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Yeah. Yeah. Ok. So, um, what I was asked to talk about was spinal cord injury and the management of spinal cord injury. Um, I think the honest answer is that's a fairly basic topic if you wanna get right back to the basics, but with loads of niche areas, loads of controversy. So I'm gonna try to cover, um, starting with the basics, er, lots of management and principles, but I'm not gonna get too bogged down in all the little details, but I'm more than happy to ask any questions later. Um, so to start off with, we're just gonna go right back to um, anatomy physiology, function of the column function of the cord. Um, and you, you'll all be pleased to know, um, there'll be, you know, a chance to look at typical vertebrae, vertebrae and all of that kind of stuff as well, then we'll look on cord injuries and their implications. Uh I'm going right back to the basic science, the anatomy and function because number one, you should know it. Ok. And if you don't then, uh, it's always good to sort of have that knowledge imparted. Um, there's not really any excuse for not knowing your anatomy, if I'm honest, especially as an orthopedic trainee. Um, and number two, that anatomy er translates really well into our clinical principles and explorations. So, um, so if you don't have a good grounding, uh in my opinion, is that you can't really understand the rest of my talk. So, right back to basics, spinal column. Ok. So the vertebral column is um essentially how you describe the bones of the spine. It's a series of vertebrae, um split up in sections each with its own characteristic anatomy. Um You'll know that it forms from um, from the note chord and er, er separates out and um the honest answer is that um if, if you don't know the special sort of the, the differentiations between different sections of the spine, then um you either haven't done a spine job yet, um, or you haven't been listening. Um, so its function is to provide mechanical stability whilst allowing movement, but also protecting the spinal cord to maintain neurological function. Um, and that sort of moves directly onto our definition of stability. Um, so spinal stability is the ability of the spine under normal physiological conditions to maintain mechanical integrity without causing pain or neurological dysfunction. Now, that definition is, um, you'll see rolls off the tongue. It's something that as people, that the pre exam people will um will, should and easily, easily, be able to recall that. So it shouldn't be something that want us to think about it comes from Punjabi and White. Um It is not by any means a sort of an all encompassing definition. And there are lots of different ways to decide if the spine is stable. But that as a definition of stability is probably the the most well recognized and definitely one that's useful to you. Um you'll notice that phrase physiological conditions, OK. And as spine surgeons, especially in our age, that physiological conditions test is vital. Um almost all of the imaging that we take in spine surgery is supine. Ok. So um they come in there. So it and I'm talking in the context of trauma here. But um you, you come in, you have your trauma ct guess what? Supine, you then might even have an MRI scan, guess what? Supine. Um and you, but you can't make a decision about whether the spine is stable under normal physiological conditions. Um unless either both of those things shows no injury or you test it by subjecting the spine to physiological conditions ie getting the patients to sit or stand. Um And really, that's one of the key ways um that you'll see us decide whether a fracture is stable, ok. Um And, and none of that bases on the history as well. So if a patient was in a car crash, but they got themselves out of the car, walked around for a bit and then the ambulance turned up and struck them to a board that's very different to, they've not moved at all since their crsh um cos they've already tested their spine. So just looking at typical vertebrae, so we've got the vertebra body at the front. So I'm going to rattle through this vertebra body at the front, vertebral foramen, which contains the spinal cord and the nerves, the pedicle connecting the front and the back, transverse processes allowing some important muscular attachments. Um the lamina which you'll hear the term laminectomy, et cetera. Um And then the spinus process again, an important spinal ligamentous attachment. And here's the the side view of that. Um So at C 12, we've got a really special relationship. So, c one as you'll see here does not have a vertebral body. It's got very flat facet joints which allows rotational movements and that rocking forward of the head. Um that CNC one axis. Um you'll notice also that all of the cervical vertebrae except sometimes C seven have this vertebral artery foramen um where the vertebral artery goes up post joins to form the basilar artery um and the posterior circulation of the brain. Um and that's obviously very important in spinal cord injuries and cervical injuries because um you know, an injury to that can cause a posterior circulation stroke and those posterior circulation strokes can mimic spinal cord. So, um it can give you, you know, dyspraxia um loss, it can give you are promoting your own science quite clearly, it can give you loss of sensation, it can give you loss of motor function and especially coordination. And so it doesn't have to be accord. There are other things um to, to the world in orthopedics and spines. Ok. You'll notice that the C one, frame is, is big. It's not quite as big as a frame and magnum, but it's a big um er, foramen. And the reason for that is because it's also the most mobile segment of the spine. So it has to move in relation to the cord quite significantly and therefore the cord needs plenty of space to allow and adjust for that movement. Um C two has the, this articular process which we call the dens or the peg, it forms as a separate ossification center. One of the big things that annoys us um is when you get, you know, someone takes an X ray or even have a forbid a CT scan of a child neck because they think there's a peg fracture. Um but it's just that, that, that peg has yet to ossify and we're just looking at a normal ossification center just like you'd see in the hip or anywhere else. Um And that does not mean there's a fracture. OK. It just means there's a normal ossification center. Um Hopefully, radiology should sort of tidy that up, but it's just something to be aware of. Um And then below, we've got the rest of the subaxial cervical spine. Sorry, I rattled through this. Um sorry, we we've got the um all of that is held in place by strong ligaments, ligaments being there to allow some movement rather than bony attachment. And got it 100. Can you, can you click the hide icon and the sharing screen? Say the hide icon. Oh, this thing. Oh yeah. There you go. Ok. Oh, now it's gone there. Hang on. I can't see it. Now, there, there you go. You can still see it. Yeah, we can see. Yeah. Yeah. OK. Sorry. OK. Um So this is essentially what I call a star of ligaments, but it's not really a star, but it's a, it was, they're called cruciform ligaments, but there's a couple in the alar ligaments at the top. Um But they are holding the peg to see one. They're also as you'll see, holding the peg to the Foramen magnum. So they do have um a really powerful connection of the head to the neck. Um disruption of those can be difficult to see and that's where all of your measuring of um er the um the spinal. Uh so the Atlanto dens intervals and all of those things. Um all of those fine measurements um that today is not really for talking about um looking at whether there's one or two millimeters of displacement to see whether the um ligaments can be detached. And of course, these powerful ligaments can cause avulsions as well. So you can see small flexor bone that look fairly innocuous but can be representative of fairly powerful injuries. And then when subaxial cervical spine, the body returns. Um and we have this bifid spinous process, um which is one of the keys we've spoken about. We now start to get a small transverse process as well for the um er muscular ligaments as attachments. Um uh but the the body remains small and the orient orientation of the facets is still allowing a significant amount of mobility at the sacrifice of stability. So um the more the spine moves, the less stable it is is basically um the way to think about it. Um And we've still got the vertical artery there. Thoracic spine um moves the least and therefore, is the most stable. The reason it moves the least is because we've got the rib attachments. So the special things about this are the body's getting bigger, the vertebral artery, sorry, the vertebra artery frame is gone. The um vertebral canal is getting smaller because there's less movement. So we don't need the spinal cord therefore, to be able to move around within it so much. But we also have these backwards facing, quite big, pronounced transverse and they're backwards facing to allow for the ribs which the superior costal facet you'll see labeled here. So the ribs are attaching here, articulating with the transverse costal facet. And so these transverse processes are deliberately angled backwards and to allow for the ribs um to be coming around and allow for that plural cavity. Ok. Um The spinus process is downward angled as well. So they do overlap each other um as you'll see in this er posterior view here. Um and that in association with the angulation of the facet joints being in a very um sag sorry in a very coronal plane allows flexion extension but not a huge amount of rotation. As you'd imagine considering you've got the ribs, um sitting there either side. Um One important thing in the thoracic spine that a lot of people talk about is the blood supply. Ok. So, um the blood supply to the spinal cord at this level comes from directly from the aorta. So there are feeders from the aorta um called the segmental arteries. Um Those segmental arteries go and feed into the spinal cord viral plexus. Um Number one, that's important because they can be injured during our surgical approaches. But number two, there is one dominant, one called the artery of adamic tends to sit um around about t nine on the left side, but there is a lot of variability with that. Um But essentially, what you need to really understand is that there's one dominant artery um and injury to that is much more likely to cause damage to the spinal cord of an ischemic nature. Um And that's uh so next up, we've got the lumbar spine OK. Um And in the lumbar spine, this is what you get for your typical vertebrae. It's at the bottom of the spine. It's taking most of the force. The vertebral body is bigger. It's got these big intervertebral discs. Um there's a lot more force going through and as you know, most of the force goes through the body. So the body's getting bigger to allow that force. Um we get a now a bit more rotation movement. So the orientation of the facets changes from that coronal plane to a more sagittal one to allow both flexion extension and some rotation as well. We don't have the ribs limiting our, our rotation and flexion now. So it's a much more mobile section of the spine. And as a result, our transverses are going much more in the coronal plane as in more straight across rather than coming back towards us like they were in the thoracic spine. Um So that's basic anatomy. I've rattled through it. It's a bit boring. But I think it's really important that you all understand it. Number one, because anatomy is important. Number two, because you can't really talk about any of the surgical approaches. And number three, because how can you look at imaging uh and decide whether there's something that needs something doing if you don't know what it's supposed to look like. Ok. So you have to know what normal looks like and you have to know your anatomy moving on to the disc. Um The reason the disc is important is because number one, obviously, it can be injured. Number two, it can be the source of our cause injuries. OK. Um And number three, it is an important part of our stability. So it has an an and if you don't know this, um then it has a, an annulus fibrosis which is made up of um concentric layers of collagen at 30 degree angles to each other to allow that, that rotation, but also some flexion extension. It's got this inner nucleus pulposus which everyone describes as a jelly. It's not really, it's just a well hydrated protein matrix. Um but it is relatively avascular. Ok. So the nucleus itself does not have its own blood supply. The outer one third of the annulus does have a blood supply and a pain supply. Importantly. So it can be a pain generator. Um But the inner two thirds in healthy individuals and the nucleus pulposus get all of their nutrition from diffusion, either from the outer one third or across the endplates. Ok. So it does not heal well, which is important when you're deciding on stability. Ok. So injuries through the disc do not heal well because the blood supply is poor and you cannot get the nutrients there, which is the same reason why infections are difficult to treat in, in the disc. So, spondylodiscitis difficult to treat because the delivery of the antibiotics to that spot is very, very difficult. OK. Um And this is all held together with the classic defer um sort of concoction of ligaments and muscles. Ok. So the front of the body is, we've got the anterior longitudinal ligament. We've got the discs in between the bones. We've got the posterior longitudinal ligament, um which sits behind the vertebral body, but not at the back of the spine. We're still talking in the anterior column of the spine here. And then we've got pedicle and lamina and then between the laminae, we've got the ligamentum flavum and there is a separate ligamentum flavum, one right, one left and one at each level of the spine. Ok. Um And then we've got the interspinous ligament and then the supraspinous ligament, all of these things working together. So both allow movement but also confer stability. And we've got the muscles um which I'm not gonna neighbor to you, but ecto spna muscles. So, um I like standing either costalis, longissimus or spinalis um amongst others and such as multifidus um at the bottom here. Um So we've got all of these muscles also conferring stability, but importantly contributing to the force on the spine as well. So, force contraction of these very powerful muscles um in, in the context of a body moving forward with momentum can cause just as much injury as an impaction type injury. Ok. So spinal cord um is our next thing which is, so we're still getting down to anatomy. So spinal cord just think of it as a continuation of the brain. Ok. It is upper motor neurone material and it behaves very much like the brain. Ok. So it has to have a good blood supply. And if that blood supply is disrupted, essentially, you get a stroke of the spinal cord. Those strokes have an area of irreversible damage and recover poorly. Ok. Um It terminates at the lower border of L1. Below that, we've got the cord corner that is lower motor neurons. OK. So upper motor neurone signs from L1 and above. Um now the spinal cord sits inside the JRA and the JRA, as you'll know, has multiple layers. If you ask a neurosurgeon, they'll say 32 but they argue about it. But for us it's three. OK? So we've, we've got the JRA, the Pr and Arachnoid. Um But um but we end up there are multiple layers. Um And so that's what we're seeing and that's going to be important later on when we're talking about the anatomy too. At each level, we've got a nerve exiting and it goes off to supply whatever it's going to supply. Um in the cervical spine. You'll notice we have eight roots but only seven our bodies. And therefore, we go from the nerves exiting above the body to the nerve exiting below the body at that transition between the cervical and thoracic spine, cross sectional anatomy and the spinal cord. Um My intention was to get people to draw it, but I couldn't find a way. Um I've been practicing with metal to get people to sort of draw on metal. And so, so you, you got got away lightly. OK. But we've got the posterior column sitting here. OK. And the spinothalamic tracts were the anterior and lateral portions sitting at the front of the spine here. OK. So these are ascending pathways and the ascending pathways are taking the signals from the body to the brain. So that is gonna be sensation, reception, pain and temperature. Ok. So these things here are taking signals up the way and then the red side is down the way descending pathways. OK. So this is your motor function, um your uh and your um er out and sorry, your sympathetics and all of that kind of stuff. Ok? Um You'll notice that it has a homunculus just like the brain does and it is therefore, so, you know, just remember it like the brain. So everyone knows that little hun with the feet being bigger than, and the hands being bigger than the face and the eyes. And um that is um organized from center to the outside. And you might think, well, why is the cervical given that it's gonna come off first on the outside? Because the nerves are gonna leave the spinal cord. Well, this big h in the middle is there for a reason. It's not just a dead space. These, this gray matter, OK? Is the cell bodies, OK? And more importantly, the synapses between the upper motor neurons and the lower motor neurons as they were coming out. OK. So actually the junction is coming in the middle. So the cervical is central because that's where our anastomosis. Um So our synapse to the lower motor neurons is gonna be and then it'll form the dorsal columns, Um sorry, then it'll form the dorsal ramus, exit the spine and go to provide nerve roots. Ok? So actually, the bit that's about to leave is sitting centrally within the spinal cord. OK? And that's really important when we're considering our cord syndromes. OK. So we've got dorsal columns, natural spinothalamic tract and the corticospinal tracts. Um both anterior and lateral um being our main ones. Now, there are others that have that you can learn them all if you want. But these are the main ones. OK? But this homunculus is the important thing. OK? And it's important because it allows us this anatomy allows us to understand our corn syndromes and why things happen in the way that they do. So I mentioned about strokes of the spinal cord and it would be silly for us to not talk about the blood supply. Ok. So the blood supply comes from the segmental, OK? And those segmental feed into two main arteries that run up and down the spine, the anterior and the posterior. Ok. The anterior supplies the anterior two thirds, the posterior supplies the posterior one third, essentially posterior spinal artery, dorsal columns, anterior spinal artery, everything else. Ok. And you'll notice therefore, if we go back to this anterior spinal artery is, is gonna affect our spinal thalamic tract. So, pain and temperature sensation, but it's also gonna affect our corticospinal tracts. So, therefore, most of our motor function, whereas posterior spinal artery, just dorsal columns, so dorsal columns um is our fine motor, uh fine touch and proprioception, sorry, not motor, fine touch and pro so a posterior circulation, a posterior spinal cord in fact, is gonna affect your sensi fine motor, your fine sensation and your proprioception, but it will spare you most of your motor function and your pain attention sensation. However, an anterior one is gonna have a much more significant probably impact on your life because you're losing your motor function as well and your protective pain sensations. Ok. So all of a sudden we're getting anterior cord syndromes and posterior cord syndromes and nailed down just by knowing a little bit of anatomy. Ok. As you can imagine with spinal cord injuries, autonomic, um er nervous system is vital to know if you don't know this, it'll come up in exams. It's things that people are, are. So these are easy to test um difficult concepts sometimes to get in your brain because most of the diagrams are um are tricky, ok? And so we uh I would encourage you early doors to revise this from your medical school and keep looking at it every now and again, so that you can understand the autonomic effects of the spinal cord. Ok. But essentially we're looking at peri the concept of er, for us is looking at peripheral vascular resistance. Um and that's important because we've got a few different types of shock and things to talk about later on. Um, of which the autonomic nervous system is gonna be an important um, decider. Now again, this was gonna be a question um for people, but um we've got the quadricep. So we've got a up here, a reflex. OK. And um a really nice easy question. A nice leading in question um is you're doing a reflex, everyone's doing them on a regular basis. Um What um what are you doing? Why are you doing a reflex? Um What does it show? How does it work? OK. And actually, um it's one of those kind of things that a lot of people probably do without really thinking too much about what it means that you might even have learnt, um you know, learnt rope that up and neuro sinus brisk reflexes, but you don't really understand, right? OK. So what you're doing is you're applying a stimulus to a tendon, that stimulus to the tendon stretches the tendon. OK. And there's a uh a new so, and the, the um spindle fibers of the muscle get stretched that um er is sensed and the sensory neuron goes in through the um dorsal ganglion anastos directly with um synapses within the gray matter. And without going up and down the spinal cord, that is then um uh a synapse directly with um the motor uh fibers and those motor fibers cause muscle to contract and relax. Ok. So it's the coordination between the quad. So in this case, quads contracting, hamstrings relaxing allows that reflex motion. Ok? Now, the reason that upper motor neurone signs increase brisk reflexes is because as represented by this green osmosis here is there are inhibitory parts to this reflex. So there are constant signals coming down from the brain through the spinal cord that provide inhibitory signals to these reflexes that keep them under check. Ok. And so it's a loss of inhibition of this reflex that causes it to be brisk. OK. So it's not something to do with um the, you know, the, the damage causes the reflex arc itself to be changed. What it stops is the inhibition of the reflex arc. OK. So you don't get those signals coming down from the brain controlling and inhibiting the reflex and therefore they become brisk. Ok. So if I could explain nothing else to you is how a reflex works and why you get up promoting your own signs of brisk reflexes. Ok. So spinal cord syndromes, this should now that we've had that anatomy be relatively easy and straightforward to understand central cord syndrome. So usually in the cervical spine, upper limbs are affected more than the lower limbs. So, if we go back to this upper limbs in the center, lower limbs in the periphery, it's a central cord syndrome, upper limbs more affected than the lower limbs. It makes sense. Ok. It makes anatomical sense. It's a central cord syndrome. It, sorry. It, it has a really good prognosis. Even though it happens in the elderly people, they tend to get in terms of scores, at least a good recovery. OK. That doesn't necessarily translate into good functional outcomes. OK? S partly because of the number of pa so the age of the patients that it's affecting the central cord syndrome, if you're looking at Asia scores and scoring recovery actually tends to recover really well. Ok. Anterior cord syndrome, we've already been through, I'm not gonna labor it. Cord hemisection. Ok? Loss of one half of the spinal cord. Ok. So if we lose one half, what we'll lose, obviously, there are the blue and the red aren't in separate h there, there's a blue and red each side, it's just easier to separate it like this. Ok. So if we lose half of the spinal cord, we lose the dorsal columns, we lose the spinal, the corticospinal tracts um on that. And those have already decussate as and crossed over in the midbrain and medulla. And therefore, they already are affecting the side of the body that they're on. But you'll remember from your basic science all the way back in medical school, probably first year. That's when we did it. Is that the lateral spinothalamic tract decussate at or close to the level that it's exiting the spinal cord. So this side is gonna cross over at this level and, and supply the other side. Ok. So if it's a left cord hem section, you get loss of left sided fine touch, proprioception, motor function, but you get contralateral loss of pain and temperature sensation, ok? Because that decussation happens in a different place. And it's a really common question, a very uncommon cord injury classically with stab injuries, probably getting more common again in certain places. Um but not so much in Norfolk. Um but that, so that's what you, that's a cord hem and that's why they love asking. It's just to understand that one dec thing. Ok? So that's cord injuries, OK? As in what they are and the different types, we'll talk a little bit about the age of classification in a minute. So don't worry, but how do we manage them? And there's, we can split the management up into different sections. So we've got this initial management, ok? Different places do different things and you do need to understand this because it is controversial, but most places have some form of flat bed rest for a period of time. The theory behind that is that it allows the spinal cord to maintain its perfusion, keeps the spine from moving too much and therefore, maintains stability and allows the rest of the autonomic um, issues associated with spinal cord injuries to settle down. Ok. So flat rest for Sheffield, it's two weeks which is who we feed into. Um, but for stoke Mandeville, I think they're also two weeks, which is the rest of the region. Um, but there are places in the country that do six weeks and there is one place in the country that does not do any, um, you give them a proton pump inhibitor because number one, their gastric motility is gonna be reduced because of that autonomic dysfunction, ok? And also because they're laying flat, you give them some heparin because they are not moving, their blood's gonna be poorly and they're at high risk of um, of uh VT E and mechanical prophylaxis as well. If you're gonna operate, obviously, you might need to withdraw the heparin. And of course, if there's an injury and in which has a risk of um hematoma formation, then you might need to withhold the heparin as well. Ok. Pressure area care is vital, ok. So they need one of those fancy mattresses, they need to be rolled every two hours, day and night, ok? Because they cannot feel they cannot move and there is a high risk of pressure sores, ok? They need a catheter and they need bowel care to s to number one to prevent the problems associated with severe constipation. But number two to prevent stimulation and autonomic dysreflexia, which we're gonna talk about in a minute as well. Do not forget. And I would encourage you both clinically and in exams to forget the past. Do not forget the past oral care. Ok. So this is a life-changing injury. Often, these people came from a place of being absolutely fine and have suddenly become absolutely not fine. They're scared, they're worried about being in a wheelchair for the rest of their lives. They don't know how things are gonna change. They're very vulnerable because they have lost all of their independence and they've got nothing else to think about because you're strapped them into a bed, you've given them nothing to do and nothing to look at except for a boring ceiling. They've got nothing to do other than mull over their situation, they get depressed very quickly. Um and they do need a bit of care and attention honesty, ok. So don't pretend that things are gonna get better and tell them they're gonna be alright because that's probably not true. Ok? But say, you know, we'll look after you as best we can, we'll get do everything we can to give you the best chance of getting any recovery that we can, you'll be rehabilitated, et cetera, et cetera. Ok? But don't, please don't underestimate the importance of that pastoral care I to talk about cord Quina syndrome. It's not really a cord injury, but it is referred to the cord injury center. So I'm gonna talk about it anyway. So the spinal cord finishes at L1 and below, this is the cord, we've already told you that they're lower motor neurons. Ok? So you're not gonna get up and mo to signs if you see a, if you get referred to Cordner syndrome and got up on motor neuron signs, it is not cord syndrome or there's something else going on. Um But it is a syndrome. Ok. So you must take time on the patients. Ok. That does not mean that everyone has to examine the patients thoroughly every time, especially APR. Um That is a new thing. The new GF guidance is that the PR should be done once it should be done by a person who knows how to do it and it should not be repeated needlessly. Ok? Um That essentially means GPS don't do it, ok? Um You've got these symptoms. So sad anesthesia, urinary tension with overflow incontinence, fecal incontinence, bilateral leg symptoms. In reality, it is a spectrum. Ok? And this is why it's difficult. Ok? It is not straightforward. Um Some people will come in and you could swear blind that they've got all of the right things and they're going to have a big disc and they've got a normal MRI scan and some people they come in and you think, oh, this one is going to, you know, this one's not going to be positive and you, you know what? They got a massive disc. Ok. Um That's why the new go guidelines say MRI scan for everybody. Ok. It is cheaper to MRI scan, everyone who comes in with back pain than it is to have the litigation associated with people not getting scans when they have Coral syndrome. Ok. So essentially that's what the new GF guidelines are in about. And if the hospital hasn't introduced it, it, they will be. Ok. How do we classify cord injuries? So we start talking about the levels. Ok. Um, so there's a dermatome and myotome for each level. Ok. And we can talk about upper versus low mos on your own. Ok. And different books will tell you different things. Ok? So if there's a, a bit of variation in the books, then that probably means that things aren't as clear cut as everyone would like you to believe. Ok. So there is some crossover and there is some sort of variation, but in general, if you use this, the Asia spine, so the American Spinal Injuries Association chart for all of your spine, neurological examinations, you won't go too far off. Ok. And it is really an idiot's guide. Ok. It tells you which muscles to test for which nerve groups, it tells you exactly where to test your fine touch and motor function for each dermatome. Ok. And it, it, it just it, it really is a, um, a really simple, easy way to not only document things but also to examine them. Ok. So if you're in doubt, fill, fill the Asia charts, ok. But all spinal cord injuries should have one of these filled out anyway. Ok. At the time of first assessment and the reason we do this is not only because it's useful, but number two, because it's really easy to see and compare whether people are getting better or worse. Ok. So we're trying to do a standardized assessment on a standardized proforma so that we can sit, stand there and look right. What were you like at the start? What do you like now? Are you getting better is what we're doing working? Ok. Because later on when we're talking about how long to continue that blood rest and all of these other things, um if people are still improving and they're improving rapidly, then we might prolong the bed rest. So it does actually change the management of the patients. So it is really important to have that first assessment is accurate. Ok. So the different levels, um this is actually really important thing, ok? Because a, a level or two in the spine can make a really big difference, especially in the cervical spine, this to your um preservation of function. But essentially, and they're always very anxious to this. Ok? But essentially, if you've got a complete injury above C four, you're ventilator dependent. Ok. If you, unless you're very lucky. Ok. That's a massive, massive change to anyone's life. Ac six, you can use a motorized wheelchair. We're only talking about two levels of the spine. What an 82 or three centimeters, maybe four. but in, within that four centimeters you go from being able to breathe, so being unable to breathe or move almost anything to being able to use a motorized wheelchair and breathing for yourself. Ok? So that 23 centimeters can make a massive difference to someone's quality of life. OK? But you go one more level down and you start to get some hand function. And at C seven, you've got some triceps, preservation as well. So you can even, she transfer cos you can push yourself up and you can start using a manual wheelchair, which is a massive difference to um to um mobility. But you can also start doing your own bowel and bladder, ok? You know, you can wipe your own gum and all of this kind of stuff too, which means all of a sudden you're not so reliant on carers, thoracic spine. Very little difference other than Trump control in the, in the thoracic spine, ok? Um But come down to L2, if you've got L2, you can stand. OK? So L2 and below you can stand. But with orthotics to control your knee, so you might need orthotics to keep your knee straight but you can stand L4, you just need ankle or faces. Um And it's worth noting at any level, there can be loss of bladder bowel or sexual function, ok? But there can also be preservation. So you can have preservation of bladder and bowel function with high iso injuries, but you can have loss of all of those things even with a low lumbar injury, ok? Because the sacral roots come out at the very bottom. Ok. I'm introducing this concept of spinal shock. Ok? Because it's a co a term that we sometimes hear used um and used incorrectly. Ok. Spinal shock is not neurogenic shock. Ok. Spinal shock is shock to the cord. Ok. So the spinal cord is in shock. It is essentially a phenomenon where the neurology can be exceptionally bad in the 1st 24 hours and then rapidly improve over that 24 to 48 hour period. During that time, you get loss of the reflexes, ok? Including the Bulbocavernosus reflex, which is the lowest reflex arc in the spine. And therefore the one that we test when the Bulbocavernosus reflex has returned, that signifies the end of spinal shock and that is more likely to be representative of the true cord injury pattern. Ok. And it is not the same as neurogenic shock, which is an autonomic phenomenon because of a lack of neurogenic input to the normal homeostasis mechanisms in the BP in the body. Ok? Which is low BP and bradycardia. Ok. So, neurogenic shock, low BP, venodilation, bradycardia. Ok. Spinal shock shock to the spinal cord, nothing to do with the BP. Ok? Or the BP can be effective but spinal shock does not define that. Ok. So spinal shock, neurogenic shock, not the same thing. Different terms, autonomic dysreflexia, I think often a poorly understood phenomenon that's relatively easy to explain. It's much more common if you've got a cord injury from T six and above, because of the fact that your sympathetic outflow is more likely to be affected. Ok. But essentially what you get is some kind of stimulus and it doesn't have to be pain although pain does contribute to it. Ok? But it could just be having a full bladder or being constipated. It could be a uti it could be a pressure sore. It could be many things. Ok. But you get that stimulus, it causes an unregulated massive sympathetic response from the spinal cord below the level of the injury that sympathetic response causes widespread vasoconstriction. And that vasoconstriction causes profound hypertension. So the BP goes up. However, because your sympathetic supply, sorry, your parasympathetic supply is still working. What happens is the baroreceptors in the blood vessels detects this hypertension via the vagus nerve. It tells your heart to slow down because your BP is too high. And so what you get is hypertension, bradycardia. Ok? And because the parasympathetic supply is still working above the injured level, you get diva, so you get vasodilation, ok? So you get flushing, redness, clamminess sometimes above the level of the cord injury, color um sympathetic type things. So pallor change in color, coldness of the limbs below the level of the coronary hypertension, bradycardia. Ok. That is autonomic dysreflexia. It is a an abnormal reflex or a loss of control of the autonomic reflexes to a stimulus below the level of the injury that causes this abnormal reflex ar to occur. Ok? And it can of course, with this uncontrolled hypertension be really, really dangerous. Ok. This hypertensive crisis can lead to strokes and other things and significant injury. Ok? And there's a little card that the patients are given from the cord injury center that looks a lot like this. Ok? Um and they carry it around with them sometimes. Um so it's a potentially eye threatening condition. Spinal cord T six and above. Um it tells you what it is what the symptoms are. So, hypertension, sometimes chills or fever, harming headache because of the BP and the veno dilation, bradycardia, sweating above the injury, nasal congestion because of the the veno dilation and the vasodilation sometimes blurring in the vision, flushing above the injury, goose bumps, et cetera, sometimes even seizures, the treatment set the patient up to try to reduce their BP. Ok? And then um go down this examination tree. Ok? Looking for. So um looking for the causes. OK. So removing the stimulus. But at the same time using anti hypertensives such as um Nitrose, which is sort of GTN um which has a really rapid onset or others to reduce that um that BP and try to break this cycle. But unless you remove the stimulus, um then you are not solving the problem. OK. So that's autonomic dysreflexia. It's actually not that common. It, sorry, it's actually it is very common, but it's not that difficult. OK? It's just an abnormal reflex. OK? And the treatment is sit the patient up, so recognize it, sit the patient up, remove the stimulus, control the BP. OK. Once you remove the stimulus and control the BP, everything else will return to normal. OK. Um Does anyone have any questions about that? Cos I've covered loads of stuff and I've been talking and we, if not, we'll move on to a little bit about fractures. And then some cases I can't see the screen. So you have to turn your mic on. OK? We're gonna assume that fractures easy, peasy. OK. Describe the level. So w at what level is the fracture? Ideally, you can use the columns and we'll talk about that. OK? Or if you really um uh wanna sort of uh be confident, then you can just tell me there is an unstable fracture or there is a stable fracture and there are different types of fracture, bones, fractures, hand fractures et cetera. Um And you learn, knows when you do your spine attachments. Ok. But essentially, we've got the three column theory which is essential, which is the anterior column being the anterior two thirds of the vertebral body, posterior column being that posterior one third and the posterior long ligament and then the sorry middle column and then the posterior column being everything behind that. So the facet joints, the spinus processes the pedicles and the interspinous ligaments, OK? Um Two column injury, unstable, three column injury, definitely unstable. Um One column probably not unstable, don't need to really do anything about it, ok. Um In high energy trauma, the safe approach is to assume there is an injury to the spinal cord unless you can prove otherwise. Ok. Um and proving otherwise can be just examining the patient and making sure it can be the trauma CT which seems to be the sort of most likely method. Now, um and it can be an MRI scan and it can be standing up x rays, et cetera. OK. Of course, it is not, we all know about ss spinal cord injury without radiological abnormality. Ok. That actually was that term was coined before the advent of MRI. Really? Ok. So it's very um so you can't really um you can, but it's very rare to get one without any radiological abnormality cos an MRI would show up most of them. Ok? But it is possible to have a normal CT and an X ray but still have an unstable injury. OK. As evidenced by this AO diagram here. So you can have an injury, a fracture that goes through the anterior longitudinal ligament through the disc, through the posterior longitudinal movement, through the facet and through the interspinous ligaments and still be vastly unstable but show no bony injury at all. OK. And beware the enclosed spine. OK. This is an X ray that was taken in an A&E I was working um and uh of, of an enclosing spine patient who had a fall down the stairs. Ok. And um uh e everyone thought it looked normal and indeed, I agree, it probably does look normal. OK? But the issue is that this is an ankylosed spine and ankylosis because of the um the alteration of the forces going through the bone means that the bone is much more likely to be osteopenic or osteoporotic. And you've got long lever arms, OK. So the spine doesn't move, it's gonna have to move somewhere. This is by the time they were put in a collar, which was obviously the wrong thing to do. This was their CT scan. OK. So all of a sudden we've got a fracture that was, we've proven, don't forget was completely undisplaced. Um Because we've got an X ray to prove it, we've put them in a collar, which is the wrong thing to do because we're extending the neck in the, in the kyphos thoracic spine. Ok. And we have extended their fracture. You'll see that has caused um disruption of these bony sp um bony fragments into the spinal cord. And this patient developed neurology after being put into um, a collar. Unfortunately, that was, uh, it was, it wasn't in East Anglia, unfortunately, that that wasn't recognized very well. Ok. And um, it took them quite a while to sort of realize and obviously they took a CT scan with the collar still on. Um, so please don't force the ankylosed neck into an abnormal position because you may create a cord injury where there was not one before and it's especially embarrassing if you took an X ray that proved that you've done something wrong. Ok. So how do we decide? So I've spent a lot of time talking about different types of cord injury and how they occur and how we assess them. Um, but what do we, and, and, and how to manage them for the first two weeks? Ok. But what about after that? So, you know, how do we decide if we're gonna operate on them? Why don't we operate on all of them, all of these questions? Ok. So the first thing is when should we operate on them? And that's controversial. Ok. Um, for the exam, um, the there's kind of, there's two parts to that question. So the first is that some, some cord injury symptoms, um, prefer there to be a period of uh, relaxation and calming everything down. So you don't give the court another ischemic insult, uh, et cetera. And for you to wait that two weeks out and then do your surgery a couple of weeks down the line as long as the patient can wait that long. Ok. Um, some are much more aggressive and want you to operate straight away and then so that the patient can start with their recovery. Ok. So the first thing I would say is if you ask that question, speak to your spinal cord injury center, say I would speak to my local spinal cord injuries unit and I would ask their advice, but in principle, I don't want to have a second insult to the cord straight away afterwards, I keep the patient flat. So as long as they were able to tolerate that and they didn't have a deterioration in their neurology, we would do this for two weeks and then we'll take them to surgery once they've had chance to recover. But essentially, what you're thinking about is the patient. Are they fit for surgery? What will they tolerate? Ok. Not only what will they tolerate physiologically, but what will they tolerate mentally as well? Ok. Some people um just cannot deal with another thing to, you know, another surgery to deal with, but some cannot deal with the fact that they've got a broken neck and you're not fixing it. Ok? So you do have to involve the patients and their families in these decisions too. Injury. How stable, how unstable is it? Can we control it by other means? Ok. And if we can control it by other means, is that a definitive management option or are we just doing that as a temporizing measure while we get them over the initial part of the cord injury? Um and seeing how things go and then the injury itself. How bad is the cord injury? What are the chances of it getting worse if we don't operate or do operate? And is my operation going to significantly affect the patient's outcome? Ok. Um, there are patients with unstable injuries who have unstable pseudoarthrotic spines that can do lots of things, ok? And their cord is being constantly battered and bashed, but their cord doesn't work anyway. So it doesn't really matter. Ok. But there are others that can get worsening and ascending of their cord injury in unstable situations. So all of these things needs to be factored into account. It is a difficult decision. Speak to the cord injury center, speak to the local spine unit is kind of your answer. Ok? If they push you and say you are in the spine unit, then say, look, I'm balancing up all of these different things, the fitness of the patient, the wishes of the patient, the instability of the fracture, whether I can control it by other means. And then if I can't, then I will consider surgery at a time that's safe and most appropriate. Ok. And then the bone, obviously, we've got to talk about the bone quality as well. So, for instance, we were talking about that ankylosing spondylitis patients, um, they, er, have notoriously rubbish bone quality. You have to do a very non fixation. Um, will the screws hold and is if you, if you can't, if you put screws in the bone, um, and you're not gonna get a good hold. There is no point in subjecting a patient to all of those risks, ok? When you're thinking about cord injury, do not forget infection and tumor. Ok? These are still sources of cord injury, ok? They don't come classically in the cord injury definition, ok? But infection can cause destruction, epidural abscesses, it can cause vascular cord injury, it can cause physical cord injuries. Um it is common and if you've got IV drug users, immunocompromised people, I'd encourage you to consider infection in your differential tree the same with tumor, ok? Especially in people with past medical history of me metastatic disease. Of course, your CT S and your MRI scans are gonna pick this up, but you have to have an index of suspicion. It has to be in the differentials, ok? While tumors um and infections often don't go to the cord injuries units, we still do have to deal with and look after them, ok? The reason they don't go to the cord injuries units especially tumors is because the cord injury unit has a three month rehabilitation program. Ok. And number one, that can impact quite significantly on your oncological management. But number two, that is quite a big chunk of often a limited prognosis. And therefore, um they don't feel as though there's, they feel as though the resources can be better used on people who are going to have a longer term benefit from it. Ok? Um When we're talking about M SCC, we need to know the prognosis, we need to know their medical state, we need to know what their wishes are. They may already have advanced directives, et cetera. Have they had any other treatment, especially radiotherapy, operating through radiotherapy skin is number one, not very nice, but number two, it does not heal well. Ok. Um And then we have to decide whether there's a chance of curative resection cos that allows us to be more, more aggressive, although that is very limited and we do have that 72 hour window ie if you've got neurology, that's been there for more than 72 hours, um then it is very unlikely to recover. If it has been there for less than 72 hours, then the chances of recovering are much better. Ok. M SCC steroids. Yes, all have a cord injuries, steroids. No. Ok. So no steroids and spinal cord injuries. There's really good evidence to say that. Ok, the downsides of the steroids, the complication from the steroids are much worse than the benefits. Ok. But in MSC steroids are beneficial. Ok. They can shrink the size of the tumor. They can definitely take the heat out to the situation and buy some much needed time. Ok. Yeah, I'm gonna reiterate this communication point because I think it is really important. Ok. These are life changing injuries. They have a massive psychological impact. We now have a regional coronary psychologist, get her involved. Ok. Um, and if you don't know how to get a hold of her, speak to the spine teams, they will know. Ok, lots and lots of repetition of the same message. Ok. It's really difficult to take in all the information that you, they, you give them the first time round, ok? And the second time round. Ok? And some people do enter this kind of phase of denial thinking that things are gonna get better and sometimes that can be for the better. Ok, keeping them motivated, et cetera. But, um, you do have to be honest with them, don't promise them that everything is gonna be ok because it probably isn't. Ok. Definitely speak to the family. Ok? And the family will be devastated by this too. Ok? But they are gonna have to number one support the patient psychologically, but also physically. Ok. Um, doing bowel care on your relatives, um, having to help hoist them, help them transfer, um, having to push them in a wheelchair. Is a, is not what most spouses signed up for when they've got, you know, when they married someone, it is a big change to their life too and does have to have an impact. Ok. There are, of course, financial implications too. Um, and there are some, uh, sign posting partnerships that you can refer the patient to, but be honest from the start. Ok. Um, your, so what I say to my patients is look, time will tell us exactly what recovery you're gonna get. But it is very unlikely that you won't have some deficit from this. And depending on what they're with, then we can guide them as to what their deficit is likely to be. Ok. Um But be honest, right from the start, you're not there to be their best friend, ok? And to make them feel, you know, better and for them to like you, you're there to be honest with them and give them the best medical information. Ok. So please be honest with the patients because undoing that dishonesty can be really troublesome. Ok. So we've spoken about anatomy of the spinal column and its function, anatomy of the co is central and its function. We've spoken about injuries and all of the different implications of that injury and how to look after them and a little bit extra about fractures and such loads of information. I've been waffling on for near enough hour. Ok. I'm more than happy to answer any questions that people might have. And if you think I missed anything, let me know and I can try to answer that too. We've got about 10 or 15 minutes. I think any questions everyone to sleep, Miss Mars, this is Jose side. Um Going back to your patient with the if these patients were to come into emergency, um how do we then go about immobilizing this vital spine or how should we proceed in terms of being careful? Fine. So, so the first thing you do is you try to restore the anatomy as normal, so you can judge it to be. Ok. Now, you don't know exactly what they look like when they were before their injury. Ok. But it's quite clear if they've, so if they've got a, um, uh, a really severe kyphosis, I've got nothing I can demonstrate this with. Ok. But if they've got AAA really severe kyphosis like this, OK. What you can do is you can put three or four pillows under their head, ok? To try to support that. So that, that you're not making their head extend like this to go back with our flat table. Does that make sense? So usually what I would do is two or three pillows depending on how much kyphosis they have. Ok. And then towels, either side, rolled up towels, either side. Ok. So don't put them in a collar. Ok. And then the tapes across either side. So just try to stop that rotational motion. OK? But, but not trying to force their head into extension. Um You know, a lot of these people will sit with a hyperflexion deformity, sort of a hyper flexion deformity and extending that all you're doing is just, just displacing the fracture. OK. Thank you. And I'll add up uh like many times you will find that it's better to ask the patient what position they are because they know, you know, they, they are, they're stooped up. So if you just ask them, they will probably tell that. Look, this is my normal position and that's why we need to do it. The first thing is to basically somebody forcing them uh into the position, which you think is right. Uh While the patient many times will just say like look, this is my normal position. Yeah, very treat. Anything else doesn't look like it? Are you happy to start early of it? Um Thanks, you covered everything which I wanted to cover anyway for the court. So I think I will ask them the question then. Ok, so share the entire screen, isn't it? Yes, entire screen. Um Oh, this is getting more confusing to me. This looks like one of those crazy mind spending things. Yeah, I think I got this powerpoint on my screen. Uh But I'm just trying to understand how to get that uh into this thing. Can somebody see my uh screen? No, we could just see the nothing, nothing's being shared at the moment. Ok, honey how I do this? Ok, I think I have to log in and log back. Sorry. Ok. Mhm. There we go. That's about it. I can't hear you now though. Yeah, so can somebody uh everybody can see the screen now? Yeah, so we can see your screen. Yeah, good. Um so how many guys are there now? Um in the room? I'll tell you one second. There are 21 including me and you, you fell. So I think to, you've come to everything which I really wanted to say. So I'm going to be more attractive and asking them the question as to what they see and uh what's the, you know. Um So I know people don't like to be answered. Um I don't want to put anybody in the spot. So I just want somebody to be volunteered if nobody volunteers and I will select somebody, I'm afraid. So. Um So I'm just going to talk about the cervical cord syndrome um uh which is basically central cord, anterior cord, brown s cord and posterior cord syndrome. So, as Mr Marum has actually uh shown you a, a slide which basically shows the ascending tract, descending tract. I think all you need to understand is that which part and which track is. And then you could understand why in a cord you will have loss of proper ion, why in anterior cord you will have more functional loss. Why in the central cord, upper limb is affected? Because if you come down to this um slide, you know, this is basically the key. And I think um when you are going for the exams, you should be able to be able to draw this. Because if they are going to ask you about any other cervical cord syndrome, that's the first question they are going to ask you is that are you able to draw the track? And once you're able to draw this, you can easily explain why in the cervical, in the central cord, why in the cervical, the upper limb is affected more than the lower limb. Why in the anterior cord, you know, these lateral spinal t the tracts are affected because you can just see on the basis of this diagram, but I wanted to talk more about the central cord syndrome. Um and is basically um there can be many reasons for central cord syndrome. But it's, you know, the thing with the central cord is that um there can be most commonly a hyperextension injury in the elderly patient who have a preexisting cervical stenosis. So my question is that what should we do? Should we do an early decompression or a light decompression? So, who's going to volunteer that for me? Anyone, you should you do an early decompression to for best outcome of a return of function aster. So, well, we have established that early decompression is suggesting. But if you look in the real practice in central court syndrome, what you will find is that we don't do early decompression. So vast majority of central court patients which we see um do not have early um uh decompression. Uh And do you know the reason why because the cord is quite inflamed and there's high risk of inadvertent injury to the cord. So I think most probably the cation settle down and a delayed decompression maybe two week. Yeah. So I think that's so the the key to understanding this is that. So, yes, you know, if you go to um you know, Mr Fairing every time he speaks and he stands up, he basically keeps talking about this 24 hours and things can be confusing because spinal cord injury and central cord syndrome is basically uh is is a constellation of syndrome. So it's not just one thing. So as I said, the most common one is our elderly patient with hyperextension injury with the central stenosis or the we have preexisting stenosis. Now, those are the patients who also have got high comorbidities. They also have got like uh you know, many of them are on Warfarin or, or one of these uh new um blood thinners. Um and there were complex medical needs. So they are not, you know, this early versus delayed, you know, the paper and the sentinel paper they have produced doesn't incorporate the most common Central Court syndrome patient, we see. So if you go to the um and the C NS guideline, so it's, it's actually quite good and uh you know, to actually look into it and see that there are four different types of central cord syndrome. So central cord, if we know is upper limb affected more than the lower limb. The reason is because of the zone of, you know, injury and but then you need to make that distinction that which one of the Central court syndrome we are talking. So when I was registered, I was always used to get confused as that. They're saying to operate within 24 hours, but we don't operate within 24 hours because what we see majority of them is basically this group of patients who have got like this. Um you know, they are preexisting, you know, stenosis, they had a hyperextension injury and there is no fracture, there is no obvious instability. What do we do? So most centers where I work where I'm working, uh we will, we are not that keen to basically jump in within 24 hours or operate vast majority of them for two weeks, four weeks, see how they are and then take it from there. But if you get any of these kind of patients, you know, with a fracture and with a big disc, they are completely different beast, you know, they may have syndrome syndrome, but you have to treat them this as an acute fracture. So I will take this patient straight away, you know, and at whatever time this, you know, obviously within 24 hours, maybe 48 hours and this one obviously doesn't need to go. So the reason why you see the literature about early decompression of management of spinal cord injury and sometimes get confused with the central cord versus what we see in the practice is because this is the one which we see vast majority of time you guys get it. Is that clear? Yeah. Yeah, good. Thank you. Yeah. So this is the basically the key thing from what this, this is from 2013. So they basically said like early reduction or fracture dislocation is recommended. Um surgical decompression um again, is uh with focal and anterior is recommended. They didn't say anything else about those hyperextension injuries. Uh But this was this uh guideline. Um And as, as you can imagine, the more guideline we get is for the things which is basically no clear but uh idea for it. So this was um another uh Sentinel paper, there was an AO commission which was established and then they try to work out uh that what is the consensus guideline. And again, it comes back to the same thing is that if you've got a fracture, if you've got a disc, then you there is strong evidence for early um you know, decompression. But if you've got um these uh old elderly patient with central stenosis. And then it is the dealer's choice, which basically means that you the, the treating surgeons can decide what they want to do. Um And as I said, like in most of our units, at least in East Anglia, um et cetera cardia, wherever we have work, most of the central cord syndrome, they don't get operated quickly. They go on a bed rest, we see how they are. Um And depending on how much recovery they have, how much comorbidity they have, some of them will have operation, some of them will be just be managed conservatively. So let's look on this one. So he's a 60 year old male, non cervical stenosis, acute deterioration of the fall, primarily upper limb involvement with some lower limb weakness. So who's going to read an MRI scan for me? I can have a look at it and start it. Yeah. Well, so it's a sagittal T two weighted MRI image demonstrating there's obvious narrowing stenosis at the C 34 level with evidence of signal change within the cord there in keeping with a central cord syndrome. Good. So how are you doing to manage this one? Uh a few more images. Uh Cool. So that's, yeah, I've also got the ax images confirming the appearance. So in the initial phase, um I assessed obviously, patients usually had a fall. So I assessed them with an at assessment as ATL protocol. I would also document there complete a full Asia chart to document my findings of up and low limb and perianal sensation and anal tone. Ah So as part of that, I'd have the patient, I'd also follow the both guidelines for spinal cord injuries and I'd have the patient on flat bed rest initially. Um And then obviously we've got the necessary MRI imaging already um in a So this wasn't. Mhm Sorry. Yeah. So the question is that, does this guy needs an early decompression or can you wait? So is he the guy who is going for a bed rest and waiting for his neuro recovery or is it the guy who you are going to take to the theater and operate? So this is the uh the how how long ago was this injury? Sorry is he's just presented. So he, yeah, he just presented but he had a fall um a few a couple of weeks ago and then he's gradually deteriorating and then he, I mean, it, it's a gradual deterioration and I mean, looking at that narrowing, it's quite, quite a bit significant. Now is I think he's the kind that you would um either the card you'd observe and, and let it settle down first. And then, so based on the guidelines which I've just presented the CNS guideline and the consent statement, which category does he falls into? Is he in the one in the hyperextension injury with the non cervical stenosis? Or is he the one with an acute disc herniation. He's the uh the first kind. The, he's got known cervical stenosis with uh a full likely hyperextension injury. Yeah, that is true. But he also has got a big disc herniation. So I decided to him. Yeah. Yeah. Um So if you operate, what are you going to do for him? So in this case, I'd go for a 34 ACDF. Perfect. So that's good. Can I ask somebody else? How will they consent this patient? I think they will just send them for the, in addition to the usual ACDF procedure for electric patient, I would consent them for basically need to tell them this is a, there's no guarantee of improvement and, and that obviously because it's an acute injury, there is swelling to the cord. So there's a higher risk of um damage to the cord, the juror. And um again, the aim is to basically hopefully arrest the damage and not last, you know, depending on what his symptoms are on. Presentation aim is to basically um essentially avoid his symptoms getting worse, not, not aiming for improvement. Obviously, obviously, there may be improvement, but obviously, that's not guaranteed. And along with all the other risks of risk of strokes and potentially further surgery. Yeah, so that's good. So you obviously you make it clear that the, it's like every other myelopathy operation that look, this is to stop the progression. You know, you may get some benefit, but that's not guaranteed. Um As long as you understand that there is an injury to the, uh, to the cord. So there will be some residual damage, which is good. Um, so what are the risks of the, uh, you know, when you talk about ACDF, what are the, uh, what are the complications? We talk about? The commonest ones are obviously hoarseness of the voice, which is usually transient. Obviously, you need to explain to them if it lasts more than six weeks, it may need further further evaluation by the ent team. Risk of injury to the esophagus, trachea, POSTOP hematoma can be quite scary. They need to be educated about that as well. So if they notice any issues with breathing, they need to let someone know straight away um and risk to the blood vessels, you know, carotid internal jugular risk of catastrophic hemorrhage during surgery. Um And I can't really think of anything else at the moment but injury. Yeah. Ok. Yeah. Ok. That's good. That's good. Um ok. Um So this is what we did. Uh Can you see what we did? Yeah, you've got so you can Yeah, fair enough. Um So then there is the next uh case. So can somebody else have a look on this one? So, same uh you know, more involvement of the upper limbs um has got uh um anesthesia um and some subtle weakness, lower limb is actually completely fine. Any more volunteers I mean, is, is that significant soft tissue edema in the in the posterior um uh ligaments in that whole thing? Yeah. Well, how will you interpret this MRI scan? Uh so slightly different. There's not so much significance in terms of preexisting spinal stenosis. There's so 2345. So there's some 56 and 67 ah anterior narrowing, but it's not as significant notice as the previous case and there's still some signal change at the 56 level but not to the same degree as the last case. Um So this sounds more in keeping as that sort of the latter type of group that that's got an acute traumatic or it's not a disc herniation, but it's an acute traumatic cord injury as opposed to preexisting. So history is that there's a guy who was actually playing with his child uh on a zip line, slipped and fell down. Um And then immediately noticed um severe pain in the neck, uh pins and needle numbness weakness in his upper limb. Uh and he was brought by the ambulance. Yeah. So does that make it? So it is, it is an acute traumatic injury but and potentially with a hyperextension um in that he's got extensive. Well, no, actually is it um would it be more of a flexion type injury from this posterior uh inflammation? Yeah. So that's the thing which I've circled because it's not very clear on the MRI scan. So I didn't want her to present the whole video. But what can you see there? Is that a classic joint subluxation? That's correct. Basically, this guy had like a, a factor dislocation. So how will you manage this one? Well, immediately in a hard collar and triple immobilized. I suspect that that's how they would have been brought into the emergency department. Um, from a spun point of view, the next step could be garden wells, tongs and apply them with a load at the top end of the bed. So that being done in, I've never seen it be done in any. Um um I know it was in the book, but in general, we don't do it. Um But go on, how will you assess and manage it? Um Well, it's got, um, so you look for, um, so you'll be, he'll be on the collar. You, um, you do it under local anesthetic. You, uh the insertion point of the pins would be roughly a centimeter and a half above the ear. Um And once you've attached the um tongs, you uh suspend probably about in increments of um a pound. So you're trying to do a reduction in A&E. Yeah. Well, like I said, like we don't do that in A&E. So, you know, this is obviously the, the theater. OK. My question is that, um, so the, the basic question is that, is it, is it the early group or is it a late group? So, are you going to operate straight away or are you going to wait? Well, you said that there's neurological deficit. So, you know, sort of time is ticking. So you've got to treat this as an emergency. Um And yeah, yeah, so this will be like uh um like time is fine, you know, you basically is like, well, all Mr Fair and what he talks about, you really have to do it within 24 hours. You have to take the patient in the theater um and try to give him the best chance um and reduce it. Um Now how will you reduce it? You tell me what, um often, often when you lay them supine and strap their head in and they do sort of click back into place. But if they don't, you can apply gentle traction to the head as well. But I mean, obviously in the acute setting, you would expect most of them to reduce as soon as you put them supine and strap the head. Um And then you just fix it in situ, I mean, in a decompress and fix it in situ anteriorly. Uh You've got the option to go posteriorly as well if you feel uh anteriorly, stability isn't good enough for that as Yeah. So what are you doing? Ok, fair enough. So I'll show you what I do. Um So I actually it's both and procedure. Yeah. Um uh and um sir, can somebody tell me about the anterior approach to the cervical spine. Uh It's been a while but um your, your main landmarks is you've got the um se m laterally and you've got the, the, well, the tracker and midline structures medially. Um So those are the main things they have to protect on the way in. You've got your skin, subcutaneous fat plasma. Um and then you're coming down to the fascia underneath that. Um oh gosh, it's been a while. Um I mean, the main thing is that you need to traction the esophagus and trachea slightly me in order to access your anterior disc space well through the A LL and anterior disc step, you get skin, you get, you know, you identify the plato what do you, what do you identify the next structure? Uh The next structure is um So you've got, also got your um uh you've got your carotid vessels uh on the lateral, laterally. Yeah. So you identify the carotid vessel. Once you identify the carotid vessel, you know that you're in the right plane, you got a blood dissection of the spine. Um When you are at the C 56 level or C 67 level, you can get a muscle in between. Do you know what muscle is that called? Um hyoid? That's correct. So it is hyoid and now some people take the hyoid off, some people don't. Um But if you're doing like single level surgery, maybe that's, that doesn't matter that much. But if you're doing a multi level two, level three level surgery, it's always good to take the Hyde off. Um It gives you like a nice um um like an open access to the cervical spine from the top to the bottom. Um And then obviously you can do that. Um posterior stabilization. Um So how will you do? You may feel? What kind of uh how do you position the patient for stabilization? So, I mean, in this scenario, II suspect you would have finished an interior then closed and they had to flip the patient over. But yes, you will have to use a male fuel clamp. Uh And with the assistance of several other people, you flick them on the operating table and lock the construct into place and then you can make small adjustments afterwards, ensuring you're happy with your approach and obviously have to expose more by giving them a shape as well at the back of the head. Good. So the other question would be is fracture dislocation again. So it's like a simple call. But fracture dislocation is again a very common thing. And once the question get asked, then will you approach it and your first or posterior first? I mean, um I would prefer anterior or posterior because there's a low rate of complications and posterior, they just continuously bleed and have lots of wound complications postoperatively as well. So if you can, if you, once you've done anteriorly, you assess for stability, you get flexion extension views. If there's any concern of instability, then a judgment needs to be made intraoperatively with potentially another senior colleague. Um whether you need to approach it a positive result, although I have seen this being done in stage stages as well, so ad have done and then a week or two later, later you come back and do it posteriorly so it can be done as a stage procedure as well. Yeah, that's what it done stage procedure. So now that's all all about central court syndrome. Um A court syndromes, they, you know, they're not common, sometimes they can ask you about it. But again, you can go back to the same diagram and see if you've got an in an injury to the anterior part of the spinal cord. Um you know, you can get, you know, there's a lower extremity affected more than the upper extremity. But essentially anti cord syndrome is more like a total spinal cord injury. So that patient behaved, not like a central cord patient that behaved more like a a complete cord injury patient. Um Brown Sicard again, you know, so basically that first slide with Mar showed and I above is that's the main thing. And once you understand that slide, you can understand all these like Report syndrome. So Brown Support syndrome, um they are not very common uh but they're very characteristic. But the good thing is that their their uh recovery is very good. So I had one patient who had a stab in his neck and presented with Brown Support Syndrome. He was alcoholic. Um and we just treated with the antibiotic just because of the small wound. Um And then he made a full recovery and Booster syndrome is very, very rare. You can only get loss of proper reception, but you got preserve motor and pain and light touch. But um the key, as I said is like, you know, the key is basically remembering this diagram. Um and you can basically answer all the questions about, you know, your uh cervical cord uh uh syndrome. But then when also, when you're seeing the patient, sometimes you will see a patient which not exactly with cord injury, but there may be a SCC patient and you will see that he has got only posterior column involvement. I was only, you know, the rest of the fine, you know, he's able to walk, but he he has lost his balance because you know, the compression is posterior. If the compression is anterior, they may get more motor involvement and the sensation may be preserved. So remembering this diagram may actually help you a lot in assessing the spinal patients. So that's all I have to say. But you guys do you want to ask any question? Could you go back to that cross section you mentioned in the beginning? I don't know if you mentioned clearly about why are the hands affected more than the legs at different levels? What was the, what's the exact reason for that? The um cervical column is actually more central. So, you know, if you, if you get a central cord syndrome, which is basically affecting centrally, then the cervical columns are actually more central. Um let me try to go back. But if you, um so if you see centrally, is, is it the, the cervical is actually more central? So this part is more central thoracic and lumbar. So actually, if, if anything is involving the central cord, the cervical um fibers, they get affected more than the thoracic and lumbar. So it's the other way around. OK, thank you. Good. Um Do you want to ask me anything else just in case I missed it, when do you decide whether to stage the procedure to do anterior then come back outpatient again, had a stage procedure. The reason is that most of the time these operations that happens in the middle of the night. So the idea is to basically achieve a stability. So, you know, you're basically protecting the cord, you're decompressing it, you've done the ACDF. So essentially, you've done the operation. Uh the posterior procedure for me is basically adding an additional stability so I can take the collar off. Uh So I always stage them. Um I've seen people doing like full at one go, but I personally feel that it becomes too much of a surgery. So you can go in and do like the critical bit because when you're doing the first part, you know, although we say like the reduction is easy, it's not easy. Um It can be very tricky, it can be very difficult. Um And so the way I do it is instead of putting the um uh Shain, I put the Mayfield clamp. So I use the Mayfield clamp, reduce the fracture and keep it there because sometimes you may reduce it and then the reduction fails and then it starts slipping back into the position. Once you've reduced it, uh you can keep the Mayfield clamp. You do the decompression and everything, then ask your assistant to go back and do the reduction manual work and you can, you know, you can reduce on the plate. Yeah. So you can basically put two screws in the bottom plate, your assistance, reduce it back again. And then you log the top plate on, you know, it's like the standard we do for the ankles and other places. So, so that's the, that's the key. So, and I think you're stressed. So I was, that's what I do for all my cases. I do it like a stage. The only time you need to mandatory, do both front and back is when you can't reduce it. So you bend, you can't reduce it and then you have to flip it back, try to reduce it from the back. And so basically, it's become 540 procedure rather than 360. And they are obviously rare, especially if you take them straight away and they are like, they're like hips, you know. So if you do the hip uh dislocation or the shoulder dislocation straight away, they are much easier to be done if you leave them overnight and then try to do the next morning or next evening and the same shoulder dislocation or the hip dislocation become nightmare. Same thing happen with the neck fracture dislocation. You do it straight away, it's very, very easy. You can reduce it back and once you reduce it back, you know, um then it becomes like an ACDF and post stabilization, there is a reduction which is difficult and you need to know multiple reduction maneuvers uh uh because it, you know, not one is like a bullet so you can reduce the mayfield. Uh And that is why MRI is important. So why some people will ask you is that uh do we need to get an MRI scan or not? So you need an MRI scan to understand where the disc is. If you were a massive disc sitting in the canal, then you really can't do a close reduction. You want to do a discectomy first before you even try to reduce the fracture. Uh So I always do the MRI. So the moment somebody calls me and say like it's gonna fracture dislocation, I at home, I probably say like run them through the MRI scan. You have the n is ready um By the time everything is done, um you will find that um you know, the MRI is done. You are done with me, sir. Is it with fracture dislocations? So you know. Uh yeah, yeah, we had, we had that many run over by a horse and carriage or something. Yeah, yeah. So what I do exactly for all patients. I get them scanned. Um I take them to the theater, I use them. I do the ACDF um And the first go and then do the stabilization. Uh uh Next time. Great. Thank you. Good. Anybody else? Any questions? Uh Nothing in the chat. Yeah, I think that's it. So, yeah, but I didn't know what to prepare for the Central Court syndrome because it was 1.5 hours and there was nothing much to talk about it. But, you know, the key thing is, as I said, that the only take away from, from my talk and especially with Master of Trump is going through all the anatomy anyway is uh you need to know that that diagram, you know, you need to be able to draw that because if they are going to ask you about Central Court syndrome, they are going to ask you to draw the diagram. So that is one thing. Um The next thing which II say like autonomic dysreflexia is very common. Um So in I PSS, we have a lot of these spinal cord injury patients. Um and they do get these kind of autonomic dysreflexia. Um And if you're a new junior or you've never dealt with them, it can be quite stressful. But as long as you know, that this is a cord injury patient, this behavior is a pattern of autonomic dysreflexia. It's basically they're constipated, you know, the most common reason and because they usually have a catheter, um then it's very easy to manage. Um And uh yeah, and II think the confusing part is basically about the timing of surgery. Um because if you look on the evidence, it always says about 24 hours, 24 hours. But what get missed in the point is that the evidence is also there is no high quality evidence to do the surgery in patients who have preexisting central stenosis, elderly patient with hyperextension injury. And what they say is a dealer choice. Uh and most centers in the UK will not do urgent surgery. They will wait. Is that the case Tom as well with you? Uh in no, um they wait for some time for those e central cord, I think, I think margins just dropped off the call for a moment. Sorry. No. Ok, that's fine. So, um yeah, anything else do you want to guys ask? I think you've answered all this Ahmed. Thank you very much. Good. Well, thank you. Bye bye. Bye bye. Ok.