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I don't know why it's taking so long. Ok, we like, ok, great. So, welcome back everyone to the new Anatomy Collaboratives. I'm delighted to present our series for this year and this talk is rescheduled from last Tuesday. So thank you all for joining and I now hand over to Dara who introduced our speaker for today. Uh Hi, everybody. Um Welcome to the final talk of section one. And today we have a returning speaker, Mr Sang. Thank you so much for joining us again. He's one of our very own senior advisors. He's a consultant neurosurgeon at Imperial College, London who's kindly agreed to give us a give our talk on spinal trauma. And with that, with that said, I'll just hand over the stage to Mrs. Thanks again. Thank you very much and uh thank you for accommodating me today because uh obviously I was supposed to give this talk last week, but I called into theater. So, apologies for anyone who locked in last week and didn't see me. Um I'm glad I've managed to um negotiate a different time to redo it. I'm going to do a screen share. Um uh And you let me know if you don't see my slides or they're not advancing the way they're supposed to. Um Right. So today I'm gonna talk about spinal trauma and spinal injuries. The first thing to say is when we talk about spine trauma, there are really two separate things we mention that we, we are talking about the spinal column. So that's the bones, the ligaments, the muscles, the discs, and then you've got the spinal cord itself and injury to one doesn't mean you have to have injury to the other. And obviously a management plan for the overall patients will depend on exactly which part of the column is injured, which part of the spinal cord is injured. And as a result, you put the two and two together to generate the, you know, overall management plan before we can do all of that. You do need to know what the normal spine looks like. Now say you guys or, or have gone through lots of lectures uh in your medical schools and also in the last few weeks with um this amazing collaborative um neuroanatomy uh course. So I'm not gonna go into a lot of details. What I am gonna show you is how the spine is as we age. OK. So uh in front of you now is a ct scan of a very, very young person, 11 year old as a child. Um You don't see many CT scans of the spine of a child because we try not to ct um young Children, you know, in terms of risks of um irradiation and cancers, especially to the neck. People do worry about irradiation to the thyroid gland. Um that's very susceptible to um irradiation. Anyway, in this particular case, this patient had a CT scan which is helping me for my teaching. Um The thing to notice here is um firstly, there is a very um obvious cervical MDOS, mdos, meaning that spine is curving backwards. So we all developed this when you're born. Actually, your spine is just one kyphotic spine and the thoracic spine. So it's a curve that's like ac shape all the way around. And then as you learn to crawl because you need to be able to see forward, you start to lift your head up to crawl and that's when you develop your cervical nodosus. And when you start learning to stand up on your two legs, you develop your lumbar, no dosis because you have to compensate for the thoracic diphos. So here you see the, um, cervical MDOS and what you notice is that the bones are not beautifully formed yet. You know, there are still quite rounded edges rather than sharp edges. Um, but there are very big disc spaces, um, and very wide spinal canal, which is in the middle. So you've got vertebral body at the front here and then you've got the spinus process at the back here. No. Now, as we get a little bit onto the hood, the things are much better forms. So when you look at them on the lateral view, they look like squares. Obviously, when you look at them top down, there's still that um kind of slightly circular shape that you would have seen in anatomy textbooks. So lots of these little squares back up on one another. Obviously, for the spine, you can see this is the C one anterior arch and this is the odontoid process of C two. They are very close to each other. It's one of the things that you always look out for in trauma. You know, if the C one arch, this circle at the front here is further away from the finger, which is the odontoid p here. Normally the gap should be less than three millimeters. So more than that would suggest that there is ac 12 subluxation. So there is some that's something that we always have to look out for. Otherwise you're starting to appreciate that the posterior corners of these bones are starting to become a little bit more pointy. I hope you can all see that these little knobbly bits is very scientific. By the way, uh these kno bits are sticking out around the back. These are little osteophytes which are forming. So it's a sign of degenerative disease. Um and this forms in every single person you can't really avoid it. Uh It happens in all of us, but you know, little osteophytes like this wouldn't really cause you any problems as you get older, these osteophytes can get bigger. So in this particular case, and you also see this very large osteophyte if we count it the C 2345. So this is an osteophyte bridging between C five and C six. And the problem here now is if you look at the spinal canal, which is where the spinal cord is sitting clearly, this part of the spinal canal is very narrowed. So the spinal cord is clearly compromised. Now, in the normal uh situation, because this has taken so long to develop. This patient may not have any symptoms at all. They may have, you know, stiffness and a little bit of pain in the neck. Um they may well have some pins and needles in the hand. Um but they may not have many symptoms at all. But the moment they fall over, just imagine if you fall over, especially if you fall forward, what happens is you hit your head, you hyperextend. And what happens when you extend your neck, when you extend your neck, your ligaments and flav them, which is at the back of the neck here, buckles inwards into the spinal canal. So if your spinal cord is already half squashed by an osteophyte at the front, and you've now got ligamentum going forward into it, you will now pinch your spinal cord. So these patients potentially can come in without any fractures whatsoever. But still, they're not able to move their arms and legs because they've now bruised the spinal cord. So as I mentioned at the beginning, you can get a spinal cord injury without a spinal column injury. And this is one of the few situations where it can happen and I'll show you a case later on. Mm. Now, look at this is obviously the lumbar spine going on to the sacrum in the child. The main thing to notice in the child is that the sacrum hasn't quite fused together. So, you know, S one and S two looks like there is still a disc in between them as you get a little bit older that disappears. And so here is, can you see that this space that now just a white line? So this is fused across. Um So in adults, the sacrum is just one long bone in the child depending on what age you scan them. You know, if you scan them as a baby, you actually see all five separate sacral bones unfused. Otherwise the rest of the spine looks very similar to the child unless you get a lot o ones is that you start to get osteoporosis and you get fractures. So you can see here you've got these wedge compression fractures of these bones. In fact, 54321, so 12 and 3 L1 L2 L3 are all fractured. They're all compressed down and you can see the quality of the bone looks terrible. You know, it's very dark in the middle 11 of the things I always say is that if you look at the aorta in front of you, which is the structure down here, you see the calcification along the wall of the aorta. That's obviously the atherosclerosis. I always say that if you see more calcification in the aorta than in the bone and you've got osteoporosis. Um And obviously, if you're osteoporotic, you're prone to fractures, which is exactly what you're seeing. Lots of old fractures, um the lumbar spine, although you do get degenerative disease, you don't develop the osteophytes that you see in the cervical spine. What you get in the um lumbar spine is you just get a reduced disc height, you make a faster joint hypertrophy, but you don't really get the big osteophytes forming. So they don't have the same problem as in the neck where you could, you know, squish your spinal cord. I mean, partly also because there is no spinal cord in your lumbar spine, spinal cord obviously ends at the neck of one important to appreciate some of these um structures and how it changes throughout the age because it completely affects um the mechanism of injury translating into the injury pattern. So for example, a child below the age of 10, if they were to injure the neck or any part of the spine, most likely they would tear a ligament, but they're unlikely to fracture a bone because the bones are still slightly soft. Whereas in an old person, once again, they can fall over, they may not fracture anything but they can still get a spinal cord injury. Whereas in between these two age groups. So you, you know, you're, you're kind of young adults all the way to, you know, kind of your older adults but not quite this very old person. Um, they will have only fractures with or without a spinal cord injury. Um, so the pattern changes. So if you see someone come into A&E you're the first person there, you know, it's really important firstly to establish how old your patient is and also what's the mechanism of injury. And you know, the way they injure themselves tells you a lot about what you need to look out for. Um So for example, as I said, in the elderly neck case, if they were falling forward and they're likely to have hyperextended the neck and what you're looking out for on the scan is have they opened up so much that they've ruptured the disc at the front, so they may not have a fracture, but you may notice two