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Excellent. And can you see the slides? Yes, excellent. I'll make them full screen. It's just, I couldn't see the chat when they're full screen. Um Oh, that's, that's the issue. Me also uh me and I will be here to hopefully rel any questions. Yeah. Come on. Happy to be interrupted as we go through just but you'll have to shout at me cause I can't see the screen. OK. OK. Um And I have a, a little person in the background as well. So if you hear a bit of noise, I apologize. Um No problem. Same here. And if we just uh if we could uh just uh hold off one second mister Mar while the recording starts. OK. Just say one. OK. Sure. Yeah. For life. Great. OK. So my um my remit was to talk about spine fractures and corner syndrome with some cases and there will be some cases at the end, but what I've chosen to do um is to take it right back to basics. Um And I don't mean to patronize anyone and I know there's probably quite a range of people on here. But I think if, if, if you if you don't understand, um, what the terms are, then you'll find it very difficult to keep up with the sort of the phrases that we use when we're talking about spine fractures. And also, um, if you really take things back to basics, it gives you a really good ground on which to build. And I think that's much more important than, than understanding how to treat each individual fracture and, and the funny names that we give each fracture like hangman's and burst and chance and all of that kind of stuff. I think if we can get you to understand the principles and how we make the decisions, that's by far a much more useful tool than me just standing here banging on about different types of fracture and showing you lots of x-ray. So I hope you don't mind, but I, and it may be a bit patronizing for some, but um but I hope it will be a good refresher nevertheless. Um So the first thing is we've got to talk about what we call the spinal column, ok. So the spinal column is essentially the bones that make up the spine. Ok. It's the, it's the mechanical support. It includes the discs as well. And again, not through onto patronizing, but we've got some special areas of the spine to talk about as well. So, um we've got the C one C two, which we call the atlas and the axis or the C two being the thing with the peg, that's the part of your spine at which approximately 50% of the rotation of your neck comes from this one level in this one junction. So it's really important um sort of and also it's commonly fractured because almost all of you will have seen pain fractures. Ok. Now, the then we move down to what we call the sub axial cervical spine. So the atlas and axis are um are sort of separated out in the cervical spine and the rest of the cervical spine, we term the sub axial cervical spine. And the reason we separate those out is because they behave very differently. Um then we've got this transition between C seven and T one. So that's where you're going from a very mobile segment of the spine. So the neck being the very mobile segment to a a relatively rigid segment in the thoracic spine. And so you can imagine that fractures around this region, especially at the C seven region are going to take a lot more force because you're going from rigid to not rigid. Um And so the levers and the forces around the what we call the junctional region. And there's another junctional region lower down, you'll notice are much more unstable and therefore much more likely to need intervention than around the sort of midthoracic region, for instance, which is supported by the ribs. Thoracic spine has a normal kyphosis curvature and that increases as you get older and it can be increased in various other things. In general, thoracic spine tends to be a lot less vulnerable to fracture. And when it does fractures to be a lot more stable because it's got at each level, a rib attached to it and that rib confers some support as long as long as the ribs are intact. Of course. So if you've got a injury to the ribs, especially a flail chest, um then that in that stability that's conferred by them is a lot less useful. All right. Um So as you know, there are 12 thoracic vertebrae and then we come into another junction 11 between what we call the thoracolumbar junction. So again, you're going from a relatively mobile segment to the spine and the lumbar spine to a stiff segment in the thoracic spine. So again, the injuries around this T 12 L1 region, as you'll know, t 11 and 12 often have floating ribs. So they're not necessarily conferring as much stability. But injuries around this thoraco lumbar junction, again, much more unstable than mid thoracic or mid lumbar injuries. And then the same goes for the sacral injury. So the L5 injuries is going again from the sacrum, which is very hard, a rigid fix to the pelvis to a relatively mobile segment. So that's um lumbosacral junction again, another area of vulnerability. And so that's one concept to really bear in mind is you just need to understand how the different areas of the spine normally physiologically move. But also the relation of one place to the next place helps us to judge uh whether a fracture is stable or unstable based on the predicted forces that are gonna go through. Um So we've gone through that and so the function of the spinal column is to provide what we call mechanical stability while allowing movement and protecting the spinal cord. And so what is stability? Well, there is a definition but, and there are lots of different classifications of stability and some of the can be useful. But the main thing that I always think about classifications is if you can understand why a classification has its different subsections and really sort of try to work out why these things are, then it doesn't matter if you remember the exact parts of each classification. The most important thing is understanding the mechanisms underlying it. So stability is the ability of the spine under physiological conditions to maintain mechanical integrity without causing neurological dysfunctional pain. Um That's a really old definition and a lot of people would dispute it, especially the pain part. Um but really, it's the mechanical integrity that we're interested in, ok, especially the neurological dysfunction. But if you, some people like definitions and that's the most common one that you'll find is from Punjabi and White. Um from all the way back in the 19 eighties. Um again, not meaning to patronize. But um just so everyone knows what we're talking about in terms of bony anatomy. So at the front, which is at the bottom of the screen on this, we've got the vertebral body. That's a big part, a big block of can bone. Ok. And um it can bone being relatively spongy lamella bone with lots of little trabecula. So lots of little spicules of bone, um kind of like a sponge um or a crunchy bar and all of those spicules of bone are actually specifically aligned to withstand the forces that the vertebrae body normally undergoes. Ok. So they don't just form when you're growing up and staying like they are, the bone is alive, it remodels and so they do alter and change according to the forces going through it. And that's, that's an important thing to consider when we're talking about vertebral body fractures because this is where um the osteoporotic and wedge fractures come into a, a decent explanation. So, um osteoporotic fractures or wedge compression fractures are really those individual little tiny tra fracturing and the bone crushing in amongst itself. So it crushes down into itself rather than splitting and cleaving in half. What it does is it crushes down into itself. And the only way that can happen is because you've got this spongy can sell bone. So it doesn't behave in the same way as a cortical bone like a femur or a tibia. Um Having said that you do need to divide fractures up into age groups. So an elderly person with known osteoporosis falling from a standing height is very different from an 18 year old person who's been in a high energy injury and, and they will behave very differently as well, but we'll talk about that a bit later. Um Over to the, so coming back, we've got the vertebral foramen. So the foramen is where the neurological structures are. That's the bit. So you can see it's completely surrounded by bone. As you would expect, the spinal cord needs to be well protected, connecting the front and the back over to the outside. We've got the pedicles. OK? And you may well be familiar with the term pedicle screws. Um So this is where we're putting our screws. So we put our screw from the back down that pedicle and into the vertebral body. Um And that's why it's called a pedicle screw because it goes down the pedicle. Um At the back here, we've got in the middle of the spinous process, which is the, the bit of the spine that one feels when you're palpating. Um and then that curves out and becomes confluent with what we call the lamina, which is basically an extension, either side of the spinous process and joining that spinous process into the articular processes which are the joints above and below the spine. Um So one goes up and one goes down from each vertebral body to create a joint with the one above and the one below. And then all the way out to the side, we've got transverse processes, actually a really common thing to fracture. And the reason it fractures especially in the lumbar spine so commonly is because it's got some big powerful muscles attached to it. So think of these like anchors for the muscles. So things like P OS, for instance, in the lumbar spine. And you can imagine if you have an injury that that causes PS S to contract suddenly and sharply in the young patient, what you can do is you can get a sion type fractures of the transverse process and so literally rips off the bone. Um and we often see those as long as they're confined to the transverse process, what you can see quite clearly by looking at the shape of this is that it's not really related to any kind of mechanical stability. So transverse process fractures, one of the first fractures that we're going to talk about um is a completely stable fracture and nothing to worry about with the caveat though. You do need to be careful that it is just a transverse process fracture. So just keep an extra eye out to make sure that it's just that and nothing else. So moving on, we spoke about C 12, this is just sort of a refresher really. So C one is the Atlas, OK. So it's called the Atlas because it carries the head. Um It has essentially just a ring of bone and it doesn't have a body, OK. The reason it doesn't have a body is because it needs to, to accommodate the peg which is part of C two. And as you can see CC two sticks up into the inside of C one. OK? And it just forms a rotational pivot uh for the um for the C 12 axis which allows up to 50% of the rotation of your head. It's a very mobile joint. So mobile joints just like the shoulder or um or the knee are kept together by some very strong ligaments. And so there are some very strong ligaments attached to there um to the peg that go across to C one, but also up into the base of the skull and keep everything in alignment. So a lot of the injuries around here that we worry about to the ligaments, ligamentous injuries. To be honest, if the bone fractures that usually heals relatively well. OK. Um peg fractures. So we'll talk about peg fractures. Again, a very common fracture that we see most commonly in elderly people. OK. And again, low energy trauma, an old person who, who is known osteoporosis falls forwards and hits their head, has an extension type injury usually. So they fall onto the front of their head, extend their neck. What happens is C one extends backwards because it's attached to their head, but C two doesn't go quite so far. Usually because you've got some preexisting stiffness or, or, um arthritis in the neck and that did that mismatch in the movement between C one and C two puts all that force through the peg. And as you can predict it fracture through that neck part, which is where the peg joins the body and that would be a type two fracture. Ok. Um The important thing is so just like anything else, um the blood supply to the peg goes up the neck. Ok. So it goes up from the body and up up to what we call the dens, the articular process up through the neck of the dens. And so therefore, just like you might be familiar with skate forwards or talus fractures, which are the classic ones, it can disrupt the blood supply although you almost never get non unions because don't yet, we've got these very strong ligamentous attachments which can take over some of the blood supply. So you don't often get this avascular necrosis that you see with sca forward fractures. You do get fibrous nonunion where it just comes together with a fibrous growth, but you don't often get bony. No, you can often get a bony nonunion, but in general, these tend to be relatively stable injuries. Ok. Um In the elderly population, the management for the vast majority is to treat them either with a collar and there are even some studies in the school of thought is that a collar in the very elderly people causes more harm than good. It can cause pressure sores, it can be discomfort, uncomfortable and especially in those who don't tolerate the collar, ie those who might have some memory impairment or Alzheimer's or dementia, a collar can sometimes do more harm than good. And so we're moving away from collars in the most elderly population now, ok. In the younger people, this represents a much higher energy of injury, ok. So, and therefore becomes more unstable. And so we tend to treat those a bit more aggressively. And our options are to, again, the collar remains an option, ok? Especially if it's quite low and going into the body because that will heal well. But other options are to put a s one isolated screw straight up the middle of the peg that's quite difficult to do and involves quite an extensive approach. And then the other options are that we can treat them in a halo, which is where you put a ring around the head and some straps on the shoulder. We tend to use those a bit less frequently. Now you'll see them sort of gradually going out of fashion so much so that the company that makes them stop making them now, so they're difficult to get hold of. Um, and then the final thing sort of, with regards to peg fractures that we can do is, we can always fuse C one to C two. OK. So if we're really struggling, we can fuse C one to C two. So you don't need that articulation around the peg anymore. But as you can imagine, because I've told you several times already that can significantly impair your rotational movement. Um So we've spoken about most of these things already. And here just at the bottom in this picture, here is a nice representation. So you're looking from the inside of the canal towards the front of the spine and you can see that multi ligament structure. So we've got apical ligaments, ali ligaments and transverse ligaments, all of which are really strong in holding those structures in place coming down to the rest of the cervical spine. So that's predicting a bit blurry. Um This is where um this is kind of classic cervico spinal sub axial C spine. So we've got a nice body. It's a more usual shape and we've got a lamina, we've got a bifid spinous process. Um But we also have interesting in these things called the transverse foramen or the foramen for the vertebral artery. And that's where your art is coming. So it comes in at C seven or sometimes C six, depending on anatomical variation. It travels up these tubes, these holes in the lateral aspect of the suba cervical spine and then wraps itself around and over the top of C two goes into the base of the skull and becomes the vertebra basilar artery, supplying the posterior circulation. So, one of the complications of an injury to the cervical spine, especially if it involves a vertebral artery foramen is that you can get vertebral artery dissection, which can lead to posterior circulation problems and high risk of posterior circulation stroke. So this is one of the few people in spine surgery that we anticoagulate early on and sometimes we get angiograms for those. So if we're asking for angiograms of the cervical spine, then the reason for that is because there's this small artery sitting in the vertebral artery frame. And if you get a dissection of that, it can cause strokes. So you need to be anticoagulated because what we don't want is blood clots to form in within that interim dissection and then those blood clots to go up into the brain and cause posterior circulation strokes. Um because obviously, that's a, a bad thing. Um So then we come into the thoracic spine and what you'll see is the transverse processes are now starting to angle themselves posteriorly. And that's because they've got to accommodate the curve of the rib. Ok. And you've got these other extra articulation. So the what we call the costal facets, which is where the vertebral body is articulating with the ribs. Um not only a source of pain, but also, as I mentioned, a source of great stability as well, you'll also see the spinous processes are now starting to form a slightly different shape with more overlapping of these vertebrae. And so this is a relatively stable area of the spine. We don't often operate in it, but it is quite a common site from metastatic disease. And so a lot of the operations that we do including what I've got to do this week are for, for metastatic disease in this region. Ok. Um So we've got the downward slope, It's getting a larger body which confers a bit more stability and we've got the rib head articulations as well coming into the lumbar spine. This is that classic picture that we had right at the start. So we've got a nice big vertebral body because a lot of the force is being taken. We've got big intervertebral discs and we've got these straight back spinous processes that are nice and big as well with all the classic laminar as previously described. Ok. Um The, the other thing that I really need to talk to you about um because we talked about fractures, but of course, um the things that you'll read are these aas so spinal cord injury without radiological abnormality, um They're Pre MRI, that's a pre MRI term. This pretty much doesn't exist anymore because you can always, you know, pretty much see everything on an MRI. So, um but um but it is possible to have purely soft tissue injuries of the spine without any fractures. And I just wanted to make you aware of that. Ok. So you can have a fracture that goes through the disc uh between the, the force travels between the pedicles, it travels out through the facet joints, tears all the ligaments between the spine and one bit can be completely disconnected from another without any fractures at all. So just bear that in mind, you don't have to have a fracture to have a complete disruption of the integrity of the spine, the spinal column, all right. Um But as you know, the disc has got a soft nucleus, pulposus, it's got a multilayered annulus and you can get various disc bulges and things and that'll be important when we're talking about corner syndrome. Um But essentially, as it becomes degenerate, those concentric layers of um of um of the annulus um start to develop fissures and splits and that allows the nucleus pulposus to sneak its way through and, and prolapse out. OK. And this is just another picture representation of the ligaments and muscles. OK. Um So we've got at the front here, the anterior longitudinal ligaments which sits in front of it. So we're talking about the left hand picture here. So, anterior longitudinal ligaments sitting at the front of the vertebral bodies, we've then got the disc, OK? And then we've got what we call the posterior longitudinal ligament. OK. So the posterior longitudinal ligament is at the back of the body, not at the back of the spine. OK? So the longitudinal ligaments sandwich the body and, and hold that upright and contain the discs. OK. Then we've got the ligaments and flav them so cool because it's yellow and contains a lot of elastin. It's a very elastic ligament behind that. We've got the interspinous ligament. So between the two spinous processes, OK. And then the supraspinal ligament is the one that sort of runs over the top of that between the tips of the spinous processes. So we've got quite a lot of strong ligamentous structures that run all the way up and down the spine at each level. But as you can now see if we were to, I don't know if you guys can see my pointer, but if we were to run a force through this anterior longitudinal ligament, it could go through the disc through the posterior longitudinal ligament. It could disrupt the ligament and flavum and it could go in to the interspinous ligament and the supra spinous ligament all the way through here without touching any bone. And you can have a complete dissociation of the spine without any bony defect. OK. And then we've got these strong muscles um which are holding everything up posteriorly, which is just to sort of say that it's not just one muscle, holding everything up really. It was to say that this erector spiny is a confluence of many different muscles, all contributing and requiring um strength and support. OK. Um And so one of the big things that I spend a lot of time talking to my patients about is reconditioning the muscles. Um And that is because they are strong, powerful muscles, they can confer a lot of support if they're in good condition. No fracture torque is I I is complete without talking to you about the nerves and the spinal cord. That's kind of the whole point of anything we do. OK, is to protect the neurological structures as much as anything. So we've got the spinal cord, which is a continuation of the brain. It comes down, gives off a nerve root at each level. And I'm sure you'll know there are eight cervical nerve roots, but only seven cervical bodies. So in the cervical spine. So C one goes over the top of the C one body. C two goes over the top of the C two pedicle and C three over the up until C eight, which obviously has to go under C seven because there isn't ac eight. And from then after the nerves are labeled underneath the pedicle. So T one passes under T one pedicle, T two, under T two pedicle. So that's just a little foible that you have to get used to with anatomical function. OK? And they all go to supply various different things. OK? Um So on that, you'll also see a little bit about autonomic function and that's really important when we come to talk about spinal cord injuries. Um but you've got sympathetic outflow and parasympathetic outflow. Ok. So craniosacral is the parasympathetic. OK? And then um the thoracolumbar um is the sympathetic and they all have different things. So, um uh ejaculation, uh cardiorespiratory center, et cetera, et cetera. Um that you, I'm sure you're aware of the spinal cord and the nerve sit inside this um multilayered sac. There are actually nine layers um of the Jura. OK. So we've got the Jura, the Arachnoid and the pira, the three most common. OK? And sitting inside between those layers, we've got the CS F which circulates all the way around the brain. And if you really want to get into it, you can do cross sections of the spinal cord. I don't, wouldn't really expect you to know this. But what it does do is it does help you to understand the cord syndrome. So I'm just going to touch on it because I think spinal cord syndromes are probably something that you'd want to know about and it's something that I spend a lot of time dealing with. So, um what we see is the, on this blue side, these are the sensory tracts. OK. So when we split the spinal column up the spinal cord up on the blue side, we've got the sensory tracts and obviously, there's one for each side and on the red side, we've got the motor tracts, ok? Um So we've got this corticospinal tract here and what you'll see is it's split up into different sections. Ok. So, in on the inside, we've got the neck and then we've got the thoracic spine, then the lumbar spine and the sacral spine on the outside. And inherently that doesn't really make sense, does it? Because you think, well, the cervical roots will be coming out first. Why aren't they on the outside? Well, of course, we've got the gray matter in the middle and I'm sure you'll all remember that the gray matter are the cell bodies there, the anastomoses of, of the neurons. Ok. And so the cervical tracts are on the inside because the inside is where the joints are, where the joints between the the upper and lower motor neurons are going to be to allow the nerve roots to form and to escape the spine. Ok? So actually the inside is where the joint is. And so the inside is where your kind of junction is to get out of the spine. So I if you think about it like that, it makes a lot more sense. Ok. So it do these tracts leave by going into the gray matter. The gray matter are the cell bodies. Ok? The synapses and then those synapses, um those junctions between the nerves allow the nerve roots to form from upper to lower motor neurons and then they leave the spine. Ok. The reason this is important is later because when we talk about central cord syndrome, you'll see how that affects the spine just quickly. I wanted to touch on blood supply cause you'll see us wangle on about it a lot, especially in infection. But basically, it's split in half. So anterior and posterior. Ok. And if we go quickly back to this, you'll see that the anterior blood supply is gonna affect predominantly the se the pain and temperature sensation, which is the spinothalamic tract on that blue side here. Ok. And maybe some of the moor but um and some of the motor function. Ok. But if we look at the posterior um spinal artery that's supplying what we call these dorsal columns or posterior columns. And they are responsible for fine touch and proprioception sensation only. Ok. So anterior spinal artery, in fact, have a much bigger, both sensory in terms of pain and temperature and motor loss. But post IOS spinal artery, you might just lose light touch and proprioception, but you might have preservation of all of those. Now, life is never as simple as that. You never get a clear definition, but that's kind of the way it's supposed to work. All right. And then we've got all this autonomic stuff which I don't really have time to go into today. One thing I did really want to go into. So this is I'm going off piece a little bit, but it took me a little while to understand reflexes. Um maybe because I'm simple, but nevertheless, because it took me a while. I thought it would be nice to relay the understanding to you guys. So we do reflexes a lot and I've just spoken a little bit about upper and lower motor and reflexes and you'll know that for your own signs, brisk reflexes, um fasciculations, um upgoing planters, positive Hoffmann's. Why is that the case? So why when the spinal cord is damaged, do we get brisk reflexes? Well, to do that, we have to understand what a reflex is. So you get a stimulus which is the tap on the, on the tendon that stretches the um the the um receptors within the muscles which sends via the Dorsa Rogan a sensory impulse that comes into the gray matter synapses through reflex neurone pathways, not involving the brain in any way comes out and affects the response through the m neuron. So you might think, well, how does, how does an upper versus lower motor ending change that in any way? Well, for one thing, if you've got a lower moorer ending, you might have direct inhibition of this but only at the level of the injury. So that doesn't really make sense, does it? Um So why we get upper motor neuron signs is because actually the base response without any feedback from the brain is brisk reflexes, upgoing planters and upper motor neurons. Ok. As we grow and develop our brain learns to control those reflexes. And so what we actually have coming into these synapses here is inhibitory signals coming directly from the brain to in this the reflex. Ok. And it's a loss of that inhibition that causes the briskness. Ok. So it doesn't change the reflex arc in any way. What it does is we lose the inhibition and that's what gives us the upper 90 of enzymes. It took me ages probably longer than I should admit to, to working that out. So I hope that's useful. I'm going to quickly touch on cord syndromes. So we've got something called central cord syndrome, which is so cool because it affects the center parts of the cord. Ok. And as you'll remember, the neck was inside of the motor tracks and then it was the thoracic spine, which is the chest and then lumbar spine and then sacrum. Ok. So we, what we can imagine here is that the upper limbs are going to be more affected than the lower limbs. Ok. And all of a sudden because we've learned some basic anatomy, the cord syndrome starts to make sense. So central cord syndrome, upper limbs are more affected than lower limbs. Ok. And because the upper limbs are more affected than the lower limbs, that gives us a really nice central cord syndrome picture. And we can understand why it is because it doesn't inherently make sense because the lower limbs will have to go through this. But now it does. Ok. And central cord syndromes actually a very good prognosis. Ok. They tend to recover quite well. Tends to happen more in the elderly people with preexisting, um, degeneration. Think of it more like AAA, really nasty bruise of the cord. Although that's not quite true, but that's how I like to think of it. It tends to recover quite well. Then we've got anterior cord syndrome, which is a disruption of the blood supply as we've spoken about that has motor loss, pain and sensory loss, but preservation of the dorsal columns. And then the one that everyone likes to talk about because it's slightly more difficult to understand is bra ayro, this is a a hemi section of the cord due to stabbing injuries. Now, it is actually having said that you never see it. It is becoming more common in some places, knife crime is increasing, especially places like Nottingham. So I think the guy, the guy, the inner city areas are seeing more of these penetrating injuries, but essentially loss of half of the cord gives you loss of half of the function. What you need to understand is that the spina thalamic tract crosses over just at the level or just above the level that it's coming out to supply what it's going to supply. So the pain and temperature is affected on one half of the body. Ok. But the rest of the the rest of the tracts in the spine have already crossed over somewhere in the midbrain. So the rest of everything else in the body. So the motor, the fine touch and proprioception is all affecting the other half of the body. So if you've got pain and temperature loss on one half of the body and then loss of motor function and sensation to fine touch and proprioception on the other half, that's a brown Sicard syndrome picture. Ok. So that's why again, basic anatomy can give us the answer to most things. Then we're gonna quickly touch on Cor Corner syndrome. And this is probably the thing that people get the most worried about. So see a fracture of the spinal cord of the spine. Um The treatment's relatively, you know, sh the decision making from a, if you're not a spinal surgeon or you're not the orthopedic surgeon on call is relatively straightforward, isn't it? It, it's broken, let's lay them flat, let's keep them in a position of safety. Let's keep, keep them low growed. Let's do a full, full neurological examination. And then we'll call the, the spine team and work out what's going on, but it's relatively easy to make those decisions and keep people safe. The way to keep them safe is to keep their spine still. Um But in Cor Corner syndrome, the decisions are much less clear. Ok? There's a lot of gray zone. Ok? And I'm not pretending in any way that this is easy and I don't think anyone has the right answers. I don't pretend to be perfect. At it, neither does anyone else. Ok. Um So the first thing is what is the quad quer? Ok. So the spinal cord finishes at L1 usually. Ok. Different in Children bear in mind but in adults, it's the lower border of L1 and then below that is the quad quer. So it's really the, the qu qu is just an anatomical description of the nerves as they have left the spinal cord. So they are now lower main ne range, but they haven't left the spinal canal yet and therefore they are vulnerable to injury. Ok? It is a syndrome. So you don't get Corder Kina syndrome from an MRI scan. Ok. An MRI scan does not tell you whether you have Corder Kus syndrome. All right, what it tells you is whether you have a big disc prolapse, that might be a cause of the symptoms of Corder Kina syndrome. But it is a syndrome. It is not a radiological diagnosis. So, one of the things we're really plagued with is MRI reports that say there's a big central disc prolapse. The, you know, emergency neurosurgical opinion is, is recommended to rule out, you know, the patient might have cord quer syndrome or some other such phrase. OK. That's really that I understand why they do it and they're covering their own bucks. But the honest answer is until, until someone sees the patient and sees them, no one can tell me whether they've got cor corner syndrome or not. Ok. So it's a syndrome characterized by but not including all of sado anesthesia, urinary retention with overflow incontinence. Ok. And that's quite important. So, um stress incontinence is not the same thing. What they get is pain, less urinary retention because they get autonomic dysfunction, the nerves to their bladder don't work and because the nerves to the bladder don't work, they can't feel that the bladder is filling up. ok? And because they can't tell that the bladder is full, eventually it gets so full that the detrusor goes into spasm and causes incontinence. Ok. So that's how this um sort of sequence of event goes if they have true Cor Cor syndrome me in the more advanced cases that can develop into fecal incontinence, but that tends to be a very late sign. Ok? Um And you also get bilateral leg symptoms. Ok. Now, bilateral leg symptoms on in and on itself is not, is no longer being considered a red flag. These red flags are changing and it's a bit and there's a new pathway. But I would counsel you to just take a step back and think about the whole picture of what the patient is presenting with. Ok. If patients have bilateral leg symptoms, they're much more likely to have a very significant disc prolapse than if they only have unilateral leg symptoms, neither of them are absolute rules, but you just have to put all of the picture together and say, does this patient have features that are consistent with a huge disc prolapse that's causing autonomic dysfunction. Um In reality, it is a spectrum and there isn't. And I'll be honest with you, some of my spine colleagues will have a very different threshold to say someone has Corder Corer syndrome with a big disc prolapse than I will. So I might not operate on people who one of my colleagues would operate on. And they might say, well, that patient had Corder Corus syndrome. And I might say, well, and if I'd seen the patient, I might not have operated on them. In reality, that's a personal decision based on experience. And we don't expect to know all of the answers. But what you can do is make a reasonable assessment. So if you get someone who comes in who's got unilateral sciatica, and they had one episode of incontinence when they're in a real spasm of pain because they couldn't make it to the toilet on time because their pain was so bad, they couldn't get there, but they needed to go. That's not the same thing as having painless urinary retention with overflow incontinence. Is it ok. So that is an important thing. And there are some new GF guidelines coming out and we're working in Norwich, but every hospital across the country should be working towards now having um emergency department access to MRI scans and I'm not saying that you should go to your ed and say, oh, you should have access because the pathway is, this is a very new thing and it's coming in very slowly and there's lots of stuff to iron out. As you can imagine that creates a lot of resource that needs to be sorted out. But eventually in, in due course, what's probably going to happen is the accident and emergency departments will have access to a Cor cor MRI just like they do for a trauma ct for trauma. And um, the aim of that is to reduce litigation. Ok. So, um, the GF people have basically identified that it's cheaper to scan everyone who comes into the ed department with any kind of red flags and it is to miss one or two every year. Um because the cost of missing them litigious, sorry, litigation wise is, um, is pretty darn high and the cost of an MRI scan is relatively low. So you can do thousands of MRI scans to stop one litigation, ok. And of course, that's nice, good for the patients too, ok. Um, but the MRI scan is to confirm your clinical diagnosis. It is not um in and of itself uh diagnostic of cord coa syndrome. Ok. So the clinical picture is I is vitally important. All right. Um One thing I haven't put in here that I've just realized that a lot of you will be familiar with is the bladder scan, the dreaded bladder scan. Ok. So, um this is something that came in about three or four years ago, maybe five years ago. Now, after a paper released from Nottingham where they looked at all retrospective. So that's one thing retrospectively looked at all of their patients with who came in query corner syndrome. And their policy was to bladder scan, everyone. Ok? And they did bladder scans on people regardless of whether they went on. And then what they did is they looked back and divided out those who went on to have surgery for Coral syndrome. I had a big disc prolapse and the other symptoms versus those who didn't and then reached a magic number of 200 mils. So, and this is being misquoted a little bit. And um, uh, and I think overused and, and over reassured. Ok. So number one, you don't have to have urinary retention and overflow incontinence to have cord quina syndrome. Ok? There is something called cord quina syndrome, incomplete i without retention. Ok. So that's the first thing to say. So you do not have to have urinary retention. Ok. But the second thing is, um, the, the paper actually said, if you had a bladder scan of over 200 mils, you were 93% likely to then go on to need surgery for a Corina decompression. Ok. What people, so what it doesn't say is if, if your bladder scan is under 200 mils that you definitely don't have quad corer syndrome. Ok. And so we do have to be a little bit careful with that. The negative predictive value. I if you don't, what's the chance of if the scan is normal, you actually being normal was a lot less? Ok. It was in the, I think it was in the low 80%. Ok. Which still means you're missing a vast number of people. So the negative predictive value for, for the bladder scan is not, is not the same thing as having a high positive predictive value. OK? And so I caution people to um to say, oh, the bladder scan is normal, everything's fine. It's all part of the picture. OK? You can't use any one piece of the puzzle and come up with a diagnosis. You have to look at the whole thing, you have to speak to the patient, but it is an important part of the puzzle. OK. So I would counsel you to use it, but just to understand what it's really telling you um rather than just to blanket 200 versus not 200 because that's not quite what the paper says. And if you end up the papers from Nottingham, just have a read of it. It's a great paper actually very well done, but it is retrospective as well. Um This is another thing just about um documentation because it's another bug bear of mine. So we've got dermato and myotome. So a dermatome is sensory and myotome is a muscle which is in innervated from each nerve root of the spine. Ok. Um We've spoken about um, upper and lower mouring signs. Of course, the cor quer is low mouring. So if you've got upper motor neuron signs, consider scanning the whole spine rather than just the quarter because you probably, it's probably not a cor quer lesion. Ok. It's probably something cord level. Ok? And there is some overlap and variation in um, in dermatomes and myotomes. But if you haven't seen this, I'd encourage you all to use it to teach yourselves a spine, neurological examination. OK? Because it literally tell it's an idiot's guide, it tells you what to do. It tells you exactly where to do it. OK. So, um, over on this far left hand side, um, we've got the motor function, OK? So we've got C five C, six, C seven, C eight T one. And it literally tells you exactly what muscle group to test. OK? And you give it a score out of 5. Um L2, 2345. And S one again, it give, it tells you exactly what to test. Give it a score out of five. OK? In the middle, we've got light touch and pinprick, we know that's important because, because we know that they're carried by different um, fibers and you don't necessarily have to fill the whole thing in for a examination. We only really use it for cord injuries. Um But it gives you an idea, especially if you're not used to examining patients and a framework from which to examine them. And each one of these little dots on this person here tells you L2, is that there, L3, is that done there? L4, is that done there? L5 is up there. So it tells you where to test the sensation and where is most reliable. And so if you're a bit rusty with your neuro exam or you haven't quite got it down, have a, just have a little read of this, print it off and write it on there. It, it, in fact, it actually looks very professional. It's a nice way to document the exam. Um just make sure you put the patient name, your name and the date and time because if people have lots of these so often, like for instance, our cord patients get one every day. Um then it, it's important to know which one is which OK. Um But this is my little tip and trick. Um if you're struggling with your neuro exam, get on the Asia American Spinal Injury Association, just type in Asia PDF or Asia chart PDF. Um And uh you find this and this is a really good basis for your neurological examination. I love it. I think it's brilliant. It's not perfect, but it is good and it, it, it's a really good starting point for you to hone your examination skills. OK. Just a quick one about spinal cord injuries just because it's um interesting to know what difference does the level make? So if you're above C four, that's gonna affect your cardiorespiratory center, that means you're ventilator dependent. Ok. Or highly likely to be. Ok. And C six, if you, so two levels down, we're not talking about very much. We what, a couple of inches in the spine, but you can use a motorized wheelchair cause you've got a little bit of hand function, OK? Um And C 78, hand function is preserved. And importantly, triceps, function preserves. So that means you can push. Ok. So it means you can transfer, it means you can manually propel a wheelchair. Ok. So between C six and C 78, you're talking about a huge difference. OK? One level of the spine, massive difference in functional outcomes. OK. Thoracic spine is unlike, you know, not much changes in the thoracic spine other than sensation, if I'm honest, OK. And a bit of um autonomic dysreflexia. Um at L2, you can stand with orthotics to control your knee. OK. So at L2, you don't have your quad, so you can't extend your knee. OK? But if you can get the knee straight with L2, you've got enough of yours os working that you can stand up. Ok? If you're at L4, that means your knee is ok. But it means you probably need an ankle orthosis to help you stand. Ok. And the final thing is you can get sacral sparing, ok. So at any level, you can have preservation of bladder bowel and sexual function, but you can also lose, lose bladder bowel and sexual function at any level. Ok. So any spinal cord injury can give you preservation or loss, ok? And that is not a good or a bad sign. Obviously, it's better if you preserve your bladder and bowel function because it has a big impact on quality of life, but at any level, it can be affected. OK. So in terms of fractures, my counsel to you is to take a really simple approach, describe the level. OK. Cause that's what the most obvious thing that you need to know. So is it in the C or spine, which level is affected? Ok. And is it stable or unstable? And there are lots of different ways the most common one and the probably the easiest to understand is the, the knee classification, which is this three column theory. OK. So basically you split the spine into three. So the anterior column is the anterior um half of the vertebral body which encompasses that anterior longitudinal ligament that you'll remember. OK. The middle column is the posterior half and that posterior longitudinal ligament. OK. So they're really big key confers of stability. OK. So e the for the first column, anterior longitudinal ligament, second column, posterior longitudinal ligament and the pedicles. OK. And then the third column is everything behind that. So the facets and the interspinous supraspinal ligaments, OK? And the Denne theory basically said, if you've got one column affected, it's a stable injury, two columns or more is unstable. Um And you should consider doing something about it. Most of the newer classifications have gone to a two column theory, but I wouldn't get bugged down too much. Um Most people, if you speak to them will understand the three column theory. Um And if you use that as a descriptor, then it's a good place to start. Ok. Ok. If you have, so if you have a high energy trauma, assume an injury until proven otherwise, I think probably that's the mantra of a lot of people now and that with the trauma ct, things have changed a lot. Ok. But if there's any doubt and there there's a good mechanism, try to disprove an injury rather than you, um, think everything is normal. Ok. As I said, it's normal to have a normal CT and an x-ray and still have an unstable injury. And this is kind of a depiction of that. So the force is going through the anterior aude ligament through the disc, through the posterior longitude, ligament, disrupting the facets and disrupting everything else. So that's a very unstable injury. It's not gonna heal because ligaments heal poorly. Ok. And so that would need fixing more than most of the bone injuries and really really beware the ankylo spine. Ok. So this is ankylosing spondylitis. OK. So you got what we call these syn desma phys, which is basically um inflammation of the anterior and posterior longitudinal ligaments. OK. And the, and um and uh calcification of the disc space, OK. Calcification and ankylosis of the joint. OK. Now, this is an x-ray of someone who had a fall and hit their head, who's known to have ankylosing spondylitis, ankylosing spondylitis patients have very poor bone quality, ok? And they are, it's like having severe osteoporosis. And the reason for that is because the forces going through the bone are very different, ok? Because it's ankylosing and it doesn't move, it's got a lot less forces. And so the bone gets resorbed because the body says, well, I don't need it. Ok? Um So and closing spondylitis assume injury unless you have good 3D imaging. This is an x-ray of someone who had a fall and hit their head. This is that same person by the time they were put in a collar and had a CT scan. OK? And you, what you can see is so I completely agree. You can't see that fracture and I'm not, I'm not saying they did anything wrong. You can't see that fracture on an x-ray. I completely understand that. OK? But an x-ray is not the right way to look at that person's spine. OK? A CT scan is OK? And the worst thing you can do as, as proven by this is to put them in. What we consider is it to put them in to what we consider an anatomical position? Ok. So keep their head in a position that's normal for them. OK. Wrenching their head back into a collar, extends the fracture displaces it and cause more harm than good. I know everyone probably knows this, but nevertheless, it's an important thing to um, to learn. OK? And you don't wanna learn it the hard way. Um So how do we decide who to operates on? Well, there's quite a lot to consider here. So the first thing is you got to look at the patient. Are they fit for an operation? Are they going to survive it? And what will their body tolerate? Will they tolerate a prone anesthetic? If I have to put them prone, will they, is their bone quality good enough that I'm gonna get really good fixation with screws or am I just gonna be putting screws in that are gonna pull straight out like an enclosing spondylitis? Um And so the, the patient is a key consideration. Ok. So some people cannot survive surgery. Ok? And if they cannot, then you can't do it. Ok. There's no, there's no benefit to it. Ok? Um Then you got to consider the injury. So the energy we've spoken about, is it stable versus unstable? And you can have a, have a guess of that with some of the um with some of the three column theory that we've spoken about and an understanding of the anatomy of which bits um are broken on which bits aren't. OK. If it's unstable, that doesn't necessarily mean it needs surgery. Sometimes we can control an unstable fracture by bracing it or treating it a, in a collar and uh modifying activity. OK. So we don't always have to fix something that's unstable. We just have to treat it carefully and keep a very close eye on it. Ok. So there are lots of unstable fractures that don't go on to need surgery, ok? It's just, we just have to treat them in a respectable way, ok? Um, if there's a spinal cord injury, so the other things that factor that affect surgery is if there is a spinal cord injury, if you have a spinal cord injury, the benefits and risks of surgery start to change quite drastically, the risks go up very significantly because there's a chance due to the hypo tension that you get with anesthesia that you could make that cord injury worse. Ok. But there are benefits of doing surgery, especially with nursing and pain. And so if you've got a ST an unstable spine that moves around a lot, it's very difficult to nurse, but also it can cause other problems such as autonomic dysreflexia, um which is basically a malfunction of the autonomic nervous system and painful stimulus such as blocked catheters such as pain from a fracture such as pressure sores, such as other things and even infection can cause an out of control autonomic response and cause this cascade of autonomic dysreflexia. Ok. Um And then we talk about the bone quality. So will it work? Can I actually do this operation? Is it physically possible? Ok. And so when you're, when you're making a decision, this is why I'm telling you that it, I can't really, I don't really see the benefit of talking to you about each individual fracture because each fracture pattern on an x-ray comes with an in individual patient comes with individual neurological deficits. And the decision is never as straightforward as, oh, this one, we operate on this one. We don't. OK. And what I really would counsel you is that those decisions are really, they take a long time to sort of learn and build up. Ok? And there's a lot of judgment and there's a lot of variation between spine surgeons as well. Some people are very conservative and don't operate on much and some people are very aggressive and operate on a lot. There are benefits to each argument. So the conservative people, every now and again, they'll make the wrong decision and someone doesn't have an operation when they should have it and then they have to have much bigger operation that they could have easily had a small one at the start. Ok. But if you're very aggressive with the surgery, there might be complications during the surgery and you might make someone worse rather than better as with anything. There's a happy medium and it's all judgment call. Ok. But if you can understand some of the basic principles of what the spinal column is, which bits are more vulnerable of the spine. So we talk about the junctional levels, why spinal cord injuries are different to normal injuries and why the why we make the decisions, how we determine stable versus unstable with those different columns in which parts are affected and how the ligaments are affected. And then you can start to understand a little bit why we make the decisions that we make. In reality, no one's expecting um no one's expecting you to make decisions about difficult fractures. Ok. But what you can do is you ce especially if you're a. So I'm told this is mostly sho si I know there are probably some other people as well, but especially if you're interested in orthopedics is start to look through the scans yourself. Have a little, look through, have a little um look at where the fracture pattern is. Try to make a picture in your mind as to whether this is a stable or unstable fracture. Have a look at the patients yourself, examine them and say, is this patient someone who's really good and fit for surgery or is it someone who's not? And then just before you make your final decision, say, is this something that we can treat in a collar or a brace? Is it going to control it well enough. How unstable is the fracture? And then, um, then you can sort of start to formulate your own management. A lot of the problem with being an sho is it's easy to fall into the trap of letting other people make your decisions for you. And the trouble is when it comes to making a decision, you won't have anyone else to make that decision for you. So the best thing to do when you're an S hr going through training is to start to work out why people make decisions to ask questions and then start to work out how um you would do each individual thing and you don't have to get it right. You don't always have to get it right. But you can go to your registrar or even the consultant, whoever's supervising you and say, oh, I've got this patient, you describe the fracture? Really? Well, I think this is unstable but I think it might be manageable in a brace and they'll say, oh, that's not quite right. But yeah, you know, and then you can have a discussion but the people who aren't interested and just say, oh, I've got this fracture. What shall I do with it? Then I'm much less likely to give you an explanation because you're not thinking about it and you don't seem interested. Does that make sense? So sit down, have a think about it, have a look through and you'll get much more out of each individual case. If you do that, never forget. Infections and tumors. Ok. Um Infections can cause instability and collapse. Tumors can cause instability and collapse and a lot of deformity in pain. And so those are both causes and something that you'll see on um on scans that are and on and during on call that are unstable that cause pain, they cause neurological instability. Um but they have very different managements. It's not really in the remit of this. Happy to talk about that a bit later, MS CC. I can talk for hours about. Ok. And um but just be aware that there are other things other than trauma that can cause instability. Ok? Um Communication is key. All right. Um There's these can be really life changing injuries for some people, especially the cord injury patients. Um repetition of the same information and gradual drip feeding of information is useful. Ok. Sometimes we can have psychology inputs as well involve the families and people who are going to have long recoveries and be honest about expectations. Ok. So people don't want you to tell them that they're fine. I mean, they want you to tell them that they're fine and that's the easy thing to do, but they won't appreciate it and you're just setting the next person up for an even more difficult consultation. Ok. So we've talked about quite a lot of things. I haven't gone too much into each individual fracture, but I'm not even shown you too many fractures other than that N one fracture because as I said, I don't think it's really talking through lots of individual fractures is completely useless to you. Um, other than showing you lots of different x-rays. And the reason for that is the, it's the principles that are important. I can, I can sit here for hours and just show you lots and lots of boring x-rays and you'll get nothing out of it. Ok? Um The key is to now take this grounded knowledge and try to bring that into decisions and try to start making your own decisions. Start thinking about the scans, start talking with your seniors about why decisions are made and that way you'll start to really get a good understanding. Ok? Any questions? Oh, hang on, I got a lot of questions in the box. So let me stop sharing for a second. Ok. So I've got one that's ok. Um So I've also advertised this around the a department quite a lot. Um And in the base of the first principles of management, um a lot of questions we ask, you know, as the orthopedic team is, can we sit the patient up? Um is there, I assume it's not a hard and fast rule as everything we just discussed. But lumbar lumbar juice can sit up to 30 et cetera, et cetera. Is there a rule that you could potentially follow or would you always suggest discussing with yourself first? Um, uh, it, the, these things are always a balance? Ok. So, um, there are benefits to sitting someone up. It's definitely a whole ton easier to eat and drink if you can sit up a little bit, that's for sure. Ok. And that's an important thing. Um, although you might want to keep them in by mouth if you're considering surgery, obviously. Ok. Um, I in general, the safest thing if you're, if you're unsure is to keep them flat. Ok. Um, and the reason for that is because obviously you've got less force going through the spine. So flat bed rest with a head, old log roll is by far your safest option. And so if you're in doubts and you think they might have an unstable injury, that's by far the safest thing you might, you know, someone might touch or something, but you're not going to do anyone any harm. You're not gonna get hauled over the call for that decision. Ok. Um, how so in reality, sitting up to 30 degrees, unless you have a, a wildly unstable fracture is unlikely to make a significant difference. Ok. Um, in terms of, um, to your stability, as long as you keep them continued flat bed rest. Ok. So as in they're laying flat in bed, they're not rolling over to one side. Ok? Sitting up just a little bit if they can tolerate it is usually OK. What you might, so what you might now be able to work out is rotational movements are awful for the spine. OK. So even if you sit them up, that doesn't mean they can roll over. OK. So a lot of, a lot of the reason people don't like sitting people up is because it gives people a false sense of um a false sense of stability. OK. So people think of that sitting up to 30 degrees, their spine must be stable. That's not the same thing. OK. Um What you really want to avoid in a, in an unstable fracture is rotation. OK? Because it's rotation, that's going to be the most unstable movement. OK? And rotation is the thing that's most likely to damage the spinal cord as well. All right. So what you want to do is avoid rotational movement. So a lot of people don't sit people up and the reason for that is because it gives you a false sense of stability. OK? Um But in general, a little bit of sitting up to 30 degrees is often a really nice compromise for eating, drinking comfort and also for the chest. OK. But yes, as you say, there isn't a hard and fast rule. Um You do have to base individual decision on its merits, ok? Um And actually it's the cervical spine that's gonna be most vulnerable to that ok, because you've got that big heavy head that's gonna start to lean forward and push forward. Ok. So the further you bring the spine up, the further the head's gonna wanna go forward. And so it's the unstable cervical injuries that I keep the most flat, thoracic injuries. I, I rarely have to keep flat. Lumbar injuries is very difficult. Depends on what's going on. Ok. Thank you. Yeah. So I suppose the taking messages, as you said, they consist up to 30 but if they need to be rolled for nursing care, that's back flat again. Uh Well, it's i it's a local. Yeah, so flat. Yeah. Ok. Uh So hang on, I'll just go through the questions. So some of that's about MRI. Uh is there a specific time period after which CS symptoms are termed chronic CS? Ok. Um uh No. Um So really the Cor Aqui syndrome. So basically what you're talking about really is that, um, there should be, uh so the, the guidelines and the evidence would suggest that you should do a decompression within 24 hours. Actually, the evidence suggests 48 hours, but the guidelines say 24. Um because the guidelines say 24. So the lawyers get their, because of their twist about, but the, the evidence is actually 48 hours. Don't get me wrong if I had cord kina syndrome. I want that discount as A S A, you know, as soon as possible. I don't want to be waiting until, until, till two days time. Ok. So, um, it, it is a bit of a double standard. I, I admit. Ok, chronic Corina syndrome symptom. Ok. As in, um, they've had them for a long time. Um, really is anything after, after a week? Really? I would say, um, I don't know, I'm not aware of a definite definition. It's not really a term that we use, if I'm honest with you. OK. Um So you either have Cor Cor Syndrome and it's an emergency or you don't. Ok. Some people have had Cor Cor Syndrome and they have the long standing sequelae of that. Um which I, I'm not sure if that's what you're talking about, but that is sort of chronic neurological deficit from previous Corina syndrome. Does that make sense? Um The next thing is, is there any examination that can detect stability of the fracture? Ok. So, yes, there is. OK. So if you have posterior pain, uh there's pain to palpation over the posterior aspect of the spine that would infer that you may have disruption of the posterior elements. Ok. And if you've got disruption of the posterior ligaments, so the those interspinous ligaments, then the fracture is much more likely to be unstable. OK. So, uh pain to palpation on the posterior elements is a bad sign, especially if there's a lot of ecchymosis. All right. Um The second thing is you'll remember all the way back to my original definition is the ability of the spine to withstand normal physiological conditions without pain or neurological deficit. So one thing that we sometimes do with these fractures that we're trying to decide if they're unstable or not. No, not the grossly unstable ones is we get an x-ray with them standing up. So we see if they can stand up and if they can, we get an x-ray with them standing up. If there's way too much pain to be able to stand, that's a sign of instability because the pain is not able to withstand normal physiological load without causing pain or neurological dysfunction. And therefore it's unstable by that definition. But also if you stand up and you take an x-ray with them standing up and the spine is starting to collapse down, then you know that that again is unstable. OK? Now, I'm not saying you should get a standing x-ray on everyone straight away. That's something that I decide rather than something that the sho or the registrar even on call decides. Ok. Um So that is um sort of a, a higher level sort of thing to do, but we often do test stability in those that we're not quite sure whether it might be stable and how it's going to behave by subjecting it to normal physiological conditions. OK. So that's one way you can do it. Um But other than that, there isn't really one examination finding. OK. So obviously, if you've got a neurological deficit associated with a fracture that is by definition unstable because you have a neurological deficit and the spine must be unstable for the nerves to not be protected by that much. Ok. That again, that doesn't necessarily mean the surgery, but it means that the injury is unstable. Ok. Um So that's the only other thing really. Um So next question, how do you differentiate between anterior and central cord syndrome? Ok. So if we go back to the uh um let me show you the slide again. One second. Sorry. Uh If we go back, I'll shut it down. Sorry. Um If we go back to the spinal cord anatomy in your mind, ok. Um What you have is you have in the anterior cord syndrome, you have loss of everything except for what we call those dorsal columns. Ok. Dorsal being at the back. Ok. So the dorsal columns take fine touch and proprioception. Ok. Central cord syndrome. Sorry. So anterior cord syndrome would affect everything else. So, loss of pain and temperature loss of motor function and it's usually a vascular phenomenon. So you usually get total wipeouts of everything. Ok? So loss of those usually quite sudden loss of pain and temperature and motor function, all right. But preservation of fine touch and proprioception. Ok. Central cord syndrome is very different. You get upper limbs, more affected than the lower limbs, ok? And your fine touch and proprioception is also affected Ok. So central cord syndrome does not spare those dorsal columns. And so your fine touch and proprioception is also affected. So it's the central cord syndrome is the combination of upper limbs more than lower limbs. Ok. And the fine and touch and proprioception are also affected. Nothing is hard and fast. Ok. So some syndromes will overlap with this and obviously everything is a judgment call and sometimes you have to look at the imaging as well. OK. But um the difference between anterior and central is the fine touch of proprioception and the upper limbs, more the lower limbs. That seems to be all the questions unless anyone has anything else. I don't know how we're doing for time. We're doing great for time. Some margarine. So yeah, good. So sorry. Last one for me, Miss Marge. Um So looking at what fractures, looking at the three column of injury, um anterior injury, anterior columns clearly affected, but that Teri column, I always think it's a bit of a uh because it's not the whole column, the PLL is intact. So does that, can we use that classification system for wedges or is it a bit specialist? So um II I split my, we so I split wedge fractures up into two distinct groups? OK. So you've got the young high energies and the old low energies. OK. So young high energies. OK. If it's just an anterior column wedge, um I would. So for the young high-energy injury patients, I would almost always get an MRI scan, ok? Um, because there's a, a chance that, that anterior wedging is just the front part of a, of a ligamentous injury, ok? Because that's a much higher energy injury. So I'd get an MRI scan for those. Ok? And so that's gonna tell you a little bit about stability anyway. But if, if the MRI scan shows that it's just anterior wedging and you've got less than um less than 50% loss of posterior height, then you're probably OK. All right. Um Because especially if that posterior lo and tu it's intact. If however, you've got loss of that posterior longitude ligament or you've got posteriors, interspinous ligament disruption, then that's an unstable fracture. OK. Now, the old people wedge fractures. So the osteoporotic wedge fractures, that is a very stable configuration. OK. So that is literally the bone collapsing into itself, even if you've got the posterior loss of height. OK. You can even have what we call a vertebra planar, which is actually a very stable thing because it can't collapse anymore. Does that, does that make sense? Ok. So even if you've got a, a plano where you've got complete pancaking of the vertebral body, that's still a stable fracture. So, um when anterior we fractures in the elderly, we get not at all excited about. And the re don't forget that the reason those bones fail is because the bone is too weak to do its job. OK? Just like the neck of femur, just like the distal radius is OK. So me trying to put screws into that bone to support it are gonna be um you know, fraught with danger. All right. Um One thing we can do is vertebroplasty and we do a lot more of that in knowledge than we do than a lot of other places. Mostly because we got someone who likes doing it in the form of our specialist radiologist. Ok. Um But vertebroplasty is essentially putting some cement down the pedicle. So like you would a pedicle screw, but you just put a tube down and you put that liquid cement in and it interdigitate between all of those trabecula filling the gaps between the bone with cement to try to add some more of that mechanical stability and help with that pain. Ok. Um So that's uh another sort of really good option for some of the elderly people and think of that like a pain relieving procedure. Ok? It doesn't change the outcome. It doesn't change in what they like in two years. It doesn't change the mortality, it doesn't really change the deformity. What it does change is the pain that they have, especially in their immediate recovery. Ok. Uh So apologies I joined. I know standing x-rays were discussed. Why do we need these in thoracic and lumbar fractures? Ok. So the reason we use standing x-rays is to subject the spine to physiological loading. Ok. So if you stand up and your spine is maintaining, so if, if you've had all of the imaging and it shows we think this is a stable fracture. Ok. The final test is to get you standing up. If you can do that, we get you an x-ray. And if you can stand up and your spine stays where it's supposed to be and everything is as it should be when you're standing up, then I know that your spine can withstand those physiological forces. And that's a very reassuring thing. And it means that your spine is much more likely to be mechanically stable and we can get away without doing anything or just a bit of support. Ok? Um If your spine shows signs that it's collapsing down and it's not able to, with, to maintain its normal alignment under those physiological loads, then that's much more likely to be an unstable injury. Ok. So that's why we do that because if you, if you think about it, all of the imaging that we get up until that point is supine, it's without any load on the spine. Ok. And so we don't have any real time physiological um sort of stress on the bone. And so things can often look very different when you subject them to that stress. And so the aim is that you subjected to the stress so that you can see how it behaves on the physiological load and that gives you an idea. Um, and it's all about building up the whole picture, but it gives you an idea in those fractures where you're not quite sure whether it's stable or unstable. Often we use it to reassure ourselves as much as anything, but also to give us a baseline from which to go forward. No problem, no problem. You're very welcome. Ok. I, I quite like teaching. I enjoy it. It takes a bit of time to prepare and it's not always possible to do it sort of when, when suits everyone. Um, but I'm more than happy if there's any other questions that people have. Um, I don't know if you can watch it later. I think Green has recorded it. So I assume so. Um, but I'm more than happy to answer questions. Ok. And if anyone is in the Norwich area and wants to come to some spine clinics and things you or surgery, just let me know. Ok, drop me an email. You can't just, it's difficult to have you just turn up because, um, what I, I have is lots of different people, especially in the operating theater all at once and we have medical students, et cetera. But if anyone who wants any questions, wants to run through anything I've covered today or has any specific things that they want to cover or wants to come and see a spine clinic, then let me know. All right. And I'm more than happy for one or three people to come through everything. I put my email in the chat. Good question. Uh Thank you very much, Mister Marm for your time today. And the excellent teaching session. Um The video is going to be uploaded to the UE uh uh page uh as usual with all the previous sessions there as well. And hopefully, Mr Mar, we can uh have you back for uh uh elective spinal uh conditions. Uh Is it, is it generally in the evening cream or is that just because that was when I was available, uh generally in the evening? Just to make sure that people get some time to? Yeah, I mean evening sus me quite well other than that, other than the little people. Ok, around but yeah, evening su me quite well. Yeah. Ok. Thank you very much. I appreciate the time. Great. Ok. So, um just let me know if you have any questions more than happy to run through some things. Um, but I hope you found it useful. Cheers. Bye bye bye.