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No, no. Hello. Good. Uh Good evening everybody. Um We, I'm the, I'm one of the orthopedic doctors at Medway Hospital. We are gonna start with the basic uh teaching sessions on basic orthopedic emergencies where we navigate through the common emergencies that we see as orthopedic doctors. Uh It's gonna be divided into five different topics. So we uh we're gonna do it like a weekly session. So, um now I will just hand over to my colleague who will start with the first session today on Q now. Thank you and you. Hello. Good evening everybody. My name is Doctor Mukerji. I'm one of the Clinical Trust fellows in Trauma orthopedics at Medway Maritime Hospital in Kent today. Um I will be presenting a session on the basics of Corna syndrome, how to identify it, how to do the initial management and how to refer it for further treatment. Uh So these are the outlines we'll be seeing in the introduction, etiology, symptoms, how to examine how to diagnose what are the differential diagnosis, the investigations treatment and the referrals. Ok. So first of all, an introduction regarding cod equina. So, um we know that our spinal cord ends at the level of the upper lumbar uh section. And after that, it ends in the Conus medullaris. And then the nerve roots continue downwards into the spinal canal as the cord equina. This is known as the cord equina because of its resemblance to a horse's tail. Uh So the Corina essentially comprises of the nerve roots from L2 to L5 and then SS one to S five and the coccygeal nerve. Um these nerve essentially send and receive messages to and from the lower limbs and as well as the pelvic organs and they also uh comprise of the autonomic nervous system. Um So why are we uh concerned about Coria Quina syndrome? As you can see, Kai Quina syndrome is a very rare uh presentation uh 1 to 3 in 100,000 population of patients who are, who are having radicular or back pain. Um The reason why Coria syndrome is a cause of concern is because if it goes unrecognized or if surgical treatment is delayed, this may result in permanent loss of bladder and bowel function, loss of sexual function and lower limb paralysis. So, missing a diagnosis of cordia equina leads to a huge detriment in the quality of living of the patient. Patients will continue to experience ongoing severe disability despite prompt treatment. However, if it is treated before symptoms become severe, this can reduce the risk of permanent disability to a huge extent. So what is Coria equina syndrome. So as we know what cordia equina is, so it translates from that cord quina syndrome is when there's a dysfunction of multiple lumbar and seal nerve roots. When does it generally happen, it happens when the nerve roots in the lumbar end cycle, spinal canal are compressed, cutting off both the sensation and the motor uh function. The nerve roots that are involved in the functioning of the bladder or bowel are also very, especially vulnerable to the damage. Um However, it is important to note that although Corona Syndrome has a list of uh signs and symptoms, it never has a set clinical pattern. No single symptom or combination of symptom has good to diagnostic accuracy. So, and and along with that, if we find these negative physical tests, we cannot definitively rule out ca syndrome syndrome if the patient mentions he or she is having subjective symptoms. Yeah. So we need to keep that in mind whenever we face a patient who is having one or two symptoms or red flag signs of cordia equina. So, what are the potential causes of cordia equina syndrome? Um The commonest cause is a large lumbar disc prolapse and it is the uh almost like uh most of the cases we see of Corona is due to due to vertebral disc prolapse. However, there are other uh comorbidities which can cause Corona Syndrome, like spinal lesions and tumors, infections or inflammation, lumbar spinal stenosis, violent injuries to the lower back plus abnormalities, spinal arteriovenous malformation, spinal hemorrhages, postoperative lumbar spine surgery complications, as well as spinal anesthesia. In some cases, as you can see in the picture, uh it's showing uh herniation of uh lumbar vertebral discs and it is pressing on the spinal canal. Uh So what will be the symptoms that uh comprises cauda equina syndrome? So, um this, we need to keep in mind because there are some nuances in it. Uh There is a time um of onset that we need to keep in mind. So, first of all, leg pain and or back pain, so the patient essentially should have leg pain and or back pain regardless of what time or how long he or she has has it for along with that, the patient can have either a suggestion of recent onset that is within 14 days or deterioration of a longstanding problem. And those problems are the following five, which is difficulty initiating micturation or impaired sensation of urinary flow, altered perianal perineal or genital sensations due to S five dermatomes. Um severe progressive neurological deficit of both legs such as major motor weakness with knee extension, ankle inversion of dors, loss of sensation of rectal fullness and sexual dysfunction. There is inability to achieve erection or to ejaculate or loss of genital sensation. So, just to recap leg pain and or back pain. So either one of them or both together along with that, either recent onset or deterioration of difficulty maturation, altered Pernal sensations, severe neurological deficit, loss of rectal fullness and loss of sensation of rectal fullness and sexual dysfunction. Yeah, those are the basic symptoms of chua. Uh This is a list of pointers which the patient might provide when giving history, which can lead us to think about uh equina. But sometimes patient might mention there's loss of feeling of pins and needles. The patient was initially having pins and needles and now there's loss of the feeling between the inner thighs or genitals, uh numbness in and around back passage or buttocks, altered feeling when using toilet paper, increasing difficulty trying to urinate loss of sensation when trying to pass urine, leaking urine, recent use of pad loss of sensation and passing bowel loss of sensation in genitals during intercourse. So, these are some of the pointers um that patient might provide, that helps you to think about. Ok. So how do we examine the patient or when we suspect Corina? So obviously, we have to do a neurological examination. So, examination would include, as we said, perianal sensations because we have to see if there's loss of perianal sensation or not. So, we have to check the dermatomes of A 2 to 5. It is also termed like saddle anesthesia. If there is loss of sensation in the perianal region. Also, we check sensations in the lower limb. We have to check the anal tone. We have to check for urinary retention. We have to check lower limb weakness and hyporeflexia. Uh if we can't find any obvious cause, we also have to do history and examination to reveal uh underlying pathophysiology like weight loss or a sign of metastatic disease or living in an area of endemic tuberculosis. This is because um metastatic disease and tuberculosis are also some of the etiology behind quina. So we need to rule them out as well. Um As part of the examination for suspected corona, regardless of symptoms, patient will require apr examination and the postvoid bladder scan. So, pr examination, although it is not a definitive uh sign in case of uh coquina, but doing pr examination and having the finding always helps us judge whether there's a high suspicion of equina or not. However, when we are doing neurological examination, we should do full peripheral neurological examination including upper limbs because there can be some other spinal pathologies higher up if the patient is having corna. All right. So this is uh one of the charts that we use to um document our examination of the Coreg Quina Syndrome. There are the different dermatomes. Uh We have spaces to fill out different dermatomes, both sides on the right and left uh sensations, motor functions, then we have the pr examination. Um So it's just the details of the examination. We do the sensory tests, ability to feel, touch or pain at specific levels from 1 to 5 motor tests, reflexes, pr examination, um bulbocavernous reflex in case of catheterized patient, uh non catheterized, we do pre and post void bladder scans so we can use the form to help us guide on which examinations we have to do. So regarding the bladder scan, just to be aware of why bladder scan is required. So it is obviously an adjunct to the assessment. As I've already mentioned, no one sign or one symptom can tell you if patient has got or not. So it cannot be used in isolation or as a discriminator to decide if patient has equine or not, it is an adjunct which we should include while examining for Corina. So uh as there's a small piece of statistic here, 60% of patients who underwent emergency decompressive surgery for Corina had a post residual volume of less than 200. So, uh urinary retention is not exactly a very good sign uh to use as a discriminator. So there are 22 types of patients, we might uh uh come across one few of them will be unable to void. So if the patient is unable to void, we do a bladder scan. And if the bladder scan shows there is greater than 600 mL of urine, then we catheterize the patient and then we have to perform catheter tug and feel if the patient can feel the sensation or not and document that if patient is able to void, then we have to do two bladder scans. One is the pre void volume and one is post void residual volume. After the patient uh passes urine. If the post void residual volume is less than 200 we just document that does not mean is excluded if it is greater than 200. And the patient who was suspecting quina, then Corinna syndrome becomes 20 times more likely. Now, even after post, after voiding, if post void acetal volume is still greater than 600 we do the same as above. We catheterize and document if the patient can feel the sensation and can feel the catheter t. So what other investigations do we do? So whenever we uh face a patient who in whom we are suspecting called equine. Now, the patient needs to get an urgent lumbar sacral spine. MRI done because this is the Gold standard investigation. Uh However, word of caution is only a minority of patients suspected to have cord have abnormality found on MRI. As I said, it is a rare uh presentation. It is rare. It does not happen with every patient. You might find a patient having all the signs and symptoms of corna but having normal MRI. But we still have to do the MRI to rule out because uh the risks of not doing it are too high depending on the imaging and the underlying cause. Some other imaging might be required, urgent surgery might be required. Uh MRI for suspected corna should be started as soon as possible. And certainly within four hours of request to radiology. So if a patient has suspected Corina, uh it should be at least within four hours that we get the MRI scan done. So, discussion with on-call spinal service is not required bef before the MRI patient, if an MRI is being ordered, patient should be kept nail by mouth as uh the patient might require emergency surgery. Um We can say that this MRI scan has to take precedence over all the routine or elective MRI cases. So this can be expedited at all costs. Um Request should be ideally discussed with the senior decision maker which is the ST four equivalent before referral. Um If there's an absolute contraindication to MRI, then a CT or CT myelogram can provides like imaging. Um So radiologist reports should not be like we should not wait for the radiologist to report the scans that that might delay the surgery. So oncall surgical teams can be asked to review the MRI and decide if the patient needs surgery or not. Uh Also the trusts of the hospitals need to make sure that the radiology imaging Softwares are linked between the uh emergency spinal surgery um services and the other hospitals so that the imaging can be accessed without any delays. So after the imaging is done, what should be the outcome or what should be the action taken from the team? So the imaging, if it confirms quina, there should be an immediate referral to spinal surgical service, patient kept nil by mouth. And if, if the trust for the MRI is done, if the hospital with the MRI is done does not have a spinal service, then the patient should be blue lighted or category to ambulance transfer to the spinal service center. If spinal surgery is available, uh if the imaging shows no chordal compression but neural compression to explain radicular pain. So there is some uh compression of the nerve roots but it is not up to the extent of cordia equina. Then uh patient has to be referred to the MSK interface service or triage service. And based on that, the patient can uh receive analgesia physiotherapy referral to the uh elective referral to urgent referral to spinal other spinal services. Um We can advise the patient that the pain is very likely to improve. However important thing is to safety net. The patient about the progression of Coria syndrome symptoms, we can give them some template videos or cards to show them all the red flag signs they need to look out for. Uh if the MRI shows there's no cause of symptoms found, then we have to look for alternative diagnosis for the symptoms and consider referral to other specialties as well. So this is the girl to get it, get it right first time. Uh National suspected cardio syndrome pass away uh summary provided in the chart. So there are four parts to it. One is the primary and community care provider. So someone in primary care in the community can also um can also suspect equine. I see some red flags in a patient and can make an urgent referral or an emergency referral. However, the secondary care of the hospital part is on the second column. So it says the same thing, patient presents triage, we do assessment of uh patient and symptoms, then we do bladder scan, then we do the emergency MRI and try to get it done within four hours. Ideally, then based on outcomes, we take the pathways either there's no corona um but there is other nervous uh nerve root compression causing the symptoms. When we go to the MSK, there's no cause we consider alternative diagnosis or there is confirm called and we go for the surgical pa. Um There is one part that we, we can do well. The patient is say uh in our hospital, either awaiting an MRI, awaiting transfer, undergoing assessment, undergoing examination is that we can we have to provide the patient some pain relief because if the patient has chin or even though the patient does not have cord, um he or she must have presented with back pain, low back pain, radicular pain. So we have to provide them analgesia. So um this is uh just one of the guidelines we use in our hospital. There are lots of guidelines available for um pain relief in quina syndromes. So while in ed. Um patient needs to be assessed for the pain score very frequently, at least like every 30 minutes. So first line that can be given to all patients who do not have any contraindications is we give one NSAID, either diclofenac or per rectal or naproxen for oral. Along with that, we can give paracetamol and codeine. Uh we review the pain score 30 minutes after the dose. And if it does not work, we go to the second line which is codeine, we increase the dose of codeine and we add diazePAM to control muscle spasms that patients have when they have nerve root compromise. Um I if that doesn't help, then third line, we go towards morphine, we can go towards oral morphine, um immediate release. We can give oral morph or tablets. If that doesn't help, we can discuss with the seniors presenting in the department and considers Autin as IM or IV if necessary. Um if the patient is not undergoing surgery, but uh patient is being discharged because cor equina, there's no corna which it is being referred to MSK or alternative diagnoses are being considered as uh imaging has ruled out cord. Then on discharge. Also, we should provide the patient with some analgesia. Uh First line would be similar NSAID oral nsaids along with paracetamol codeine. And uh second line will be after discussion with you in senior. We add diazePAM and if there's true sciatica, neuropathic pain, we can give them some neuropathic analgesia like uh pregabalin and amitriptyline. So, just to touch upon uh what kind of treatment can be provided or what surgery is provided when there is uh confirmed called equina. So once the diagnosis is made and etiology established, um the goal is to free up the nerve roots. So the nerve roots are compressed and that's why they are leading to the symptoms. So, only way to relieve the symptoms and and prevent uh permanent nerve damage is to free up the compressed nerve roots. So um what we do is we just uh do some decompression surgery. There's uh urgent decompression surgery, which can be done which um generally involved. Let's see if I have anything mentioned here. Yeah. So it can be laminectomy, instrumentation or fusion or for stabilization or discectomy. So, in certain situations such as if there is a malignant spinal cord compression, uh sometimes radiotherapy or chemotherapy can be used. So especially if the patient is not suitable to undergo surgery and we consult with the radio uh radiotherapy team and the oncologist and see if um chemotherapy or radiotherapy can be appropriate. Um Yeah, as I mentioned, if they do not receive permanent immediate treatment, then it can lead to permanent problems like paralysis, impaired bowel control loss of sexual sensations. So we need to keep an eye out. We need to be very vigilant and look for symptoms of corna and we should keep a low threshold of suspecting Corinna and do proper history examination when get urgent imaging and urgent referral and if it is confirmed, urgent surgery, immediate surgery. Thank you, your milk disease. Sorry. Uh Thank you guys. Uh If you all have any questions, y'all can drop it in the chat box and uh and we can answer them for you all. Um And as I mentioned, we'll be doing every Thursday, we'll be doing further sessions of the series. So uh I would really appreciate everybody else's presence as well. And if you all could also leave some feedback for us so that we can obviously work around for uh whatever points we need to work around. That's all for tonight. Thank you guys. If there's any questions you can drop in abul is asking kindly repeat treatment. Uh Do you want to know about the surgical treatment? Hi. Well, I'm assuming you wanted to know about the surgical treatment that is done. So, uh I, I'm not neurosurgeon myself. I won't be able to give you like the proper details of the surgery. But basically, uh because um because there is a compression of the lumbar and sacral nerve roots, we have to do urgent decompression of the nerve. So it generally involves laminectomy, uh fusion uh for stabilization or discectomy to relieve pressure on the nerve roots and later on further procedures can be taken. But it's the emergency that we do just to relieve the nerve pressure on the nerve root three. Someone's asking if we are recording. Yes. Yes, we are. We will upload it on the, uh me side. So if someone wants to go through it later on, we'll upload the, uh, slides as well. So if someone wants to go through them or see them, they can thank you any more questions. Anybody, I think that's it. Um, I don't think there's any more questions. Thank you. Thanks. Bye bye bye. Have a good weekend.