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Right. Hi, guys. My name is Jerome. I'm one of the heads of the many path international. Um, I have the pleasure of introducing Dr Matthew Arnuity. He's a T to, um, he's just about to start red training in orthopedic surgery soon enough. Uh, this lecture is sponsored by the M D U and it is also has CP approval from the Royal College of Surgeons in Edinburgh. Um, at the end of the lecture, the feedback forum will be sent to you automatic to your email and you'll have to fill that out and the certificate attendance added to your metal account. All right. Now, I'm gonna pass you over to Matt who's about to be electoral on spinal emergencies. Thank you. Hi, guys. I'm Matt. I'm, uh, as Jerome said, a court trainee, um, working in London at the minute. I've got quite keen interest in global surgery. So that's where most of my research focus has been. Um, and yeah, I'm hoping to go into orthopedic registrar training in the near future and today I'm going to talk to you about spinal emergency. So I think we're planning to start with some anatomy. Let's move on to that if we can. So um just the general um bony anatomy. So the vertebrae consists of 33 bones in total, which is split into your cervical thoracic lumbar sacral and coccygeal. And these are separated by intervertebral discs, except from your sacral coccygeal vertebrae as they are um fused as you know, um and the general function is for protection, support to provide a functional access and also to enable mobility. So, next slide, if we can um just have a quick look at the general anatomy of generic vertebrae. Um So there are some special vertebrae to know about, but that's something that you can go and read about in your own time. But the general anatomy of an individual vertebrae, so we consist of a body which is the main part that is separated by the intervertebral discs. You've then got two pedicles on either side um with transverse processes projecting off of those, you've got a superior and an inferior articular process which uh interact with the above and below vertebrae. You've then got your laminar which join it onto the spinous process, have a look at the next side. So here are some of the features of the other vertebrae. So your cervical vertebrae are slightly different in the sense that they have a defib spinous process as opposed to just a single point. Uh They also have transverse for Amanar which transmit your vertebral arteries. And they also have a triangular vertebral foramen. Uh the thoracic vertebrae have demitasse. It's where your ribs articulate. And um they also have a bleak slash inferior lee angled spine is processes and around vertical four. Um And, and number vertebrae have a large kidney shaped body so that they sort of look like the picture that we looked like looked at on the previous slide and have a more horizontal spinous process with a triangular vertebral forum. So have a look at the next slide. Um And I just put a picture up of a thoracic vertebrae here to show you guys what the Demi facets are there something that I kind of got confused about? But these are the Demi facets that you can see here. So the rib that it corresponds to the actual vertebrae articulates with the superior Demi facet, whereas the rib of the vertebrae below will articulate with the inferior Demi facet. Um And then you've also got costal facets on your transverse processes which articulate with the rib of the corresponding vertebrae in terms of a intervertebral discs, sorry. Um So they consist of two um structures. The analyst fibrosis is the structure that it goes around the circumference, which is a fibro cartilaginous ring made up of type one collagen. Um And then you've got your nucleus pole, pole, pole posters, sorry, which is a remnant of the notochord and it's type two collagen. The type of joint that you see at the intervertebral discs is a secondary cartilaginous. Um and these are all found centrally and it's basically a synthesis. So your pubic synthesis is a, is a secondary cartilaginous joint as well. What distinguishes them is that they've got a bit of fibrocartilage in it, which is different from primary cartilaginous joints, I'm leaving on. So the spinal ligaments, this is, this is quite important stuff to know. Um in terms of exam questions, this is something that does come up fairly frequently and it's good to have an idea of. So the main ligaments that you need to know about are the super spinous ligament, which runs along the tip of your spine is processes. You then got your interspinous or into spinal ligament as it's labeled here. Um The ligament and flavor which goes between the pedicles, um sorry, the lamb in. Uh and then you've got your posterior long distributional ligament which runs along the back of the body of the vertebrae. So this is the closest ligament to your um spinal cords. It's basically within that vertebral canal. Um And then you've got your anterior longitudinal ligament and this sits on the front of the vertebral bodies. And this would be basically on the side where your abdomen would be. Um if we're thinking about lumbar vertebrae and this is just another picture. You guys should have access to the slides afterwards. Happy to send them around. I think this is quite a nice anatomical picture that shows all of the important ligaments with a bit more context why they're quite important to know. So, I'm sure you've all heard of a lumber puncture. Um And it's good to know what ligaments you're going through as it's a blind procedure. And you need to be able to know when you're actually in the space that you want to withdraw the spinal fluid from. So you perform a lumber puncture usually at the level of the L4 slash L5 space, which is your, at the level of your Intercristal line. So this is basically the top of your iliac crests um that you can feel on the side of your body. If you palpate them yourself, the layers that you would go through your skin, subcutaneous fat. Firstly, the super spinous ligament, the interspinous ligament and then the ligamentum flavor some, sometimes this ligament has a gap in the middle. Um So you might not necessarily feel that third pop when you're putting the lumber puncture needle into the back. But in most patient's, it will have uh continuity in the middle. You then end up in the epidural space, which is the most likely area to encounter a bleed. Um As there's a vertebral venous plexus. Here you then go through the Jura martyr into the subdural space and then you go through the Arachnoid martyr into the subarachnoid space. And that's where you get your CSF from in terms of the spinal cord itself. So it originates at the brainstem in the medulla. Um and then it terminates at the Conus medullaris in adults. This is usually at the level of L1 or two. Um but it neonatal, it's a little bit lower down uh and is at the level of L3. This is again, stuff that tends to come up, come up in exam questions. So it's quite useful to know the end of the spinal cord is the phylum terminale, which is a continuation of your Conus medullaris. It's got no neural component to it and it attaches onto the first constitutional versa break. Okay. Yeah. Um in terms of the spinal nerves that you've got, so you've got 31 pairs of spinal nerves, which is a bit less than the number of vertebrae that we looked at earlier eight at the cervical level 12 in the thoracic five, number five, sacral and one coccygeal. Um and the cord require a is quite important structure to know about in terms of spinal emergencies. It's basically. So we said that the spinal cord ends at the level of L1. So anything below that level in terms of spinal nerves is what makes up your cord require. So it's L2 down to the coccygeal, um spinal nerve root, it's covered only by endoneurium and therefore, it's quite sensitive to compression, which is why you get called require basically, which is something we'll talk about in a little bit. So spinal tracks, something that's useful to know this diagram is really scary. That's why I put it in. It looks really, you know, confusing and there's lots of stuff going on. You only really need two, no three. So if we move on to the next slide, hopefully everyone's nerves will be calmed down a little bit. So thinking about them in terms of your ascending and descending tracks that you need to think about. So you've got your a sending tracks which are your spinothalamic and your dorsal. And it's good to know where they crossover as this is clinically relevant. Um in terms of uh some of the incomplete spinal cord injuries that we'll talk about later. So you're spinothalamic tract. For me, it always seems to stick in my head just with thalamic, seems to be similar to temperature. I don't know that might be because I'm a bit dense. But for me, I always remember temperature spinothalamic, it also transmits pain, sensation and pressure and crew touch in the lateral and anterior divisions have slightly different function. So this tract crosses over at or just above the spinal level that it enters the spinal cord, your dorsal column, which is for your fine touch, vibration, appropriate reception crosses higher up. So it goes into the spinal cord doesn't crossover goes straight up and then crosses in the medulla. Um It's got two sort of components to it. The particulars cuneus in Brazil is. Um and the way I remember which one does which part of the body is um C comes before G arms before your legs just again, helps it stick in my head with regard to the descending tracks that you need to know about corticospinal tract, particularly the lateral corticospinal tract, which crosses in the pyramid, which is located in the medulla. Uh This is all your motor function. Uh so that they're the three that you really need to have a read through and have an idea of it will probably take us a bit too long to go through all of those in detail now. But this is a bit of an overview for you. And this is a much nicer diagram that's much less scary. And I find quite useful. So the blood supplies the spinal cord again, something that's very, very complex. I've just put this diagram in here to show that it's a bit crazy. Uh We don't need to know all the ins and outs of this unless you're going to be a neuroradiologist or a spinal surgeon of some sort, which you may well be, but it's not something that you need to know at the junior saves of your career. Um If you look at the next slide, well, have it in a nice manageable way for us to think about. So the main things that you need to know, you've got an anterior spinal artery which is unpaid artery that runs down the anterior, surprisingly part of the spinal cord and it comes from your vertebral arteries, you've then got your posterior spinal arteries. And this is a paired set of arteries that begin from the posterior inferior cerebellar arteries. And again, these are branches of the vertebral artery. So basically, the anterior posterior spinal arteries both come from your vertebral arteries. And then you've got ridiculous branches which feed into anterior and posterior spinal arteries lower down the spinal cord. The most important one is the artery of Adam quits. Um And the reason this is important to know is that if you have a aortic dissection that's going into the thoracic aorta, it can disrupt this artery and then people can get a spinal stroke. So it's something that they can, you know, there are clinical symptoms that you can notice with these patient's. Um and you might think, oh, that's this artery has been involved and that's something that's, you know, you need to be aware of. Brilliant. And again, this is just a nice diagram that actually shows the important stuff that you need to know in the junior parts of your career. Um is a good picture that I've got in my notes that I use with regard to what parts of the spinal cord that these arteries supply. So the anterior spinal artery supplies the anterior two thirds and the posterior spinal artery supplies the arteries sorry supply the posterior one third of your spinal cord. So, moving on to some clinical emergencies Uh So first thing we'll talk about quarter equina. And if you look at this MRI, you can see between L4 and L5 that there's a disc prolapse that's protruding onto the cord, a equina part of the spinal cord. So that's not good news as we know that that's quite sensitive compression. And this patient would be at risk of having neurological dysfunction. So we'll move on. So it's, it's a neurosurgical emergency. It's something that we, we need to deal with quickly. And the most common cause is a central prolapse of the of, of an intervertebral disc, particularly at levels below. Well, it has to be at level below a one slash L2 because we know the spinal cord finishes at L1. Um and compression of the nerve roots in the fecal sac result in severe back pain and then other symptoms, neurological and visceral symptoms, commonest cause disc herniation, other causes space occupying Asians, hematoma in the extra durable epidural space. Whereas what we spoke about earlier is the most likely place to have a bleed when you're doing your lumber, puncture. Um Tumor's in the spinal cord, synovial facet cysts, um and epidural abscesses as well as trauma and spondylolisthesis. Spondylolisthesis is something I've put in a few slides in a second. Just to explain visually what it is. Basically, it's a translocation of one vertebrae in relation to the inferior vertebrae to it. It can either be anterior or posterior in terms of the trans location. Um But when we see it reported in scans, it's generally synonymous, synonymous, sorry with anterolisthesis, um which is where the vertebrae above has fallen forward, basically. Um And if we look at the next few slides, this is a nice, if we click through these, we can see the progression. And this is basically what spondylolisthesis. This is technically an antihero this thesis that we're seeing here. Um as we it's moving forward in relation to the vertebrae, but like with regards to the half a biology. So you get compression of the spinal cord which has two effects. Um The first being reduced nutrient delivery to the nerve roots themselves. This is as a result of reduced blood flow and reduced CSF diffusion. And you've then got an intraneural compartment syndrome. So you basically have venous congestion, which results in edema as the tissue that is under perfused gets injured. It becomes a dermatis in swells and you then eventually end up with reduced arterial pressures and subsequent ischemia. So, there are two ways how the in in which the spinal cord gets damaged and with regard to pathophysiology. So you get a lower motor lesion as it's below the level of the spinal cord, the nerve roots have been given off. So it has to be a lower motor neuron lesion. Um again, interruption of nerves that form the bladder reflex arc as well. Um And then you have an issue in terms of sensing your bladder filling and you can't initiate the true sir contraction, which is the main muscle in the bladder. Um And you can't relax the external urethra sphincter to pass your and eat that in terms of assessing a patient with suspected corder equina. Um So your initial assessment always needs to have a history in it. Um And that's going to cover, you know, your past medical history, past surgical history, etcetera. But the important things to pick up on in a history when your um speaking to a C E S patient um is the onset of their symptoms and whether they've had any previous episodes before um taking a good pain history, I would still use Socrates. Now, I think it's a really, really handy way to structure a history for pain. You want to check whether they're on a anti coagulation. One because it could be a predisposing factor and two because they're potentially going to need urgent surgery. So you need to know that and then you want to check whether they've got any of the red flag symptoms, which will come onto in a second with regards to conducting a clinical examination, you need to go and do a full neuro exam, both motor and sensory, a lumber spine examination, which should include a straight leg raise test and this would elicit what we're looking for. Basically is true sciatica, which is a shooting pain below the knees and pain occurring when the angle angle of the raised leg is anywhere less than sort of 60 to 70 degrees. That's the kind of worrying pathological cut off. Um And you need to a pr exam, this is something that's actually the guidance has changed recently on this. So you no longer need to check anal tone in terms of if you're going exactly by the guidelines. But you do need to check whether there's any perianal sensation loss. So you still need to conduct a pr exam for that reason. And these are some of the red. Well, no, these are not some of the red flags. These are all of the red flags from the nice guidelines. So, bilateral sciatica, a severe progressive neurological deficit. Um any issues with urinary flow in terms of initiating um passing urine or whether they're patient can't actually feel the sensation of passing urine. Um loss of reptile sensation, perianal or genital sensory loss. And then laxity of the anal sphincter is still including the nice guidelines. Although it's not something that necessarily needs an assessment and another red flag symptom in males is erectile dysfunction in terms of investigations. So the way I always think about how I would approach a patient is bedside tests first, then I think about blood tests and then I think about imaging. So bedside tests in called require. The most important thing you can do is a post void bladder scan because that will show you if there is urinary retention. Um And you want to be sort of thinking about whether there's more than sort of 50 to 60 mils, that's something that would be making you think. Ok, that's abnormal. Um It's good to get an E C G as. Again, you're thinking about whether these patient's mani's go to theater and also starting an Asia chart to document their neurological deficit. If they have any, the Asia chart is a really, really you can just Google it, it's really, really handy. Um And it's how I go by when I do a neurological exam, I basically use the dermatomal distribution that all my total distribution that's on the Asian charts as it's a nice structured uniform way of assessing a patient with regards to bloods. So again, we're thinking, what do we need to know about the patient now? And also what, what we need to do to get them ready for theater. So clotting group and save are very important for that reason as well as full blood count. Um And using these in terms of imaging, the most, the most important imaging modality is MRI. That's what's going to tell you whether there is indeed caused Akina compression or not. If patient's can't have an MRI scan, then ct myelography is a useful adjunct. And again, if you're, if it's not going to delay getting them to an MRI, getting a PA and lateral lumbar spine, X rays is something that you can consider something that's really important, probably the most important thing at our stage of training. So in the early parts of our career escalate these patient's early on, it's a neurosurgical slash orthopedic spinal emergency. So you need to speak to your registrar or consultant on call, depending what the service is in your particular trust or hospital. So management, the for true cause required a syndrome, urgent surgical decompression, that's the main state of management. And ideally you want to do it as soon as safely possible um within 24 hours if you can and definitely within 48 hours. Um As anything beyond that is going to risk permanent damage to the patient's neurological function techniques, you don't need civilians and outs of these, but I've included them for those who are interested to go and have a further read about. But you can do microdiscectomy, laminectomies and then very rarely laminectomy with a fusion in terms of classification. So the most useful classes, there are a few out there. This is probably the most useful one that I found. So it's a functional classification um that splits into suspected in complete retention and then complete. Um And these are divided up as you can see here. Um Again, you should have access to these slides. So this is a nice image that I've got in my notes that I can go and refer to myself if you're interested in doing some further reading on this three bullets or can we pop back a little bit? Sorry. Um, or I was just gonna say, although bullets have got a really good article on their website and that's what I used to revise for my exams. Um, they've got loads of stuff on there that is really, really, really handy. Right. Moving on. So it would be silly of us not to talk about spinal fractures since we're covering um, spinal emergencies. Um And as you can see here, there's a thoracic spinal fracture and we'll talk a bit more about them now. So with regard spinal fractures types and classification, you don't need to know these by heart, but it's a good idea to have um some understanding of the different types of fractures. And then also a classification system, there are one, the A oh classification system is the one that I've read about and find the most useful seems to make the most sense to me. Uh So that's the one I've been clipped. Um So in terms of pipes of fractures, you can have a compression fracture. These tend to be the ones that you get in your elderly osteoporotic patient's. These are often a bit less concerning than some of the other types. Um But again, any spinal fracture is something that needs to be taken seriously, then you've got your burst fractures. Um These tend to be at the local lumber level. You've also got flexion and hyperextension fractures and then probably the worst in terms of instability are your fracture dislocations, which you know, it makes sense that they're the least stables, you've both broken your back and you've also dislocated the vertebrae. So that's not going to be good for the soft tissue structures either. So those vertebrae are going to be very unstable in terms of classification. So the A O classification splits them into type A type B and type C. Um And yeah, these are divided up as you can see here. Again, it's something that if you're interested in is worth having a look at in your own time. Um And if we move on to the left slides, we've got a good visual representation of all of these different types of fractures. And then the correspond you can see um that they've got the A O classification next to them as well. So this is quite a nice diagram to have a look at just to get an idea of what's going on in terms of red flags for spinal fractures. So things you need to think about here. Again, this is nice guidelines. Um And it's old age, any major trauma um and mild trauma in elderly patient's or those using corticosteroids or have, who have known osteoporosis, um any structural deformities on examination, um contusions or abrasions over the vertebral column and any point tenderness stuff that you need to be looking out for. So, again, approaching these patient's bedside investigations sorry, I should have said the the the initial approach is going to be much the same as you would for your cord equina patient's, you need to take a full history and examine them in exactly the same manner. So, doing your um spinal examination, motor and sensory neuro examination and also considering a pr if there's any neurological deficit um with regard to investigation. So bedside bloods imaging, the post void bladder scan is a bit less important in this unless they've got, you know, neurological dysfunction, and then you'd be more focused on that. The bloods are basically the same, you're thinking about the two same things, what, what's going on with the patient now and I need to potentially get them ready for an operation. Imaging modalities are a bit different than what you might initially go with for cord require patient's. So CT is probably your most useful um imaging modality in the first instance, as that's what's going to show you the fracture pattern in the most detail. Um Then if you've got a neurological deficit or concern over any cord or nerve root injury, then you go down your MRI route. Um and X rays again are important but shouldn't delay further investigation. And again, you need to escalate this stuff early stuff that we need to be thinking about our level. So management again a bit different. So I've included here your initial approach. If you were seeing a traumatically injured patient Um So you'd want to make sure you've got your trauma call put out and you've got your whole trauma team there. We do our standard eight, we approach as per HLS for those of you that have done a TLS, it's a really useful um structure to stick to. And basically the airway that the eight we approaches airway and c spine, breathing, circulation, disability and then exposure. Um I won't go through all of these in complete details. I don't think we'll have time to go through all of them. Um And then you want to go ahead and resuscitate your patient as needed. Um That's an important part of your 80 approach as well. You want to make sure you've got access um consider other injuries as well, which is part of your exposure and don't forget to log roll the patient um at the end of your primary survey. Uh and then obviously escalate it to the appropriate specialties in your trust. And as we mentioned earlier, so you want to have that same structure that you did for any patient basically. So take a full history, do your relevant examinations, specific management for spinal fractures. Again, this isn't something that you need to know the specifics of per se, but it's good to have an idea of what the different treatment options are. Um They're basically, you know, split into non operative and operative. Um and the for those with stable injuries without any neurological deficit. You would be choosing your potentially choosing your non operative management. Uh And this will consist of observation, um which would be allowing the patient to mobilize as per their pain allows them to or considering bed rest in patient's who are unable to mobilize because of pain. But that's something that we need to um consider the complications of as, you know, being in bed for a prolonged period of time has its own uh health risks, which I'm sure you're all aware of. Um you've got bracing options, so you've got your tlso braces. Um and there can be casting used in some places. Um um And then obviously, you want to consider that medical management um of any underlying disease is particularly important in spinal fractures would be considering osteoporosis. Um So once maybe start some bisphosphonates and vitamin D supplementation, then you've got your operative options and uh this would be in your patient's, as I said earlier, with unstable or neurological deficit with regard to that injury. Um And the techniques again, you don't need to know the internets of these can go and do some further reading. They basically depend on what the fracture pattern is. Um And what the treatment objective is as well. So now we'll have a look at spinal cord injuries. Um And this is just another, so you can see at the, I think this is between C two and C three, you can see that there's a retro propulsion of a disc that's prolapsed and it's pressing on the spinal cord there. So, moving on to the next slide. So in terms of classifying spinal cord injuries, um the, it's quite simple there, either complete or they're in complete, complete spinal cord injuries are the symptoms really easy to remember. It's just complete loss of function below the level at which the injury has occurred with regard to incomplete. They're, they're slightly different in terms of the symptoms that you might see depending on what type of lesion is. Um And these are the different types that are the main, different types that you need to know about. Um in terms of most the least common. So they're central and anterior cord syndromes, your browser card syndrome, and then your posterior called syndrome as well. So we'll talk first about our central cold syndromes. And this is again, a nice diagram is a bit more complex than the one that we saw earlier. But it's quite useful. I find to see what spinal tracks have been affected and that's why we spoke about those um in the anatomy session earlier. Uh and you can see here the area that is affected by um uh central course it is affected in sorry, central Court's syndrome. Um And you can see that the upper limb I hand motor pathway is affected most um in this case. And if we move on to the next slide, we can have a talk a bit more about the other symptoms. So, the clinical features are predominantly weakness. Um And as I said, as it affects those, the tracks that supply the upper limbs predominantly, that's where you get your symptoms. You do also get lower limb symptoms though. However, um the pathophysiology, so you get compression and then chord edema with selective destruction of that lateral corticospinal tract that we spoke about earlier. And that's what does the motor function for your body. Um And as the upper limb is more centrally represented, um that's why it's affected more. The prognosis is generally good. And there's, there's a particular recovery pattern in these patient's where the lower limbs which are at least affected, recover faster than the upper limbs. Um And your management options, again, our operative or non operative, you don't need to know the ins and outs of these, but it's, it's good to have an idea of what your potential options are. So, anterior cord syndrome. So, remember we spoke about earlier, the anterior spinal artery supplying the uh anterior two thirds of the spinal cord. This is the area that you basically see affected in your anterior cord syndrome. Um And you can see that the spinal thalamic tracks, corticospinal tracks um are all being affected, but the dorsal columns are largely um spared in these patient's uh so move on to the next slide causes. So it can either be injury um causing a fracture which then results in compression or, you know, disc prolapse, causing compression or all of the other things that we spoke about earlier. Um and then also injury to that anterior spinal artery, which disrupts the blood supply to that portion of the spinal cord. Um So you get disruption of the anterior two thirds bilaterally. So you get loss of your spinothalamic um and corticospinal tracks. So that would give you sensory and motor dysfunction and we'll look at those in a bit more detail. Now, it's the most likely to mimic a complete cord injury. And you get below the level of the lesion, bilateral sensory loss in terms of pain and temperature, which is from your lateral, lateral um spinothalamic tracks, and then crew touch and pressure from your anterior spinothalamic tracks and then motor loss because you get damage to your corticospinal tracks, which we spoke about earlier. And in this um cord syndrome, it's lower limbs more effective than your upper limbs. Uh And as I said, your dorsal columns are indeed preserved. This has got the worst prognosis of your incompletes by record injuries. So these patient's often need intensive rehab afterwards. Brands card syndrome. This is one that they absolutely love in exams. Always, always seems to come up both in written and practical exams. Um It's not something that I've ever come across in real life. Um And I've worked in a few trauma centers uh over my career so far. Um But I've not done any neurosurgical jobs. So that is probably why I've not come across it myself. Um, and you can see here that it's a, it's a hemi section of the cord. So you get injury to one half of your spinal cord. Um If we move on to the next slide, we'll talk about the symptoms in a bit more detail. It's pretty rare, but it's not the least common, but it is, is fairly uncommon. Um um And as I said, it's a complete heavy section of the spinal cord and usually, um it's something that's due to penetrating trauma, I a stab injury. Um And just as a side note, something that when I was given a teaching session on spinal emergencies as a medical student, when we were talking about France card syndrome, I trained at ST George's and obviously they've got neurosurgical unit there and one of the neurosurgeons were saying that in London, they've started to see a bit more of these injuries coming up because people in gangs who use knives had learned that if you stab people in the back near the spinal cord, you might not kill them, but you could end up giving them a pretty nasty injury. So it's a bit of a dark um side note there, but an interesting one nonetheless, um with regard to clinical features. So you get ipsilateral dorsal and corticospinal tract injury. So you get motor loss on that side and loss of fine touch and vibration. And this is because so remember when we spoke about the anatomy earlier, these two tracks go into the spinal cord and then they go up and then they cross over. So the same side goes in, on the same side goes up and then it crosses over to the other side of the brain. Whereas with your spinothalamic tracks, you get contralateral pain and temperature and crude touch and pressure loss. And that's because the injured, the this the side of the injury, the spinothalamic tracks have gone into the spinal cord and they've either gone up one or two levels or directly crossed over and then ascended up to the brain stem before going into the relevant part of the cortex. And therefore you get a contralateral injury because on your side of the injury, my um spine Islamic tracks have come across from the other side and then they're getting injured. Whereas it's ipsilateral with regard to your door. So, and corticospinal tracks, they do have a pretty good prognosis and a lot of these patient's will regain pretty much full function, which I didn't know about until I was preparing for this lecture. So that was an interesting thing to find out myself, pastilles record syndrome. I've not gone into too much detail here. It's very, very rare and it doesn't really come up in terms of examination questions that you will see. Um But it's something for us to be aware of clinically um causes inflammatory infective ischemic, mechanical metabolic and hereditary um with regard to ischemic. So it's um the territory of the posterior spinal arteries that you want to be thinking about. And basically this is your dorsal columns. So below the level of the lesion, you'll get um loss of vibration and fine touch, which is your dorsal tracked, um the a sending, dorsal tracked. Um and then you can also get sensory ataxia. So because of that loss of pro pre exception, you get a tax ear and I don't know if anyone who's in the lecture has seen in a tax sick patient before, but it is, once you've seen it, once, you'll never forget it. It really does look like the patient is disinhibited and drunk. Basically, they don't have proper control um of their motor function. It's a very bizarre clinical sign management principles for your spinal cord injuries again. So if it's dramatic, you want your initial approach to be that A T L S A two AM resuscitate, that's going to be your main stay in those cases initially. Um And then you want to find out what's caused it. The general management would consist of conservative i supportive care and rehab medical therapy to treat any underlying causes. So, you know, as we just looked at, you can get infective or other causes of um some of these syndromes. Um and then potentially surgical intervention and that's dependent on what the causative factor is another couple of things to just touch on. So, neurogenic and spinal shock. This is only one slide and it's something that I'd advise you guys to go and have a bit more of a read on afterwards. If it's, if it's something that's not um entirely made sense is these are quite broad topics, but it's good to have an idea of that. They are separate things. So, neurogenic shock, um it's a distribute sorry, distributive type of shock. Um and it typically requires a spinal cord injury to be at the level of T six or above um the path of physiology. So you get loss of autonomic function um in regard to your parasympathetic and sympathetic nervous system. So you basically lose your sympathetic uh nervous supply, but you preserve your parasympathetic supply. So you get this unbalanced um homeostatic state basically, um where in patient's will end up with bradycardia um and subsequent hypertension as a result of that. But because they're parasympathetic um supply is intact, they'll still be able to vasodilator which then makes the hypertension worse and makes the seeming bradycardia. Um the bradycardia is even more inappropriate given that the patient's will often be hypertensive. This is something that you would consider in traumatically injured patient. However, if you've got a patient who's hypertensive and has had some sort of traumatic injury, you want to be investigating them completely for other causes of shock as in traumatic patient's um neurogenic shock is a relatively rare cause of their shock. So you want to be making sure that they're not bleeding elsewhere. Basically, the features are hypertension and an inappropriate bradycardia. Um As we know that patient to a on the low side of their BP shouldn't be having a low heart rate. Um and basically the management for this, the mainstay is making sure that adequately resuscitated and then supportive measures in terms of vasopressors, I inotropes or Corona tropes, um which will affect the cardiovascular system. Spinal shock is a bit different. It's, it's not a um type of shock that's related to the circulatory system. Um It's a bit of a misnomer in that, in that regard. Um It's basically to describing shock to the spinal cord, literally, um a direct injury that might be transient or might be permanent. Initially, these patient's will have a reflex eah and flu acidity. Um And eventually, if it is a permanent injury that they'll progress to becoming um spastic in terms of their um musculature, so they'll be rigid and not as they were at initial presentation. And as I mentioned, it's not circulatory collapse. I've put these two general rules in as I found them quite useful to just having the back of my mind when I am approaching these patient's uh in terms of examination. So below the level of L1, again, this is a recurring theme, that's where the spinal cord ends. That's where you're gonna be more likely to get your lower motor symptoms, which is where everything's reduced. So that's the initial phase of spinal shot. Basically, you've got your floppy patient's, the muscles have got no tone. They can't mount any, you know, decent motor responses to commands and their reflexes are all reduced. And then above the level of our one, that's when you've got a predominance for your upper motor um signs. Um and these are where things are a bit more rigid. So that kind of, you know, spastic paralysis with brisk reflexes, an upgoing plantar um reflexes as well. So everything goes up in your upper motor lesion's. Um And it's just good to know that um sorry features typically manifest several weeks later once this final shock has resolved, basically. So that's, that's what we're speaking about previously, right? I think that's everything I'm happy to take any questions at this point. I know that seemed like a hell of a lot of information. I hope that's been useful. I try to include everything, you know, you're gonna need to know in terms of exam stuff. Um And also cover the important things that you see in your clinical practice. So there's one, there's one question, um it's a two parter really. Um So, so first part is which primary tumor's tend to metastasize to the lower spine. So, what tumor's that go to bone? Um So I don't know if anyone's heard of the Pneumonic I'm, I'm a big fan of know Monix. They really, really help me remember things, but it makes me seem like a bit of a thing that when I'm going through silly know Monix to work out what's going on the L T Kosher pickle is all of the tumor is that will metastasize to bones. So that's breast lung, thyroid, particularly follicular thyroid cancers as they spread hemato hematoma. Uh Oh my God. I'm really not having a good day here. He mitad hematogenous Lee. Wow, that was a mouthful. They spread through your blood is what I was trying to say. They're so thyroid and then kidney and prostate. So BLT coach, a pickle is a good way of remembering the primary tumor is that go to bones. I hope that's helpful for some people. Um The second part of that question was uh and if the history of particular radiotherapy could such patient's have resultant Lee suffered erogenic neural damage, which may therefore mean that they could see a silently miss the red flag pain symptoms. Um Sorry, that means you read effect. Yeah. Yeah, I think I can see it. So they're asking does radiotherapy potentially iatrogenic lee damage the spinal cord? Um And then mean that a patient could be missed. I could, you could miss a quarter equina. Um That's a really good question. Um I'm going to have to say I, I I honestly I'm not entirely certain, it's very, it's very difficult question. Um, radiotherapy, I mean, you've identified that it is, it doesn't have no complications that has got its own risks. And we know that radiotherapy can damage the other tissue. I think it would be unlikely that radiotherapy would be able to directly damage the spinal cord enough to result in, you know, significant neurological dysfunction. You get things with radiotherapy things you have to think about in surgical patient's is whether a wound is going to break down or if they've had a graft following. So I, we I met Jerome at Stanmore, the Royal National orthopedic Hospital where we are working on the sarcoma team together and a lot of our patient's there would have these big receptions and then need plastic surgery and put afterwards to help close the defect. And a lot of them would also need postoperative radiotherapy. And the thing that would be the worry would be that the wound would break down or that the graft would fail. Um but they can alter the dose of radiotherapy that is given to, you know, reduce that risk. So I think it would be quite unlikely that you give such a high dose of radio therapy, such that you could completely duff up the spinal cord. Um If that makes sense, there is another question. Um which cases have you seen from these emergencies which are more common to see? So I, I started with Cordray equina because it's, that's probably the one that you will see the most in your clinical practice. Um Not because it's massively common in terms of actually being diagnosed with Cordray equina, but back pain is super, super, super common. And we've got all of these symptoms that are red flags and patient's will have those. And when you're in that scenario, you have to, you, especially nowadays, you know, where we're in a very medical legal world, we have to make sure sure that we're ruling out the nasty diagnosis properly. And that means lots and lots of people get MRI scans now because you can't, you can't really rely on your clinical examination to go. Definitely. Yes, definitely not cordial equina. Um So yeah, that's probably the one that I've seen the most spinal fractures are probably, I'd imagine they're a bit more common. Um, but they, uh I don't know how frequently they would result in the sort of neurological symptoms. Um Exactly. But yeah, there you see many more trauma patient. So you'll probably see more spinal fractures than you will. Genuine called Rick Weiners. Although I've been on call yesterday and we saw two in one shift genuine called Requires that had to go over to Queen's Square Hospital for neuro surgical intervention. So it is something that, that you do see. Yeah. The second part of that question, I think you've answered it. Which ones in particular shouldn't let one look out for? Oh, so yeah, sorry, sorry. Yeah. So my, when I was a foundation doctor in a, and a chord rock whiner. You know, you really, really need to rule out your trauma patient. You'll have a bit more of a safety net generally because you should have, if a trauma call goes off, then you should have um your whole team with you. It won't just be you as an F one on your own. You have your, your seniors there alongside you. Um But having said that you do see these, these patient's who will walk in, I saw a chap as an F two who just walked in off the street had had a fair few beers um and fallen over and cut his head a little bit and there was just something about him that I wasn't quite happy with and we got a ct scan of his, of his neck and he'd broken his C one and C two vertebrae, which is not, not good at all. Um But had absolutely no, he didn't have any neurological deficit and just was someone I had a feeling over. So you do need to look out for fractures as well. But yeah, called a coin as you want to make sure you've got a really good structured history for them and you're ruling out all of the nasty stuff and examining them in a very thorough way. So then when you go to request the MRI scan or speak to your senior and say, look, I've got X Y Z, which is why I want to go and get this MRI scan. You're, you know, you're able to justify your investigations. Another question, guys. Um, I think that's it. Um All the questions. Oh, uh, one more question actually, uh, could you please explain how to figure out which level of the spinal cord is damaged based on symptoms, symptoms presented? So, gosh, that's, that's a tough one. Thank you for putting me on the spot there. Uh Jerome, you might be able to do a better job than me because you're, you're working on spine at the minute here. Um Probably the best, the best way to you, you can do it. You know, it depends how, well, you know, your myotomes and your dermatomes. Um So the Asia chart, that's why I always revert to and to Asia chart has got everything listed on there. Um But there again, there are a few, few ones that you should sort of know off the top of your head. So in terms of your um dermatome, so your C 51 is on your shoulder here. See, six is at your thumb, C seven at your middle finger. See eight is your little finger. T one is up on the middle of your forearm here and then T two is a bit higher up sort of just before the axilla. Um And then with regard to your lower limb dermatome is that you should know off the top of your head, you've got L1 is on your, at the level of the oasis. L2 is the anterior part of the thigh. L3 ni in in front of your knee. L4 is um behind your medial malleolus L5 is the big toe. S one is behind your actual malleolus. S two is in your property all fossa and then you've got S three S four is where you get a bit higher up in sort of the thigh and then the perianal area. So you can, this is stuff that i it's only really, you know, I've started to learn the ins and outs of as I've gone into um revising for exams and the rest of it. So you'll pick it up as you get or experience clinically. But Asia chart is probably, that's, that's probably the right answer to give you's Eurasia chart and have a good structure in front of you. So you can clinically examine the patient any other questions. Um I think that's it. Um Thank you for everyone that text um at uh for giving this great lecture. Uh Again, at the end of this lecture, you will automatically get a feedback form to send your email. You just have to fill that out to get your certificate of attendance. Uh Again, thank you to M D U for sponsoring. The event are events, ours are CPD approved by the Royal College of Surgeons in Edinburgh. Uh Thank you all for attending. Make sure you attend next week. This lecture is on Wednesday given by Mr Niall Boykin. He's emergency medicine doctor. He's been uh in the field for almost 20 years. Um So he has a lot of experience to give. Um but tune in next week around same, same time on one thing. Thank you guys.