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Ok, so we'll make to start. Um, hi guys. My name's Panji. I'm the president of the University of Leicester Orthopedic Society. And today's session is on spinal fractures and conditions. Er, so we're gonna go over two Sa Qs and we're gonna go over I think six or seven SBA S at the end. Um If you have any questions, pop it into chat function, it should be open for everyone. And um similarly, if you want to answer some of the questions, feel free to um to have a look and pop it in the chat function. Um And without further ado um can you all hear me? Someone just type in? Yes, if you can. Um, so then I'll make stop. Wonderful. Wonderful. Ok. So today's session is on spinal fractures and conditions. So I don't act cos I'm sure on the screen I won't be able to monitor the chat function. Um er David should be arriving and he can um monitor the chat function. Um if you have any questions and if not, I'll pick them up at the end. So, yeah, so let's begin. So case one a 30 year old construction worker presents with acute low back pain, loss of reflexes and loss of power in the extremities similarly, has lost sexual, has lost sex, sexual function. He reports a history of heavy lifting objects and you suspect quadra outlined the pathophysiology of quadra quina. So have a think about how it, what actually happens uh perhaps at what level that starts. So, so it's basically the lumbar sacral nerve roots to extend below the level of L1 where the spinal cord ends and the cordal cornus starts becomes compressed and then that can cause various symptoms which will go over. So give me four causes of cadra. So what can cause the compression? I'll, I'll give you a few minutes to uh to jot something down. So that's all the answer. So the most common cause is a central disc prolapse and this occurs usually around the L5 around the L4 area. Um Also s one other causes include tumors um which can be growing. It could be metastatic infections could be abscesses, it could be discitis. Uh You can also get trauma to the area. You can plan to get hematoma build up that could be forming from uh from i injury. So there's quite a various causes. So just be aware of requi and what causes it. So give me some signs and symptoms of cord quina. We've mentioned some in the stem of the question. What other ones do you have to think about? What the coqui is responsible for the nerves around they were responsible for. So, let's see if you've got two of these. So, yeah, so you can get lower back pain. You'll get bilateral sciatica. Uh you'll get reduced sensation, potential pins and needles to the perianal area. It's also known as saddle anesthesia, uh decreased anal tone, um and urinary dysfunction and obviously sexual function that we did mention in the stem. So if you've got some of these, that would be that, that was wonderful, we'll move on to the next question. So what investigation would you do to confirm your diagnosis? So you're in the A&E setting, you're one of the f ones there. You wanna go to your reg or your consultant and be like, I want to do this with this patient. What, what's the key one? And there are some other ones you can, you can do as well. So let's review the answer. So it's an urgent MRI scan, usually lumbar sacral MRI. Um And then that usually you have to wait for the report to come back. I think I've got a picture here. So you can see um, the spinal cord and you can see how it becomes the quadra equina around here somewhere and you can see how it's compressed by a bulging disc, um going anteriorly here. So you can see that this is, this is quite evidently called, requiring is quite a severe one. And that leads an eye on to our next question is how do you manage this patient? So our patients got confirmed called Quina. How are we gonna manage him? Don't just give the obviously definitive management. Think about the patient as a whole. So think about the patient, how they're gonna present rather than just giving the definitive, which is also correct. But what are you gonna do before getting the er relevant teams involved? So I'll give you a minute or so to have a think so contact the, depending on the hospital you're in. Some, most, some hospitals you contact the orthopedic team, some teams, the neurosurgery team do it. And the obviously definitive treatment is surgical decompression and that comes in the form of a laminectomy or a disc discectomy, um, usually within 24 hours. Um, ideally you wanna do it before that, but as it can lead to permanent ni permanent damage, which leads nicely on to our next question is what your patient comes back to the ward and asks what his long term complications may be following surgery. Can you list two of them? So there are some, obviously general risks, post surgery. But what about specific to cord equina? Ok. So infection, it's, it's a big one. DVTs, obviously, a person is not gonna be walking around a lot. So they're, they're susceptible to, uh, a venous thrombosis. So, but the biggest thing is if it, if the decompression hasn't worked, it can become paraplegic they can get permanent numbness, chronic urinary retention or incontinence and they can get chronic erectile dysfunction, et cetera if they're male. Uh So it's always be good to be aware of if, if the decompression doesn't work, it's not usually that common, but it's good to be aware. So case two, before I go to case two, I'm just gonna quickly have a look at the uh the chat function and see if there's anything in there. Ok. Um Does anyone have any questions about Quadra Quina before we move on to our second case? So quad requirement is quite a good one. This came up in our second year exams, I believe. Um, from what I remember and it's, it's, it's a condition we should all be aware of one of the M SK, one of the very few M SK emergencies. Um, um, so yeah, let's move on to the second case then feel free to pop your answers in the chat. Um, if you want to and David's here so he can monitor the chat if he, if he's free to do so. Uh, so it will continue with case two. So this is a 60 year old female who has a history of breast cancer, um, presents to A&E with severe back pain that's progressed, um, very, very bad over the last two weeks. So it's progressively getting worse. She also reports new onset of weakness in her lower limbs, difficulty walking, and urinary incontinence on examination, there's a 10, there's a tenderness over the thoracic spine and reduced power in both legs. What's the most likely diagnosis? And I'll wait perhaps if someone can pop something in the chat for this one. And let's see if um if you guys, oh, I think I've just answered and answered my bad. So the answer is metastatic spinal cord compression. Um So basically that's where um this is fourth year content we learn at Leicester. So for those in third year and that's always good to good to know what's coming. Um So basically the dual sac and the contents of the cord um or the cord quina compressed by that cancer. So yes, you can get very similar symptoms to cord quina, but there are some very few subtle differences between the two. It's always good to know on how to differentiate between the two. Um So yeah. Mm SCC is what it's called for short and what other cancers beside breast cancer are commonly to metastasize to the spine. So it's always good to be aware that orthopedics isn't just bones and repairing fractures. It's also about onco oncology and how that can affect our patients. So it's always good to think holistically uh across sub of other subspecialties. So anyone anyone aware of um how what other cancers can metastasis spine. So we've got breast cancer. So the other two are um so I call them BPL cancers. Uh So breast prostate and lung. Uh so prostate and lung cancer is quite common to metastasize to the spine. But also you can get lymphomas, um myelomas renal cancer or thyroid cancer. So it's always good to be aware. But yeah, breast prostate and lung are your three biggest cancers that will metastasize to the spine if it unfortunately gets to that stage. So this is a good question and this is a question that you can see it coming up in exams at some point. So describe the difference between the symptomatic features between metastatic spinal cord compression and cord quina. So I've got, I think I've got three answers here. Um So the two difference are the, the two differences you could have put down is um it's quite gradual in M SCC. So as the tumor grows, um it can start to cause the obstruction. Whereas in cord quina, it's sudden, um the back pain in cord quina is usually the first sign before you get any neurological signs. As the, the metastasis affects the musculature and starts to cause myalgia and pain. Whereas Enroquin is commonly, commonly, people describe it as a sciatic buttocks, pain as opposed to a thoracic pain that you commonly get in M SCC depending on where it is. I think it's most common in your thoracic spine. Um and in M MSC. So you get a late loss of incontinence whereas in chro it comes a lot earlier. So it's always good to be aware of, of um, of the two of the subtle differences between the two. So, how would you investigate this patient? So, think about how to investigate it. And uh in the meantime, I'm just going to make David uh admin. Um, so we can monitor shot. Yes. Yes. Mhm. Yes. Hi, David. I've just done, invited you to the stage. Um If you, if you wanna just monitor the chat, if there's anything on there, that'd be great. All right, let's go back to the question. So, investigating it, how would you investigate it? So the key, the, the key biggest thing is um an urgent whole spine MRI within 24 hours of presentation. And you wanna do a neuro exam, you wanna check the upper motor neuron signs and the level of the sensory level it's affecting. So then you have a baseline measure that you can also compare against after you do give you treatment as well. And it's also be a good, be good to be aware of the limitations when they present because that will help therapy teams et cetera when they look and review the patient in a day or so it's time and you can also do ad re to assess the anal tone um to see if that's limited as well. So next question, how would you manage our patient? So there's quite a few things you need to think about here and again, holistically, it's not just about how you'd fix the problem. It's all about getting them to theater or? Yeah. So getting them to theater, obviously, I'll give them 11 point away. But, um, how would you manage it? Looking at the stem of the question? So I'll give you a minute or so to have a look. Yes, for sure. Ok. So no, so you wanna give out to quite analgesia? It says that they've got severe pain in the stem and you also wanna give bed rest until, until you think the spine's stable. And that's obviously a decision that's made by the senior clinicians. And you can't, you liaise with neurosurgery, et cetera following your MRI scan, um you wanna give them VT prophylaxis. So either that's heparin depending on what trust you're in and Ted Stockings, you wanna do high dose dexamethasone uh with a PPI ideally, which is 60 mgs orally. Um And you want to do that twice a day. So you want to give your second dose ideally at midday at the latest as it can cause insomnia. Um Again, treatment, the definitive treatment is surgical decompression within 24 hours of diagnosis. However, if this patient is palliative, um and they're not fit for surgery, you can do external beam or radio uh tactic, radio, uh radiotherapy. So you'll, you'll, you'll learn slightly about radiotherapy in fourth PM and how it all works. But the definitive treatment is surgical decompression. But however, most patients that do present with M sec, they tend to be more on the metastatic slash palliative um pathway if that makes sense. So, yeah, ad analgesia VT prophylaxis, heart cos they're not gonna be moving around high dose dex and surgical decompression or radiotherapy. So that was a, that was uh the two of our er SA Qs. Uh does anyone have any questions about cadra require or metastatic spinal cord compression? Um I'll have a quick look at the chat to see if there's anything. Ok. So we're now gonna do seven Bs um that they're quite straightforward questions. Um but they're more about fractures and spinal conditions and as opposed to the um compressive disorders, we've just went through um so pop your arms in the chat and that would be ideal and we'll go through them. So just pop down the letter you think it is? So a 28 year old male is brought to A&E after a high speed crash, he complains of severe neck pain and inability to move his legs on examination. He has decreased sensation below the level of T four and an absent deep tender reflux in his lower extremities, which of the following is the most likely diagnosis. So pop the letter in the, in the chat and think about what could be going on here. So, yeah. So the answer is B thoracic spinal fracture. As you can tell it's, it's effect to that level of T four, anything lower down than that is affected. So it's very common to be a thoracic spinal fracture. Next question. 70 year old female with osteoporosis presents with an acute onset, severe back pain. After lifting a heavy object, she reports no trauma on examination. There's tenderness over the mid thoracic spine, which of the following is the most likely diagnosis. So this is quite a common condition we can see on the orthopedic wards, um where these elderly, elderly, male or male or females present um with back pain, she'll always be wary of this condition. What could happen. So the answer is c compression fracture. So it's commonly known as a compression wedge fracture is where um as the vertebrals, uh vertebrae are quite osteoporotic. The one above kind of compresses the one below. So that causes a fracture and subsequent, it can have neurological damage as well depending on how bad it is. So you do want to have the give these patients the adequate um the adequate treatment and you want to investigate with it usually with an MRI scan liaise with the radiologist and um neurosurgeon or orthopedic team. And based on that, they'll give uh a treatment plan. So you it can either be a stable fracture or unstable fracture. If it's stable, the patient will be told to put on at LSO brace, um which is a brace that looks like a bit of a bit of a um army vest um to make sure they're not putting excessive force through their spine. But if it's unstable, they might need to have a bit more precautions and they may need surgery. So, third question. So, a 35 year old male, uh, with a history of prostate cancer, uh, presents with worsening back pain, weakness in his legs and difficulty walking. On examination. There's tenderness over the lower thoracic spine and decreased motor strength to both lower extremities. Which of the following is a likely diagnosis. So what do you think could be called quina? Could it be spinal stenosis? Could it be M sec? Could it be uh spinal epidural abscess or could it be degenerative disc disease? Pop your ass in the chat. Let's have a look at what you've put and the answer is, yeah, M sec. So we just went over it uh in one of our Sa Qs. So it um so it's basically as you know, like commonly affects the thoracic spine prostate cancer. Like someone said in the chat earlier, what is a, is a, is a um one of the main cancers that does um that does metastasize. I appreciate this guy's a, a bit young for prostate cancer. Um however, can present in early early life as well. So, yeah, so it's M sec. So question four, a 35 year old construction worker presents with lower back pain, radiating to the right leg with numbness and tingling in the same uh leg. The straight leg raise test is positive which of the following is the most likely diagnosis. So this was a condition we all learned in second year. Um However, it can present similarly in these other conditions. So do be aware of it. So let's pop your answers in the chat. Yep. So the answer is sciatica. So, sciatica is commonly known as a unilateral problem. Um and it's usually down to a bulging disc around the L4 L5 area where that's the weakest. Usually that then can present with neurological features such as numbness weakness um on the whichever leg is affected. Um And you usually diagnose with a straight leg brace test. There are some other tests you can do. Um treatment tends to be physiotherapy related um and exercise based. Uh You can do like neuro flossing exercises, et cetera and you might have seen someone, someone in your family that might have sciatica. Um So it's always good to be aware of it and it's a common presentation in GP as well uh for the M SK presentations. So good job if you've got all four, correct so far. So question five, a 45 year old woman presents with chronic back pain and stiffness which improves with exercise and worsens with rest on examination. There's limited spine, mobility, mobility, x-rays show sacral iis which of the following is the most likely diagnosis. So let's, let's now break the, let's break the question down. So sacral iliitis showing it's got some form of inflammatory uh perspective, 45 year old patient um improves with exercise. So, again, you leaning towards that inflammatory kind of pa pathology. So, what do you think? So, the answer is ankylosing spondylitis. So, yeah. So that's common with ATRIO Iis. It's kind of like a fusion of the joints. Just kind of think it presents commonly with, I think it's a HLA a 27. Um we uh genetic predisposition, I think, but don't quote me on that. So, yeah. So it's ankylosing spondylitis. It's always good to know that it's been ankylosing spondylitis, spondylar spondylosis, spondylolisthesis um because it can be quite confusing, especially in that exam setting. So, penultimate question. So a 50 year old female presents with progressive lower back pain, bilateral leg pain and difficulty walking. She reports numbness in her legs and occasional bladder incontinence. MRI shows lumbar spinal canal narrowing, which of the following is a likely diagnosis. So, pop the letter of the answer you think in the chart. Uh Yeah. So the answer. So let's break this down. So, bilateral leg pain. Um yeah, difficulty walking thinking it's not spinal related. There's, there's some neurology involved. Um there are some continence. Um There's, there's there's narrowing in the canal. So it's probably gonna be lumbar spinal stenosis. So it's always good to know the difference, lumbar, spinal stenosis, cord, quina mesto, spinal cord compression um because they can present similarly, but there are differences. So, last question. Um I'm unsure why it's underlined but it's ok. Er, 72 year old man for the GP, complained of reduced sensation in his lower legs. That's got worse over the last three months, he feels increasingly unsteady on his feet, on examination. Um, the vibration and pinprick sensation are reduced symmetrically and he has a wide ataxic gait. His ankle reflexes are absent, however, his knee reflexes are brisk. His past medical history includes hypertension managed with ramipril and gastric cancer, which was treated with a subtotal gastrectomy four years ago. He has a body mass index of 29.2 and drinks 10 units of alcohol a week. So what's the most likely cause of the patient's symptoms? So this isn't so much orthopedics but it might present on an orthopedic ward. So it's always good to have your medical hat on as well. It's a common misconception that when you do orthopedics, you forget all of the medicine. Um However, it's always good to know the foundations of what can happen and how potential uh back pain can present because it's one of the really common symptom that happens in, in, in the UK of back pain. That's one of the most rehabilitating, er, there's loads of yellow flags involved and there's loads of teams to get involved as well. So, what do you think with this question? Anyone put anything in the chat? So the answer is subacute combined, degeneration of the spinal cord. So the thing that gives it away in this question is the fact that he's had gastric cancer and he had subtotal gastrectomy four years ago. Um So, uh so the generation of the cord um is commonly due to deficiency in b12. Um and that's produced in the terminal ilium. So, if he had a gastrectomy, he would have had um that part of the bowel potentially taken out or reducing its function. So that's what kind of leads towards that answer. So, yeah, so today we've gone through cord requi that, that spinal cord compression. I've done seven S PA S and today's session was a bit shorter. Um As I appreciate it's coming towards exam season and many people call you advised for the exam. So I don't wanna log it out for a whole hour. Um So thanks for listening and joining us today. Uh Please scan our QR code it with great feedback. I appreciate that. This week's my last session for this series. However, um next academic year we've got a new committee starting and we'll make one very similar and we'll add more sessions to it and practical sessions, et cetera. So this is the QR code, I'll pop the um link in the chat as well in case your QR code doesn't work. Um And it'd be great to get your feedback. Uh Dave, do you have anything anything to add? No, no, that was great. Can you, can you hear me? Ok. Yeah. Yeah. Oh, that's nice. Yeah. Uh, yeah. No, that was great. Yeah, thanks for that. Yeah, that was great. That was really good. Yeah, all very, um, high yield common presentations especially. Uh, and that's, yeah, you miss that then. Yeah, that's not good at all. So, yeah, it's really good. Yeah, thanks. Yeah, as I said, yeah, next year will definitely, um, do more of these sort of teaching sessions and, um, some, you know, a as well or more ay based practice as well. So, yeah. Yeah. So it would be great if you can scan the QR code and then we'll, uh, we'll send you the slides via email um, if you want them. Um And yeah, um, thank you everyone who's joined us for the six sessions or if you even joined us for one, it's been great to, uh, have you on board and, uh, look forward to seeing you all in the next academic year and good luck with all your exams. So, if no one else has any questions, um we'll, uh, we'll call it a night. Yeah. Awesome. Yes. Cheers. Thanks, David. Yeah. Thanks Mom G. Thank you.