good pain outcome and the pain gets better very, very quickly. Um But if you do it in a chronic fracture where there is no more in information then it doesn't work. So sometimes if you've got a patient with a lot of pain, you've tried all sorts of analgesia opioids, et cetera and they're still struggling to stand up. Um Then it may be worth getting an MRI scan to see if they're suitable for some cement, uh which may then, you know, speed up their recovery. Um So this is the procedure, you stick a big needle down the pedicle into the vertebral body. Um and then you inject cement into the vertebral body. As you can see in this patient, this is actually our original patient with a T 12 fracture. You see, we've put cement into the vertebral body, strengthens the bone and prevents further collapse. Ok. Thanks just some data to show you quite interestingly, these are relatively old studies, but they created a lot of debate when they first came out. These two trials came from um the New England Journal of Medicine. This is when Cemento Plasty was a relatively new thing and lots of surgeons were doing it. And then these medics randomized patients into having either cement injection or placebo. So they still went in and had the needles inserted, but no cement was injected. So they're sham procedures and they then came out and said, oh, there's no difference as you can see between placebo and vertebroplasty grip and you should stop doing this procedure. And if you ever come across a fracture and, and you're doing a medical rotation. And your medical consultant says to you, no, no, no, don't refer them because you know, it doesn't work and they're quoting these papers. Then I can tell you these papers are really rubbish because majority of these patients did not get their cement injection at least until 6 to 9 months after the injury. Um None of them had an MRI scan to prove whether they still have acute inflammation in the fracture or not. And therefore most of these patients actually would have gone beyond the period that the cement injection would have been useful for which is why they found absolutely no difference. It's the wrong patient group that they were injecting into right. Um The newer studies, um especially the REDS study are doing these injections within the first six weeks of the injury as as you can see, the blue line, which is the cement group has much better pain control compared to the red line, which is the placebo group. Um So it's certainly not the cure. Um but it has to be and it has to be performed very early um with an MRI scan confirming those ongoing information. But if you catch these patients at the right time and you inject them, they really do get very good pain relief and they recover and go home much quicker, sorry about my coughing. Um Now the second patient is another elderly patient. Um this time he fell from the scaffolding. Now from the history, you can tell, although he's 82 he must be still quite fit and well to be working on the scaffold. Um So he's to um A&E um obviously we assessed them using our usual ABC PE Protocol Airways patent. And the patient's talking respiratory rate is 20 per minute, saturating 91% on air with some abdominal breathing, circulation wise, heart rate is 55 per minute, BP, 90/44. So some fluids were started because the BP is looking a little bit low. Um Neurologically, GSS is 15, upper limb power is two by five, lower limb power, four by five. E nothing else exciting. Patient had a CT scan which did not show any fractures and subsequently went for an MRI scan given the weakness in the arms and legs. Now, the main thing about this case, um if we focus on the neurology part, first is that the arms are weaker than the legs. Now, if you go back to the anatomy of the spinal cord, motor power is conveyed by your cortical spinal tract, you may well remember which is mainly in the kind of ventral half of your um spinal cord. So the anterior half of your spinal cord um and the way the corticospinal tracts are arranged is that the arm fibers are medially placed, the leg fibers are laterally placed. So if you see a patient whose arms are weaker than the legs then it is the medial part of the corticospinal tract that's been affected. So this is very typical of someone with a central cord syndrome. Central cord syndrome is where the spinal cord is pinched. And therefore, it's the center of the spinal cord that has been injured. So this is typical if you remember back to my first couple of slides of an elderly person with a preexisting, degenerative osteophyte. The spinal cord is already slightly narrowed and then the four and the sudden hyperextension injury causes pinching by the ligamentum flavum of the spinal cord. These patients get essential cord syndrome where the arms and hands are much worse than the legs really, really typical. And it's probably the most common form of spinal cord injury that we see. Um at least at Saint Mary's Hospital anyway. So even without any scans, just from the physical examination, you can work out. This patient has central cord syndrome. And so the MRI scan confirms just that if you look at the spinal cord coming down, firstly, there is no CS F in the uh mid cervical region, as you can see from the C 34 disc space all the way down to the C 67 disc space. There is no CS around here. So this chunk of the spine is very narrow. And also if you look at the diameter of the actual spinal cord, it's much wider than the rest of the spinal cord. So the spinal cord itself is also very swollen. There is also increased signal intensity. You can see the whiteness within the spinal cord here and the little dots of black right in the middle and that's hemosiderin, but that's a bit of blood. So this spinal cord is compressed, contused, a little bit of hemorrhage and now very edematous and swollen and taking up the whole of the narrowed canal. So this is a very typical picture that you see in the central cord syndrome patients. And from a neurological point of view, obviously, the best thing to do is to try and free up the spinal cord by creating space either from the front or from the back. So that you allow for the swelling, just like we talked about in the brain. You know, if you've got a very swollen brain and you've got raised intracranial pressure here, it's raised intraspinal pressure. You know, then, you know, you've got the problem of obviously the neurological compromise because of the pressure effect and also the lack of perfusion because the BP can't match the raise pressure there. So apart from pushing your BP up, the other thing is to free up the spinal cord, reduce the intraspinal pressure and improve the perfusion to the spinal cord. So that decompression operation would be quite useful in something like this. Now, before we get there, um I've jumped to the gun slightly uh is to look at the other parameters this patient is very well, not very, it's quite techy and saturation is not great. I know he's elderly and I know sometimes we allow elderly people maybe with COPD to have a slightly lower, you know, saturation target. Um but you know, you can't assume this person has COPD with a low oxygen saturation without any past history. So this is low and the patient's got some abdominal breathing. Now, this is what happens when you have cervical cord injury. Everybody talks about high spinal cord injury. So we all know c 34 and five keeps the diaphragm alive because of the nic nerve. So if you have an injury to the spinal cord above the level of C five, potentially you take out the phrenic nerve, which means your diaphragm doesn't work. But people often forget that even with the lower cervical cord injury, such as in this case, the injury is mainly at the C 56, C 67 levels. Although the phrenic nerve may be intact, your intercostals are all affected because the intercostal nerves come off your thoracic spinal cord. And so if your intercostals are not working, then your chest wall is not expanding. So this patient is now completely reliant on the diaphragm to breathe. And at some point, the diaphragm is gonna get tired, it's gonna get fatigue and the patient is gonna go into a type two respiratory failure. It's almost inevitable. So any patient with any cervical cord injury, high or low needs to be on at least HDU if not ICU because you know that breathing is gonna go off at some point. It's just a matter of time, whatever you do, it's going to get worse and something to think about, you may even want to intubate these patients early to help them ventilate a bit better prevent them from going into the tired, you know, um, um, uh, type of respiratory failure mode and catch them early on. Now, if you look at the circulation, now, heart rate 55 that's a bit slow and BP is also on the low side. So this patient is bradycardic and hypotensive. Um come on to that in a minute. Um Just remember that in your head, uh, bradycardic and hypotensive, um very brief word about the collar, just like what I said about the brace earlier on collars don't really hold an unstable fracture. If your fracture is unstable, it will still be unstable. It can still shift in the collar. The collar is useful in a stable fracture and you just want to hold it in a nice position so it heals nicely and that's what collar is for and it provides some comfort for the patient. If you've got a patient who wears the collar, NCES, it actually makes it less comfortable. It's giving them extra pain or it's causing other problems such as making it difficult for them to swallow because they've got something tight against your neck like this and take it off. You know, there is no reason to keep the collar on. If a spine surgeon says to you, this collar must stay on because the injury is unstable. Then the question is, well, why aren't you fixing this injury? The collar should not be used to support an unstable fracture, it should be fixed. If the answer is that the patient is not well enough to have a fixation, then the next kind of discussion point should be where in that case, should we be palliating the patient and just keeping the patient comfortable, they're not fit for surgery. Collar is causing them problems with pain, pressure, sore on the chin, swallowing problems, possibly giving them aspiration pneumonia. It's actually making things worse. So if the patient is that frail and they can't have surgery, then maybe they shouldn't be wearing the collar either. And we should just allow things to take their natural history. Um So collars are not quite as straightforward as stick on everybody and then you're safe. It's not quite like that. Um Remember to do a full neurologic exam on everyone. Obviously, this is an Asia chart which you can Google um on uh and and find the image. Essentially, it's a cry sheet for people who can't remember the derma terms and Myo Gees. But it's useful because if everybody used this sheet and test the derma terms and Myo as it's stated on this sheet, then at least there will be less inter observer um uh variability because we're all using the same derma terms. Now, back to the bradycardia and the hypotension. If you have an injury of the cervical spinal cord, then not only do you take out the intercostals that comes of your thoracic spinal cord, you also take out the sympathetic nervous system that also comes from your thoracic spinal cord. And when you lose sympathetic tone, that's called neurogenic shock. And if you have neurogenic shock, you will be bradycardic and hypotensive because you're no longer able to constrict your blood vessels and you've lost a pacemaker for your heart. Um So it's very, very common when you see people with cervical cord injury, that the BP is low, the heart rate is low, you're giving them tons of fluid and the BP doesn't come up. And in fact, because a lot of times these patients could be quite elderly. You don't want to be giving them tons of fluid because you just give them cardiac failure. What you want to do is to squeeze the vessels, you know, they've lost their noradrenaline and adrenaline from the sympathetic chain. So you give it to them, give them some metaraminol, which is a vasopressor or you can give them some noradrenaline. Uh essentially you're helping to constrict the blood vessels to pump up the BP. Um So it's quite important to recognize that um spinal shock, which some people also talk about is a completely different thing. Spinal shock is literally your spinal cord in shock and therefore it's lost all of its function. So no reflexes, everything is very flaccid and they have grade zero power, they will at some point come out of the spinal shock and some of the function will return. And this happens when people say, oh my God, it's a miracle. You know, he was great zero power four days ago and now he's moving his ankles or some surgeons come along and say, you know, my operation has saves your legs actually, probably not, it's probably just because they come out of spinal shock. Um but just, just to distinguish spinal shock, uh shock and neurogenic shock are two very different things. Um Neurogenic shock is the important one in terms of the acute management of the patient. Here is a protocol that we use that I wrote a few years ago as you can see for ST Mary's Hospital. So if you've got a patient with a spinal cord injury at the first box, either from the mechanism of injury, um because of, you know, the polytrauma nature of the patient or that they've got some neurological deficits or confirms on imaging. Then the next thing is, do they have signs of shock? If they're tachycardia, they can high potency, then of course, they're probably bleeding from somewhere and you have to look for, you know, a source of bleeding, fast scan, ct chest of the pelvis or even just open up the chest and abdomen, if necessary. If they're brady card, they can hypo, then they probably don't have a hemorrhage. They probably have neurogenic shock from a spinal cord injury. In which case, what you're trying to do is to bump up the BP and you can do that with a combination of fluids and inotropic support or vasopressor support. Um And you're aiming for a mean arterial pressure of anything above 85 millimeters of mercury, which is the current bas guidelines, basing the British Association of Spinal Surgeons. So that's the guidelines. And ideally, you wanna maintain this higher BP for the first seven days to optimize or maximize I should say the chance of neurological recovery. Um This is a study that one of our s did a couple of years ago, as you can see published in 2021 and we looked at 10,000 sets of mean arterial pressure in patients from arrival in A&E all the way through to being on the intensive care. And what we found is that if you manage to get the mean arterial pressure above 85 as we mentioned, you know, say in two thirds of the time within the first three days, you're much more likely to get motor function improvement compared to if you don't manage to reach your mean arterial pressure target. So you can see how important it is to get your mean arter BP. Right. Right. From the beginning. And actually, if you ask me, even though I'm a surgeon, I will say to you that the BP is much more important than the surgery. If you get the BP right from the moment they arrive in A&E or ideally in the prehospital setting, if possible, sometimes not possible. But if you can get the BP right and maintain that all the way through, they will have good neurological recovery whereas surgery on this own is unlikely to make much difference. Um And one really good example I can give is relatively recently, we had a um, a premier league, er, rugby player coming in ra zero power and all four limbs and with a neck injury. Um, and, you know, it looks absolutely dire when the patient came in, you know, there was no sensation, everything looked really, really bad. Um And then we noticed the BP was through the boots. Um, the mean arterial pressure at the time I think was like 55 or 60. So popped an arterial line in, popped a central line in, um, started some vaso presses and gave you a bit of fluid, got the mean arterial pressure up to 90 suddenly started moving his legs. Um, and then about two days later, he underwent surgery to decompress the neck and basically stabilize the fracture. Um, but the movement came back before the surgery, it's very clear that it's the BP that helps the movement, not the surgery itself. The surgery obviously is necessary to stabilize the spine, but it is really the BP management that made the difference. Um, and he's now back in training. Um, so, so it's really important to get that right. Hence, I just spend a lot of time talking about it. Um Now because the, the, the final thing to talk about in terms of spinal cord injury is something called autonomic dysreflexia. This is the complete opposite to neurogenic shock. Um and it occurs once again in more the cervical and upper thoracic um spine injuries. They can occur pretty much in anyone with a spinal cord injury. Um Don't worry about reading all the text. Um Essentially if you have a um big stimulus to the sacral region. So anything that's supplied by your sacral nerve is bladder bowel or something down into your legs, such as an ingrown toenail, um uh uh pressure sore um cellulitis, it could be anything. Um but any kind of stimulus from the waist downwards essentially will trigger an unparalleled sympathetic response because the fracture means that you've lost a sacro output. So you've lost a parasympathetic um system, but you've got some sympathetic outflow. So that causes a sudden search of sympathetic and hence the opposite to neurogenic shock. What you get in this case is you get tachycardia, you get hypertension, they're sweating a lot and they get terrible flushing and the flushing is quite impressive literally across the dermato of wherever the injury is. It's all read about and it's pale below. So it's really, really quite clear cut. It shows you the dermatome of that patient. Um And if it's not treated or recognized, um in time, then the sympathetic surge will continue and they can end up with really high fevers which can then trigger seizures status, epilepticus coma and potentially death. Um The best treatment is to avoid it in the first place, which is why every single patient with spinal cord injury must have a catheter inserted from the very beginning to make sure the bladder does not get, you know, over inflated. Um They must have the bowels open on a daily basis and it has to be soft stool. You don't want them ST draining, you don't want them constipated. Um So they get daily mob get daily pr examination. If the rectum is empty, they get glycerin suppository. If the pr rectum is full, then they get manual evacuation every single day. It's really important to get these right. They have to be seen by a sero to look at the toenails. They have to have obviously all your vte prophylaxis to make sure they don't dvts. Um pressure areas have to be looked after, et cetera, et cetera. So you can see looking after spinal cord injury patient, it's not just about the paralysis. The loss of function. There's a lot of other things that you have to think about and it's a truly multidisciplinary team effort. I know we talk about MDT a lot and, and I think unfortunately for most doctors, MDT means the nurses look up to the patient, they will come to you. If there's an issue, you sort out whatever the issue is, you prescribe the drugs, necessary, whatever. And then at some point, um they've gone over the acute phase and you're type into what round next, you know, physio and ot assessment, discharge planning and suddenly you wash your and it's their problem. Um uh for spinal cord injury, it really cannot be like that. You know, you have to look after all of these things, you have to talk to all of these other teams. Um Otherwise your patient will not do well. Um So spinal cord injury is much harder to look after than a head injury patient. Now, just for the last of um 5, 10 minutes, just gonna show you a few more injuries. Um The majority of this talk really should or if there's any message to take away from here is spinal cord injury is thinking about the mean natural pressure, think about um uh cough, uh neurogenic shock, um and autonomic dysreflexia and also recognizing um stable and unstable injuries as we talked about at the there are some other injuries. Oh, the pictures come up slightly wrong way. It doesn't matter. Um This is a patient with a PEC fracture. As you can see, you can see the fracture line across the PEC a bit like the 11 year old scan that I showed you. But this is a real fracture rather than just a growth plate. Um We fixed this one with what we call pec screw. Um So pec fractures are very interesting, which I put it in. It looks very innocent or innocuous. The peck fracture is a bit like a fractured knot. It's a sign of frailty. It's a sign that you've got an elderly person with loss of physiological reserve, they are falling over recurrently and that's why they fracture across the base of the peck. And the problem here is that the blood supply to the odontoid process is actually a vessel that comes into the Venable body and it goes up into the peg a bit like the head of the femur or the scaphoid bone. And so if you have fractures of these three bones, you can get avascular necrosis or at the very least a very high non union rate. So a lot of peg fractures do not heal properly. You can leave them in the collar for six months, one year, the fracture will still be there. Um So one way to get around this is to fix it and um to provide some stability, you don't have to fix it. Um And actually potentially you could just leave it alone if the fracture is relatively well aligned. Like in this case, um the patient may never get a problem with it and they may just, you know, have to live with a nonunion. But if it's not causing them a problem, then it doesn't really matter. This other one which I'm so sorry should have come before this one. Hence, it's not overlapping. Um This is a young girl who was hit by a police car at a very high speed. Um had a respiratory arrest at the scene, somehow managed to have return of spontaneous circulation, ros intubated, ventilated and brought into A&E. Um And I remember my registrar calling me saying that this patient um uh just had a CT scan. Um It looks a bit odd, can't really put my finger on it. Um What should we do? And the first thing I pointed out and actually, it's quite useful to have the second scan here. Actually, if you look back at the scan, I've talked to you before, look at the tip of the odontoid process and look at the tip of the cliver spring, which is the anterior parts of your forum magnum. There is a very short gap there. That gap really should be less than five millimeters. In this case, you've got a gap of about two or three centimeters. This patient's head is no longer connected to this patient's neck. This is a cranial cervical junction dislocation, which is why she was in cardiac arrest and respiratory arrest at the beginning because the whole head has been internally ripped up and therefore the spinal cord and all the blood vessels, et cetera, et cetera are all avulsed. Um It's amazing they managed to get the circulation back, but this is not a survivable injury. If you ever see anything like this, the patient is not going to survive moving on. Hopefully, we can all see the obvious injury here. This is a complete dislocation between these two banks. As you can see a very obvious one, you can see how the spinal cord is completely kinked and compressed at this level. There is high signal within the spinal cord going all the way up to C two. Um because of the edema extending up and down the spinal cord, this is obviously a very severe injury. Um Now, just like I said last week, about head injuries, whether it's blunt closed, open, penetrating doesn't matter, treat everyone exactly the same and same in this case, just go through your ABC D, get your BP right, get the perfusion right, get the spinal precautions in place. So no one's wiggling this this neck around and necessarily intubated, ventilated early in this particular case, especially because this patient is not going to breathe very well for very long. Um and then get this patient up to theater as soon as possible so that we can reduce the dislocation and fix it in the right place again. Um So don't get scared just because the scan looks so dramatic, you know, go through your standard steps as per usual and everything will be fine. The other end of the spine, this is a very bad crush fracture. So if you remember the osteoporotic compression fracture, we saw before where there is a bit of reduction in height, but otherwise the pain is still relatively rectangular in shape, maybe it will be a trapezoid. Um But in this case, you can see the fragments are just everywhere. And the main problem is there's this huge big fragment that's gone into the spinal canal. So, you know, for a fact that the nerves in here, I either the coin and their wrist are definitely compressed by this big fragment. And this patient may well be presenting with paralysis of the L5 S one segments. So ankles and and toes and obviously loss of sensation from L5 downwards including sensation to bladder bowel and the anal tone might well be gone as a result. So this is actually a terrible injury. Um This needs surgery ASAP, you know, we talked about maintaining a good BP in the spinal cord injury. It's very different when it comes to nerve risk. Nerve risks are not part of the central nervous system. They're part of the peripheral nervous system, obviously. So they don't need the same amount of uh uh perfusion pressure like you do for the central nerve system. So you don't need to bump up BP for something like this. Um uh So this actually just needs surgery for the nerves to be decompressed ASAP, but this big fragment in the spinal canal to be removed um or push back into right place. Um And the dura which presumably will now be ruptured to be repaired so that you don't end up with a CS F leak. But once again, a very unstable injury, as you can tell. And lastly, I can't finish a talk like this without talking about some form of penetrating injury. So this is a gunshot to the spine. As you can see the bullet is still there. This is a patient who opened the door to a doorbell and somebody just shove the gun in his mouth and shot him through the um back of his mouth and the bullets gone through the pharynx through the C two bone all the way to the back of the neck. Um You can see the bones are completely shattered. The spinal cord is now divided into two because of the bullet. Um Now, in this particular case, this patient has been quite unlucky in that this bullet actually took out the vertebral artery um as well. And the patient's got massive brainstem stroke and actually didn't survive as a result. But if this bullet only went through this, like, let's say it's right in the middle, goes through the bone and the spinal cord but doesn't touch the blood vessels. Potentially, the patient could be alive. The breathing would be a problem because it's a very high survival cord injury, but they may well still survive, especially if the intubator and ventilated. Um, you don't need to operate on the spine. Ok. You can take the bullet out if you want. Um, but actually all of these pain fractures will heal by itself over time. Um So you don't actually have to go in there to operate, take the bullet out, keep a good wash closed. Um And then just pray that somehow this bullet has missed the spinal cord and the patient might have good neurological outcome unlikely. Um But that's not much you can do right? Quick summary, there's a lot that I've talked about because spinal injury is a massive topic. Um But I think really important to involve every team from the beginning for all spinal injuries, the physios, the nutritionist, the speech and language therapist, occupational therapist, they should all be seeing the patient from day one onwards because you know, they are going to be the mainstay of treatment. So they need to get to know this patient, consider both the bony column and the spinal cord, as we mentioned, MRI scan may or may not be necessary. So I have to think then do a knee jerk. MRI of every single patient, avoid immobilization. If at all possible. Sometimes you have to um uh, but the sooner you can clear the spine, the sooner you get the patient up and about the less pain they're gonna suffer and the better functional return they're gonna have. Think about neurogenic shock. Think about autonomic dysreflexia. We've talked about those, think about osteoporotic treatment in the elderly patient. We've talked about those as well. And that's the end of my talk. Any questions? I'll stop sharing. Hi. So there is a question from Louise on the chat. Uh She asked, how long would you aim to maintain the, um, mean arterial pressure for? Yeah. So the, the best guideline says anything up to seven days. Um, in reality, what you do is you basically assess the patient's clinical status. So let's say you've had the BP up with some no adrenaline for 48 72 hours, but you see absolutely no change in the patient's. Then there is probably very little point continuing because they're not getting better. You know, you should see improvement pretty quickly. And remember these drugs, although I've made it sound like they're the miracle, um kind of cure for neurological problems. They do have their own side effects and you don't want them to be on high doses of noradrenaline for a long period of time. So if keeping the BP up really has made a difference to the neurology, then keep it going for seven days. Um But if it's not made a difference, then you can just stop it early. And I just had a quick question, um, just briefly about the pathophysiology about spinal shock. Is it to do with the edema? Yes. Exactly. Absolutely. Yeah. So, um, and you know, most people would say spinal shock actually is a poor prognostic sign because if you have a lull of edema, like you said, um, then they're less likely to have a good outcome at the end. Um, although it's worth noting that the patient is in spinal shock because it then, then you should go back and re reassess the patient, you know, every day, just to see if they come out of spinal shock. In which case, there may be some improvement that you weren't expecting from the beginning. Now, if you say to a spine surgeon that a patient is what we call Asia A, which means gray zero power with no bladder bowel function, then most of us would tell you this patient is never going to get better, which is true and that changes everything. They may not get the surgery because there's no point. It makes no difference. They may not even get to go to a rehab center because they will say there is no rehab potential and they end up in a nursing home. But actually, if this was all due to no shock and five or six days down the line, there is some movement in some of the muscles that changes the outlook completely. I'm not saying this patient will now be running, but actually this patient probably now should have surgery and will qualify for rehabilitation. So it does make a difference to the kind of old floor management. I had a uh I had a question myself as well. Um Do you see the role of sort of spinal cord stimulation and potentially functional implants, maybe aiding the recovery and improvement of those spinal cord injury. Um So spinal cord stimulation in itself doesn't. Um spinal cord stimulation we use for more pain control. Um So some people get really terrible neuropathic pain as a result of either spinal cord injury or a nerve with injury. And even using neuropathic agents such as gabapentin, pregabalin sometimes doesn't work and the spinal cord may be the answer for some patients. Um There is one case from a few years ago where a Polish surgeon implanted some stem cells that were cultured from the olfactory bulb into a very clean cut spinal cord and managed to recover some function that has never been reproduced ever again. It's the one case. So maybe there was something about that patient that allowed it to happen or maybe the technology isn't quite there, but that's a potential um uh uh stem cell therapy. Um The, the we do use a lot of other types of stimulators. Um So for kind of bladder bowel dysfunction in patients who have some very terrible spinal cord cord injury, um you can give them um kind of sacra stimulators um to help contract the sphincters. Um So that gives the patient some control of the bladder and bowel. Um There is kind of newer anterior um and tibial nerve stimulation, which also seems to help with um uh uh uh uh bladder control. And I think that's an sending kind of input. So that's a relatively new thing that's being done at, I think guys hospital at the moment. Um And also Queen Square does it as well, I think. Um And then from a breathing point of view, you can put in phrenic nerve stimulators to try and make this die from work. The problem is often by the time the implant, the nic nerve, the nerve is already under con laan degeneration. Um and the um diaphragm because it hasn't been stimulated for days, possibly weeks. Um It's completely thinned out. Um And what my general surgeons actually say, if you do a laparoscopy at that point, and you look at the diaphragm, you can see through into the lung because it's so thin. So actually, p nic nerve stimulators don't tend to work very well and it's kind of a last ditch um option in a really young person. Um What potentially has better uh cuff uh uh uh chance of working is a diaphragmatic stimulator. So we are hoping to start a trial in implanting diaphragmatic stimulator from day one. So when they come in through the A and you know, they've got survival cord injury, they going to theater for fixation of the neck. At the same time, the general surgeons go in laparoscopically, the, the foi ligament bring the liver down, look a few electrodes onto the diaphragm itself. Tuck them into a battery a bit like a pacemaker that they hide in the little pocket in the tummy. And that keeps the diaphragm stimulated. And these um stimulators can be synced with the ventilators. So it will stimulate the diaphragm in sync with every breath the ventilator delivers and to try and keep the diaphragm going and that potentially might have better outcomes. So we'll wait and see. Yeah. Sounds very, sounds like a very exciting prospect. Oh, ok. I was gonna say if there aren't any more questions. Thank you so much for your told. That is very interesting. Thank you very much. Sorry. It's quite a big topic to cover. I'm very sorry if I've gone through it very, very quickly. It's quite a lot for an hour to be like it's impossible to condense it all. I see. Well, thank you very much, everyone. Thank you. Thanks a lot. Take care. Have a lovely evening. Thank you. You too. Bye.