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Talk about some of the anatomies pertinent to the anterior approach of the spine, which I'm aware is a popular Fr CS or viva question. So I thought I'd actually put that in as a specific subject and go into some detail about that because that is a popular question, particularly the four fascial layers. So we'll go over that as well. And then there's a few slides at the end of our examination of the c spine which are fairly basic. Um I think many of you probably know most of it, the most I will say about examination is this is not something you can learn from a slide show or even really a book. It's a good start. But and you should be on that by now. It's really about going to clinic. So this is a good time during this term if you, if you have access to a spinal clinic, um particularly with some new patients or even a follow up patient to ask if you can join one or two of those clinics, just a practice examination, a practice history taking. And it's a good way of stimulating the gray cells in, excuse me, in conjunction with this next four weeks, which um just to mention will culminate on the 25th of July with a meeting at the Bob Champion Research Center at the Norfolk and Norwich site where we will have some clinical cases and we'll try and conduct a sort of FR CS or long case, maybe a few short cases scenario depending on the number of patients we have and the number of people that turn up that day because I know it's well into the summer time and some of you may be off on annual leave and other things like that, but that will be available on that day, right? Let's kick off. So let's start off with some anatomy. Um, so the first thing to appreciate, um, and we're gonna look at is the the spine being such a slender, the cervical spine being such a relatively slender part of the spinal anatomy. Um, in terms of there being a large head and this cherry with a stalk underneath arrangement means that it is vulnerable and it, it needs to have a wide range of movement for us to be able to do what we did, particularly sort of when we were hunting and running away from animals millions of years ago as you know, so its function is very much set up for what our needs are, but it makes it more vulnerable, particularly when it has an increased range of movement both to injuries which we'll swim and we'll talk about later on and you really need to break that down into the very constituent parts because there's some fairly unusual vertebra in the spine, which I'm gonna spend some time talking about and I'll talk a little bit about some of the more per pertinent pathology, but that will be covered obviously in other lectures. But a lot of these questions will be centered around sort of vi exam questions and things like that. Just a, just a quick check in. Can everyone hear me? And am I speaking at a reasonable pace or is it too fast for everyone? Hello? Ok, good. That's fine. Thank you. I'll continue. Um So there are two main parts really that when some, some surgeons still talk about the spine, there's the axial spine and the subaxial spine, the axial spine refers really to the upper two most vertebra, which are the atypical cervical vertebra, which are very important in its relationship to the sort of fairly stiff part which is this big skull that sits on top. The subaxial spine refers to everything from three down to seven. As you can see there, you'll see later on that the ranges of movement are particularly large in the axial spine, but they also peak around the midpoint of the subaxial spine. But of course, it by the time you get to C seven T one, you've got a very thick stiff thoracic spine. So the range of movements will decrease proportionally as you get closer to that sort of stiffer junctional area at C seven T one. Um Remember I always like this slide. Remember when it comes to considering the biomechanics of the spine that it really is like one of those big cranes that you see, you know, around London and other building sites where you've got the compressive load going through the anterior strut. As that slide shows about 80% of your weight roughly goes through that part of the spine. And then posteriorly, you have this tension band arrangement where you can see at the back in the posterior column. And if you imagine something like the fourth and the fourth bridge, that's probably the most commonest example of a, a construction which relies on that prints basic um biomechanical principle. And this is of course, very important when you're considering the alignment of the spine and dealing with cervical trauma or when you're dealing with other pathologies where the stability of the spine, which of course was originally defined by Punjabi and White. That's a very useful definition to know for the exam um is threatened or at risk or indeed um has been affected. Um because this is an anatomical section, we'll quickly talk about um anatomy and development. So there's remember there are three main sections as the embryo develops right from the first week, which is, you've got the sclerotome and the derm derm dermatomyositis and each of those individual somites go on to form individual vertebra. That's what the bit in blue is. And then the muscle is the der dermato dermatotome um area in orange, the notochord, which is originally a sheet folds over and it's not the notochord that's underneath. But the neural tube, which is really a neural sheath initially folds over and that's where the central canal is in the middle and that becomes the cord as out on there. That's just I think as long as you know about those three basic parts, the neural tube, very quick revision here of sorry, some of that text is cut off. I don't know why. That is a revision here of a cross section, important cross section through the spine. It is labeled accordingly. And I really want to draw your attention to a few important anatomical features. That is the sympathetic ganglion here, which runs from C seven upwards and is um present particularly at C seven. Um where you have the ganglion uh C seven, which is important to the sympathetic f function. Does anybody know what that's called? Can anyone tell me what that's called? That ganglion has got its own name cos of it the way it looks. Hello, this Ed Ganglion. Fantastic full marks over that was, I'm sorry, I don't know who that was but well done. And you can see here that's the main spinal nerve coming out through that tight canal sandwiched between what is a tiny pedicle between the transverse foramen and the facet facetal facet joint, which is around here and um between there and there, it can get sandwiched by the disc and of course, by this joint, which can cause osteophytes and trap the nerve just like it does in the lumbar spine, which is also a very got a big range of movement. These are lots of cross sections of the epidural vessel. And here here of course, is the cord with the sulcus at the front. Um And you can see the anterior and posterior uh remi and then of course, it's the anterior reai that gives off these pain fibers around here which supply the disc and all the rest of it. I think that in purple, they're light purple. That's a representation of the um anterior longitudinal ligament and the posterior longitudinal ligament, which is important. Good. And then you've got the jira excellent. I got the dorsal root ganglion which is quite sensitive. Um Right. So let's, this is a little ii got these from my old lec this um lecturer years ago. Um I quite like this. It looks like a busy slide, but it's actually a fantastic summary of the type of things to look out for the typical cervical vertebrae, which you might be handed a aviva and you might be asked to talk about it. And so the important things are all the things here that are listed here that you could talk about the fact that anatomically it's a bifid spinus process, which is important when you're doing a posterior approach to the spine because you can feel for the bifid spinus process. OK. One of them, apart from C one that doesn't really have much of a spinus process at all. Can anyone tell me which of the v which vertebra doesn't have a bifid spinous process tip? Does anyone know which one that is? It's written on this slide? So that's a big clue. It's C seven. No one's spoken, but I'll save time. So it's C seven. OK. So if you're trying to feel for C seven, it's a pretty easy way to do it posteriorly when you're doing an approach to the spine. Of course, they also have these really important things here. Unconvertible joints also known as the joints of Rusher. But that doesn't matter so much as long as you know, them as the unconvertible, they are unique. Two. Can everyone see my cursor moving around the screen? Can you see? Um And the uh yeah, great. And apparently you can see it and the um facet joints here which align with those from the side. Um I think the rest of that is fairly self explanatory, but that's a nice and also note C six has a particularly prominent um anterior cubicle. So the anterior cubicle is this little thing here which I'm circling here. And why is that important? Does anyone know why that's important why that's been identified. Hello, because you can get, you can stretch the nerve root during an anterior approach to the neck and it gets stretched and pulls as a traction injury around the cubicle. And you can wake up with a neurapraxia of that nerve root. So that's one of the reasons why that cubicle's been identified. It's quite rare but it can happen and it also passes, it's not a landmark because it passes close to the common carotid artery. Um Right. Let's keep going. Right. So here's some pictures of the axial spine that I spoke about before. And you can see C one on the left, C two on the right, you can see they're different, got an, an C one particularly has got an anterior and a posterior arch. So again, it's a bit like the pelvis and the polar mean, if it breaks, there's never gonna be a break in one place, there'll be a break in more than one place. And frequently it's quite comminuted. It not often associated with neurological involvement, particularly in the elderly who get that type of fracture. The most that type of fracture has a name when you get a fracture of the C one posterior, anterior and or anterior arch. Does anyone know what it is? It's named after an American president. Great. Someone's just said Jefferson will accept that. Um You can see the dens here which has its own little articulation with the back of the arch there. And you can see it's got a bifid, big thick bifid spinus process behind the back of C two, which is quite important. We'll look at that anatomy in a bit more detail later. And of course, it's got the transverse foramen and this is the area where the vertebra artery ends and it loops around the back of the um posterior part of the sea arch. There's a little groove on the back of the lamina before it goes through the tectorial membrane and forms the basilar artery as it goes into the foramen. Very important. And there it is on this slide, you can actually see it's been drawn really nicely by these diagrams. You can see here the dens which is being held in place by a green ligament inside the arch, anterior arch of um C one, does anyone know what that ligament's called? It's the one that gets attacked and destroyed in autoimmune diseases, particularly rheumatoid arthritis, which we're seeing less and less of, of course, because of the biological treatment. Does anybody know what that? No, the A R is at the tip of the dentist. Does anyone know what that little green ligament is there called G? Yeah, it's a transverse cos you can see the way it's working, but it's important to know about that. Cos that's the one that disappears in rheumatoid arthritis. Also, what you need to know is that you've got just below coming over the top of the C two pedicle below the C one is where you have the greater occipital nerve, which can often be AFA cause of pain and discomfort, uh frequently with occipital neuralgia, which you can inject. But the pain team do it and sometimes they do it under ct guidance. We don't do it as spinal surgeons. So, yeah. And there, this is a little steel rules of third, nothing to do with me. Um He's basically, it's quite useful because you've got the dens at the front that takes up a third of the space. A third is for the cord and the rest of it is for the epidural space itself. Um That's quite a nice way of looking at it, particularly when you're looking at pathology and when the dens has moved because of instability, as I said, usually from autoimmune diseases or even from trauma. Bit unusual though. And it's highlighting where the groove is for that vertebra artery. That's an important landmark when you're operating on these vertebra, which isn't very often actually to be honest. Uh but when you need to operate, it is, it is important usually in trauma. This is the C two you can see here, that's where the ach called ligament goes at the top. And there's a small little ligament that attaches to the bottom of the clivus. And there you've got the articular facets, articulate with the Atlas C one and you can see the transverse foramen and the greater occipital nerve coming out to the side. And there's a nice side view and you can see here, posterior view there is the all important vertebral artery and we'll look at that in a little bit more detail in a minute. Um Yeah, feel your own. Yeah, it can sometimes be palpable if you have a feel on the back of your neck. This is an important little picture. I think that one at the top that I'm circling now because it shows a lot of the anatomy that you would sometimes miss that you see on act scan and to a lesser ex uh better extent on an MRI scan. A CT scan, you only see the bony bit and there it is, there's the apical ligament. You have the alar ligaments coming out from side to side and there's that crucial transverse ligament that's holding everything inside. And it's got this star cross shaped arrangement and that's the one that disappears in rheumatoid arthritis. Um You can see it here there, it is. That's a really nice picture of it in green here. And you can see the artery, first of all arteries swooping after the coming out through the transverse foramen, going into the back of the pectoral membrane, uh just above the arch of C one. And when you operate on the back of C one, you're very close to that artery. And this artery can sometimes loop right down behind the posterior arch of C one. If you damage the artery, the virtual artery at that level, what are the risks? Does anybody know what the risks are to the patient? Anybody? Yeah. So you, yeah. So there is usually a dominance. If you hit the dominant one, there's a risk of a catastrophic reduction in the blood supply to the brain because the basilar artery is the main supply to the circle of Willis, which in turn can lead to a stroke uh depending on how good and how quickly your coaxial vessels from the ring of Willis can respond. But that is a cause of sometimes stroke and death uh to patients. That's hence why I mentioned it. And of course, the transverse ligament that highlighted there is a major stabilizer and then you've got the alar ligaments which go out out either side just above the transverse ligament, which are also uh stabilizers but do reduce the rotation. They do interfere with the rotation just diving in with a bit of the development of the peg. If you see these in younger x-rays, you shouldn't really be seeing these too much cos plain x rays of the spine are not always that useful. There are exceptions in this age group, particularly the younger age group because the radiation exposure is much less than the CT scan. And if you see this sort of thing that you know, certainly up to the age of three or four, then it's not unusual for there to be this ossification at the tip of the dens. And this does not represent what I'm highlighting here. A fracture. The other thing that you can often see is this, there's a subdental synchondrosis which you can see under here and frequently that can be mistaken for a fracture. Uh but that usually disappears a bit later in life when they're 11. Also, the space between the anterior arch and the dens is wider in Children, you can allow up to five millimeters, I believe as opposed to less than three in an adult. And um there is the uh there's a few crucial bony landmarks that you can use for CT scans. And you've got the adi which of course refers to the anterior dens, intervals opposed to the paddy, nothing to do with diving posterior uh Atlanto dens interval, I think it's called and there's the Atlanto dens interval above and it should be less than five mil because of the transverse ligand, which is the main stabilizer as we've said. But that one of the main, as I said, it's usually some rheumatological conditions, but this is disappearing more and more now as a problem with since the introduction of biologics because they're just so effective. Again, if you do have disruption of those stabilizing ligaments, you can get occipitocervical problems. And there's these three lines, rays chamberlain and mcgregor's, you probably only need to use one. I frequently use MC rays because it's the easiest because all you're doing is you're going, drawing a line between the tip of the clivers and the tip of the bastion which represents the front and the back of the frame of magnum. And it should pretty much line up with the tip of the dens. And you sometimes see that it will, it will uh protrude above that. Does anyone know what that's called when you see that radiologically? What do we call that? Hello? Well, there it is radiologically. What is that? Radiologically? When we look at it, it's called basilar invagination. And you can imagine that this degenerative peg which has moved well above Mre's line which I'm drawing out there, good 56 centimeters or more is now pressing on the brainstem. And that obviously is not always that good a situation, but we're seeing it as I said, less and less now. Ok. So now dealing with the rest of the spine, you've got the cervical vertebra down below uh the important areas to look out for. Again, is this unusual joint which is unique to the cervical spine as I outlined by that animation. And that's pretty much what you're looking at in terms of bony anatomy. When you expose the front of the spine, which you usually only see this area here, this bit is all covered up by a muscle which we'll come to in a minute, which you all ought to know, you can see some of it now and it's labeled there Longus coli muscle just here. And you can see the vertebral artery and see how close that is to the uncinate process. It's literally sometimes no more than one or two millimeters away. So if you, when you're exposing a disc space, if you go beyond the uncinate process or you slip and move outside or lateral to the unci process, you have to be careful that you don't damage the virtual artery even knocking it can cause an intimal problem which in turn can cause it to thrombo, which in turn can lead cata catastrophic consequences that it's already dealt with. I love that picture because it just shows you how close it is to the virtual disc space when you're operating where the transverse foramen are. Um This is a nice little diagram, slightly busy. There's another picture as well. And I want you to draw attention to the big circles. And of course, this is about the fact that there's a difference to the course of the recurrent laryngeal nerve. And remember this is the main nerve that controls the vocal cords and on the right, it loops around the subclavian and all to do with the arches that form in the embryo. And on the left, it goes all the way below the arch of the alta. So it's much further in the chest, which means the nerve is much more medialized than on the right. And this means the right sided recurrent laryngeal nerve with the right sided approach, which right handed surgeons like myself prefer because it's easier and quicker and shorter surgery and less chance of a traction injury, length of traction, de length of surgery does have an influence on that still makes that nerve more vulnerable. And there's a lovely illustration, some other important anatomy on there. Um including you can see here in the sympathetic chain and the vagus. Of course, the vagus lies within the carotid bundle inside the carotid sheath. So provided you keep that intact, you shouldn't have any vagal problems. Um And then there we are. That's a nice little, I think that's anatomy book, isn't it? And you can see here it's quite a nice drawing of omohyoid and you can see just below it. I think it's been moved and lifted away, but there will be the inferior belly of omohyoid, which we frequently cut. And then you've got the strap muscles, sternothyroid, sterno Hyde, you don't need to know these for the exam, just know that they're strap muscles that lie at the front and that the cervical plexus is usually quite superficial. It's meant to look like a goose's foot. You could persuade yourself. It does, which I understand is where the phrase ansa cervicalis comes from because you've got this foot type appearance with little claws coming off the front, which is small, superficial nerves. It's not unusual in a high um subaxial spine approach to have some numbness, residual numbness over the side of the neck due to the injury of that nerve. Um, the sternomastoid is the main landmark. Can anybody tell me why that is in an anterior approach of the neck? What do you look for when you mobilize the sterno Cer mastoid on the medial edge? Does anybody know the main structure looking at the? Absolutely. Absolutely. Well done. Who said that? That's what you're looking for and that what's, and who was that? You Ben? Yeah. Yeah, I recognized your voice to hear you. Um So rather than I said, look for, what's the, what, what do you usually do to identify where it is without doing too much dissection? So the first thing you do, that's it. I can feel some other voices great. You know that, and it's important if you get asked about that approach to mention that because more than anything else, it shows you've done it or assisted with it, which is really good, well done. That's great. And then there's a few other landmarks there. So this is when you've taken away a few more of those muscles. This is what you can see, I think 29 and 30 represents, I don't know, something like a combination of the thyroid and the thymus. You've got the, um, laryngeal cartilage and the cricoid, I think in there that's a residual strap muscle at the front. You can see again, this is the vagus, which they've neatly dissected out from the carotids. I don't quite know how they've done that. There's a hell of a dissection. It's amazing. And you can see here some of the internal, external laryngeal nerves which do have some role, I think with swallowing. And of course, there's the sympathetic trunk which mainly lies over the top of Longus Cola, which is where it can get damaged. And I think the main reason for this is where you can see in red here, this is the recurrent laryngeal nerves. And you can see even here, you could persuade yourself the right sided one is a little bit more la lying lateral away from the midline compared to the left. Um Yeah, here's AAA few more pictures quite nice. Um uh You got the vagus nerve there and then sometime the, the, the, the glossopharyngeal and the hypoglossal, the cranial nerves are closely associated with the submandibular gland as is number seven, which isn't labeled. But I imagine that's gonna be the mandibular branch of the f of the facial nerve. And that can actually, it's very sensitive as, you know, like Bell's palsy, people can wake up with a slight asymmetry to their um their around their um mouth and they're smiling. If you do ac 34 approach or something like that, it's quite easy nerve to, to cause a bit of traction injury to it does usually recover, but it like the vocal cords, it can take absolutely ages if you get recurrent laryngeal nerve problem. Any questions about that anatomy? I've got a few other pictures later on. Right. Let's crack on cos I've got 45 minutes still got a lot to cover. Um, roughly speaking, that is what you would expect in terms of, um, a full range and a healthy spine of movement. That's just the arc of movement, but it's obviously more complicated than that. Most of the movement does take place in flex as well as rotation in the ax axial spine, not the subaxial you, it's actually 50% flexion extension, more like 45 50% rotation occurs at that level. So there's a lot of movement at that level. Hence why if you get a fracture at that level, like a peg fracture or you break a hangman's type fracture, it can be incredibly unstable um and does, does need treating in one way or the other, certainly immobilizing. So the important thing to make preach about the, the spine, it has a coupling movement when it moves due to the orientations of the facets and the way that the bones lie and, and uh including the unconvertible joints. And I love this phrase. This is just one way of remembering if you ever get asked by basic spinal anatomy. There will be another picture I'll show you about this in a minute. I always remember the phrase Boo b Bye. That's the way they lie. OK. So this isn't the beginning of a silly p um drinking song. This actually means backwards and upwards, boo backwards and outwards BB, backwards and inwards are the orientation of the cervical thoracic and lumbar spine in turn. And once you know that you suddenly get an appreciation of how they move and their arc of movement and what they permit in terms of flexion extension and, and lateral rotation. Um and as well as rotate, pure rotation. So here they are, that's the way that this is a little diagram. I've tried to highlight. You can see that's backwards and upwards, the way the facet joints and the lateral masses, like you can see that's backwards and outwards and there they are backwards and inwards lying in there which obviously reduces the range of movement that the facet can do. Uh It's quite important. I have known that being asked, Aviva, here's this, here's some studies by some famous people um showing the range of movement. It peaks, as I said in the middle of the axial spine because C 67 and certainly C seven T one is restricted because it articulates with the top of the thoracic spine which is very stiff. Um the um movement of the spine. This is in relation to disc replacements when they were originally being designed, it's got a roller ball motion, it doesn't just automatically flex down and upwards. The spine actually moves forward a bit when you flex before it flexes downwards. So there's this rolling forward as if the whole thing's moving around a ball. And that's why one of the very first disc replacements were these things. I think they were originally called Fermi balls, which they used to remove a disc put in this tiny little ball bearing between the disc bases buried into the two vertebra. And, um, and that was one of the first things they used back in the fifties in America to try and do a basic cycle disc replacement. Does anybody know a famous president that had one of these balls in his neck? Complete lateral um question, but it's quite interesting and it might help you remember it. Hello. Does anyone know? So J JFK had one in his neck and they mistook it for a bullet. One of um what's the name of that assassin? You know, from the book reposit? I can't remember Lee Harvey Oswald bullet, but it wasn't it, he had a disc replacement done, which I thought was interesting. A little ball. So this is the movement you get, this is a coupling movement to do with lateral um flexion or rotation. It's not just a flexion to the side, it does involve some rotation as well. And uh yeah, now we're moving on to approaches any questions about movements in the cervical spine and the anatomy. Good. Let's move on. So, um those are the really key papers, particularly c cowards, but the top one Smith Robinson today is still the approach. Let's look at from 1958 the approach that is used for anterior cervical spine. So the approach that we use is originally from Smith and Robinson. Um and then there was the clouds procedure and he had put a slight variation on it. So that's the main one. Those are the sort of key historical papers and the development of the approaches to the anterior cervical spine. This is the different types. There's the transoral approach which can be used to get and you can see here easily to the front of the peg. But this is a high risk, poor wound healing, high infection area. And it really only should be done by people who are regularly doing this approach and in this area that really is Richard Mannion, the neurosurgeon and he mainly uses these for some of his um Pury tumors and transsphenoidal approaches as well. But he does also operate on the um fronts of the spine when he's doing chordomas. Um in younger kids, usually, um there's a very high cervical spine, we can get even C one C three from the side of the neck, um described by Dara and mcnab. I don't recommend it um because um it does usually result in some injury to do with swallowing, the superior, um laryngeal nerve gets affected quite badly from this and you usually get swallowing problems. I have seen people um have very long term swallowing problems from these approaches. Mcafee's similar Smith Robinson is the one that we all use. Um So this is another picture of the high retropharyngeal approach, which I just mentioned, which can cause problems. And you can just see from that basic anatomical diagram, which has been teamed up with an actual interoperative picture what you're dealing with and you're even going above the submandibular gland and there's a lot of clockwork up there. And you can see um the um hypoglossal nerve could get affected. The um certainly the mandibular branch of the facial et cetera. And then that can cause problems as I'm sure you all appreciate with eating and f and, and cosmetic appearances. If you do want to get to the front of the spine, particularly in cancers to get a good exposure um uh to decompress, then probably the best is to get your max fax people in and they can do a mandibular spit, which is called an open book approach where they split the mandible disarticulate one of the temporomandibular joints and you get this hell of an exposure. It's quite extraordinary. And the number of times I've seen it, which is only about less than half a dozen in my career, you can see with that photograph in the top uh bottom right hand corner, they usually they're very swollen face postoperatively, it disappears in 48 hours and the healing is amazing. So particularly if they grow a beard like this bloke, you do have got a scar but they do very well. It's an extraordinary approach and that can help that. That's really only to be used mainly in tumor centers or some really nasty um trauma or tumor. This would be a sort of fairly classical position for an anterior approach to the spine. In this case, I've got some traction. You can use that if you want to, the neck is usually slightly extended. There is usually an intrascapular bolster as many of, you know, and we do like to strap the shoulders, particularly if we're trying to deal with the axial spine to make sure we can go good, good lateral views and you should all check that beforehand and mark the skin. Um This is just a quick summary of Smith Robinson's approach. There's the different levels that you might use in relation to some of the key anatomy in the neck and the top left hand corner. You can see a finger here going in feeling for the carotid pulse, which I'm just highlighting there. And that is really the approach um through there and there's a sterno, a mastoid here has been moved to one side. You need to be careful because the recurrent laryngeal nerve does lie between the esophagus and the back of the trachea or the side of the trachea pretending the side you're on. Those are the different levels. Um Yeah. And this is again, this is a cross tule of uh chassis neck. That's the one where you can get that neurapraxia. If you pull too hard. And remember there is no, they sometimes ask this, there is no vertebral artery in the foramen of C seven, you only get the vertebral vein, the vertebral artery and vein are then coupled together through the transverse foramen of C six, all the way up to C one. That is why the C seven vertebra is used for osteotomies and ankylosing spondylitis. When you used to get these sort of question mark spine and their, their chim angle is completely gone and you can osteotomy C seven without danger, uh any risks uh to the vertebral arteries by working on the C seven vertebra. That's the main reason. Um Here's a little picture, what am I highlighting there. Can anybody see in the red circle? What nerve is that? Uh so recurrent laryngeal, correct? Well done. Um And, and there you again, you can see the approach just underneath sternocleidal mastoid with that blue arrow. It's quite a nice little picture of that to get to the front of the spine and things to tend to mobilize really nicely unless of course, they've had previous surgery to the front of the neck. In which case, you must check the function of the recurrent laryngeal nerve because frequently people can have palsies of the vocal cords. And um they're often asymptomatic and the risk there is is if you operate again on the opposite side to the palsy, then you can cause a palsy to both vocal cords, which of course leads to as all as you all of, you know, stride or, and Respi acute respiratory difficulties, which is always a shock when they pull the tube out, POSTOP and suddenly they can't breathe and it's difficult to get the tube back in without damaging the cord. So it's very important. You always do get the cords assessed before you go back in. I love this diagram because this, that little purple nerve there shows you where it is on the left, it's closely aligned and on the side of the trachea. And that's making it much less vulnerable to a traction injury. The recurrent laryngeal nerve compared to the right. That's why that picture you can see the p the purple hooking underneath the ar the tic arch there just to show you anatomically. This is probably one of the better cross sections. The fascial layers that you must know are highlighted in green, but there's one missing which fascial layer is missing. Folks, you got the investing layer, you've got the pretracheal and this big thick sheet here is pre vers doesn't know which one's missing the four layers. Yeah, superficial fashion. Yeah, it is well done. Yeah. Yeah, well done. I'll highlight it here and it remember the superficial invests as it were similar to around what the, the, the, the, the sternocleidomastoid here invests around platysma, it's very superficial, it's just under the skin, uh, and it forms part of that, you know, that original embryonic thing that some animals have, I think like horses all over their skin called the, er, er, calmus panicularis or something. Anyway, we have it in our scrotum as well, don't we? So that's the platysma there and it's important to repair that afterwards for cosmetic reasons. But, yeah, well done. So those are the four layers you will get you if you do get asked about an approach there. I don't know why examiners like asking about it investing, pre, superficial investing, pre pre first of all, those are the four levels layers. Oh sorry, in order apologies, quick jump. Uh That's just another picture of the anterior approach to the spine. I need to crack on because I've got to do examination though. There we are. It's a nice little summary of the um of the complications. Remember when you fuse the spine there is this two f 2.5% per year of an accelerated adjacent segment degeneration from Hillebrand S paper in 2001 in the American JB GS. And that's that is that is a pretty good data uh in my opinion, and that does need to be mentioned and hence why we've been so keen to try and develop disc replacements to mitigate that risk, which I think they do to a certain extent. But I think over uh my opinion, most cycle discs are not working much beyond at the very best 15 to 20 years. So when you do a neck neck fusion or a neck disc on someone that's at 20 or 30 years, even 40 years of age, they will eventually get that problem, but it's good to mitigate it. I'm sure you agree. Um I love this paper. This is amazing. There's this, there's this n neurosurgeon that also did an ent job in Germany called Axel Jung. And he must have clearly been really good at doing indirect laryngoscopies. Now, that's as I understand, that's with a warmed little dental mirror and you get and say, ah with a tongue spatula and he was looking at the vocal cords and this guy did about 300 indirect laryngoscopies on different neck surgeries left and right, all to do with anterior approaches. And he's got some credible data and he discovered if you go from the right side as opposed to the left, you can see there's a doubling of a of recurrent laryngeal nerve palsy, even though the vast majority of them are asymptomatic. And um and then if you use the pressure cuff thing which you use in peds and you keep the cuff low, the left side reduces almost by 1/6 down to 1.3%. So if you go from the left and use a cuff pressure cuff cuff, pressure monitor and lower the pressure as much as is safe for that leak. You can reduce the risk from 13.3 to 1.3 which is very, very impressive. Um And it was quite extraordinary really. Um And then it gives you a little bit more data about how frequent it is. So that's a really, I love that paper because that's a really good appreciation of just how vulnerable the right side is right side. It is, but the point is the vast majority are asymptomatic. And if I'm gonna operate again on the neck, I always prefer to go from the right. So if I've done a previous operation on the right, and there is a palsy, uh and they are asymptomatic, there isn't a risk of giving them strid or, um, although sometimes they are hoarse, the ones that have been hoarse, I've only had two cases in my career. So far I've done about just over 1200 ACDF S in my career. So far, only two of them have had permanent hoarseness as far as I'm aware at the time of discharge, which is about 2 to 3 years, POSTOP. Um Quickly posterior approach. I will briefly mention it. Um There's this classic one which is a skip laminectomy where you try and leave these bits of lamina in between and you just decompress um from the flavum, um where you have these bulges of the disc which correspond with the flavum is and it's quite a nice because it's a sort of, it's a slightly soft tissue preserving approach and you normally osteotomise the spine is processed the bifid spine. This is completely wrong, isn't it? Because this is a lumbar spine. This isn't a cervical spine because they're not bifid. But if you imagine they were bifid, I don't know what that's doing there, actually. Sorry about this. Um, er, if you split this down the middle with the two bifid processes and you break, keep those intact, all the muscles are still attached to those, you can then go down the front and remove the space in between as a skip laminectomy. It was described by Shiras, a Japanese surgeon some years ago. Um If you're gonna do screws, which some of you hopefully will get the chance to do. This is your, this is the original Mare Ma GRE L approach. Um For the lateral mass screws, there are also um um there's two more two other approaches and it was a mcgill and something else. Um But the mare is the one that most people use and that's quite a nice neat illustration of where you need to go where you center up around the lateral mass. Obviously, they're degenerative. It can be harder to see those things and you can see that it's quite a neat way that angle to avoid the VERS archery in the transverse foramen, you just need to be careful of that. It's very rare to hit it to be honest with you, but you just need to make sure the screw has got at least 20 degrees of angulation on it. The other thing you must do is try and line the screw with the angle of the facet joint. And you can do that sometimes once you've taken the ligament away or the tissue, the soft tissue off the back of the ft and there's a space and I often find you can get li either the tip of the curved mcdonald's or the straight mcdonald's up there. And it really makes you, gives you an appreciation of what the angulation needs to be for the drill for you to make the hole. You must use drills to minimize the amount of trauma to the lateral mass. Cos they're quite delicate bones, right? Quick tests, quick fire answer, quick please. From these. Ok. Who can tell me what the brown, yellow and red things are. Hello, red. Your vertebral artery, yellows, your posterior longitudinal ligament and a spinal cord with. Yeah, neurological structures. It this basic stuff. Thank you, Ben, Ben. If you can keep going, Ben, I'll be impressed. Uh So the, the black sort of bits outlined in your un unconvertible joints, also known as the of the joints of lush. Oh my God. And then red would be longest coli muscle well done and it's just here. It's lying quite superficial over the fronts of the longest coli where you get the sympathetics and what happens? Ben, if you damage the sympathetics, particularly if you're doing ac 67 approach near the stellate ganglion. What does the patient wake up with? Um, what's the name of that condition? Oh. think of a little, a little a nursery r about a boy. I don't never mind. Um, anyway, yeah, very good Horners syndrome. And can someone else tell me what three things you see in Horner's syndrome are, there might be 1/4 by step three ptosis, meiosis and hidrosis. Very good. Can anyone name the fourth that follow? Is Mister Davis stumbling again? Wow, Ben. Where are you? Isn't it? An O Thaler? The, the eyeball sinks into the socket a bit. That's the fourth one, isn't it? I have seen it a couple of times actually, my career Horners. So it does happen. Very good. That's the longest coli again, you can see that in this sort of transverse I um sat image as opposed to that transverse image. There's the virtual artery and the virt nerves because they're still very good, right? Um Let's have a look. Uh What is number 14? Anybody? Mm. Which head? Right. Someone's just told me that's the sternal head of sterno cleidomastoid. And I think 15 is meant to represent the clavicular head as in cleo. And then you've got, of course, your jugular notch or suprasternal notch as some people call it. I think all those 789, 1011 is there's a combination there of crico cricothyroid membrane, th um uh laryngeal cartilage probably larynx and then 12, I think probably is the thyroid something like that. Ok. Very good. Um Can anybody tell me what the blue fascial layer is? It is, it's the reversible, very good red investing. What are good yellow pre and can anyone tell me where I would expect to find on the right hand side, the recurrent laryngeal nerve anatomical between which two structures it's not marked on the, the, on the cross section. But I want you to in a Viber, I'd I'd ask you to point out where it would be, but I want someone to tell me no volunteers. OK. So guys, can everyone see my cursor? That's obviously the trachea, that's esophagus. It lies in this groove, but in the left hand side, uh which would be here. It sometimes lies more on the side of the trachea or just inside that groove here. On the right hand side, it's a little bit more lateral and out here. So as you're doing the approach and you push things over to one side because my cursor just a bit because the recurrent laryngeal nerve is moving from lateral to medial. You can put a traction injury on it. If you understand what I mean. Once you put your Casper retractors in and you retract, you can see how you're more likely to get a palsy on the right than you are on the left. I hope that makes sense. If not. Um, catch me later and I'll try and explain it a bit better. Um, and this is an illustration of that and I think, uh, I think 46 is meant to represent the recurrent laryngeal nerve or it could be 12 actually. Sorry. That's a bit rubbish. I should know that a bit better. Does anybody know what muscle is? 54? Which part of omohyoid? It's the inferior belly of omohyoid and you're allowed to cut it. That's the one that you, you classically, you can cut and there's usually no functional problems at all and you can see sternocleidomastoid there and then the carotid artery that's various branches. Um, let's keep going. Ok. What pathology does this young girl have? What would we call that clinically anybody? Hello? Torticollis. Well, yeah, it's a torticollis. What might be the cause of torticollis? If you decided to get a plain X ray, what can you see down there? I'm sorry if the image is a bit small. Mhm. Uh Un facetal dislocation. Well, you, there is a type of dislocation. It's unusual for it to be completely dislocated. But can you everyone see, look at that peg, look at the anatomy that is a, a dead center through the mouth view, which a decent radiographer will always take. Can you see the peg is slightly over to one side, everybody? Ok. That isn't normal. And if you see that image in association with a, a young patient like this. They're usually a toddler age, five or six years of age. And if they've had a throat infection, it, it's known as Gristle Syndrome and that is associated with. What condition can anybody tell me? Yes. Right. Can anybody tell me what, what anatomical axial spine pathology is this in Children? I here's some scans to try and jog some memories. That's what's happened here. That picture there in the middle shows you what's happened, rotatory rotator, rotator, anti lax subluxation. OK. And we often sometimes call this Cock Robin sign where they're looking to one side and it's fixed like that. They can't move their head back because they've subluxed, not quite dislocated usually, but subluxed and stuck there. Ok? And you can see what you do is you get a CT scan and you can see here the difference in the angles and you can see here in that reconstruction that that's what they've got. The reason for that is, is because their bony anatomy hasn't fully formed. It's a bit more unstable. Their C 12 junction. Does anyone know how you treat it? Anybody? Uh gentle traction? Yeah, it is. Do you know what sort of traction device you use in Children? It's very well tolerated and it doesn't involve having to stick pins in their skull. No, it looks like something out of sort of, what is it called Spanish inquisition, I think. But they tolerate it incredibly well and it only needs to be on for less than 24 hours. But that is holter traction and we still use that occasionally, um, to do that, particularly if it's a bit stiff and all you're doing is applying just a little bit of axial traction and then the bones slip back really quickly and then you put them into a collar for a few days, let the soft tissues come up and they're fine and just keep an eye on them from there. Very good, well done, right? Any questions about anatomy? Great. We've got 20 minutes to do the examination, which I think is about right. Um Good. OK. Now, remember this little slide, it's amazing. Quite senior doctors sometimes still get this wrong. Remember that the numbered nerve root comes out above the pedicle of the same numbered cervical vertebra, which means you have an additional nerve root that will come out under C seven before in the thoracic and lumbar spine. The same numbered nerve root always comes out under the pedicle. All right guys, just remember that because that is important obviously to fight anatomy. What helps me remember that is that basically the most complicated and software intense part of your body, hardware, sorry, intense part of your body is your arm and your hand with its range of movement and its incredible fine motor skills and it needs a lot of hardware to do that. And so by doing this, you're creating an additional nerve root. You're creating a little bit more hardware for the brachial plexus to be the brachial plexus, which is obviously the most complicated plexus in the body. Given what it needs to achieve the other things to remember. Of course, it's not person so much as like is that the spinal cord always ends normally directly behind the body of L1, halfway down the body of L1. If it's lower than that, then you've gotta think of tethering very good. And there it is highlighted, remember basic stuff. This history is pathology examination really is the level but of course, it's not so pertinent anymore because um we got MRI scans but the examination also, of course, in most circumstances will support your pathology and certainly your differential. And there's a little reminder about the definitions of radiculopathy and myelopathy, which you should all know. And myelopathy usually refers specifically to compressive pathology. So you wouldn't define de um demyelination in the cord without a compression as myelopathy. That's a different pathology, that's demyelination. So that definition, apology should actually say um compressive spinal cord pathology uh rather than just spinal cord pathology. Um Of course, there's the whole uh I'll mention it again, Professor Graham Apley, God, rest his soul. Um er look feel and move uh that you must uh must at least try and look like you're making an effort to do when you look at the cervical spine So you, you look at the neck, you usually approach it from the back, but as you do, so you move from front to back, you're looking at the triangles, looking for scars, looking for any asymmetry, et cetera, et cetera. Bit of Talty collas, rotation, et cetera. Um And the type of things you look out for when they move their gait is obviously ataxic gait um which is related to myelopathy. Again, if they're using walking, walking aids and TGIC would be either lower limb or lower problems. And trem is not really pertinent to high stepping gait pertinent to this uh this this lecture, but those are the different features you obviously look out for. Um And then you must make sure that you do a decent exposure, but usually you won't have time in the exam. What's important to do is, you know, is after you've introduced yourself politely and asked permission, have they got pain anywhere, et cetera, et cetera, it's a safe examiner. Then I would a sure there's an adequate exposure of the neck and the upper limbs and that'll be fine. There's at least three golden words which you all know so well. So um again, there's a little summary of the scars, rashes the shape of the neck. Normally there is a slight low doses just like the lumbar spine. If they've got a lot of neck pain and you were to do a plain X ray, you could see which you shouldn't really, should only be doing CT scans, not plain x rays. Um, now, uh, on all spines, pretty much in an acute setting. It would lose its lordosis because of the erectile spinning spasms. And then you can have sometimes have patients with a bit more lordosis or previous fusion. Does anyone know a congenital disease where you do get congenitally fused? Either, um, usually subaxial vertebra. Does anyone know condition like that with a low hairline and a short neck sprinkled shoulder? That yes, you, well, sort of, but the sprenkle shoulder isn't, it is to do with that sort of neurological involvement and movement of the scapula. This is specifically a congenital neck pathology. Yeah, someone's just said it. If you couldn't hear that Clipper file, I think you meant. So, uh Clipper clip and you could get a clipper in the cos sometimes there's associated with ace um uh actual leg length discrepancies and other um physical features. They can get a lot of varicose veins for some reason. There's a few other things. So they may, they, that could come up in an exam. Certainly worth looking for. Also when you're around the back of the neck and you're doing the feel bit, look for lymph glands, swelling, obviously in a child, if you can feel lots of lymph glands with a torticollis, then that's your sort of diagnosis for a possible Gristle syndrome, et cetera, et cetera. And then there's the range of movement, you feel for temperature, not so common. Really? Um tenderness around the occiput, spinus processes, et cetera, et cetera. And then there's the sternocleidal mastoid. Why is it important in Children to feel for the sternocleidal mastoid? Anybody particularly in the presence of um at alticollis? Mm. Anybody in absence, say again, congenital absence. Ok. So is that that, what's that thing where they haven't got any clavicles? Um I did George, isn't it? Did George? Yeah, you might be right. I there probably is some deficit to that muscle in that. That isn't specifically why I said it. If there's a torticollis like that child, I showed you earlier. If they've had a torticollis for a long time, the sternocleidomastoid usually on the same side as which they've got that lateral flexion, rotation, fixed deformity becomes extremely scarred and fibrotic. So if you feel it, it's this tight, tight band in the neck, it's like it becomes like a tether to the whole neck. And of course, if the head is permanently fixed in that position, they can have visual problems, eye development problems. You've got to send them to an ophthalmologist, you do need to treat it for that reason. So they don't get permanent visual problems for the rest of their life. And what's the treatment of a torticollis in that situation without there being any underlying bony abnormalities after you've done an MRI scan, does anybody know it is release of the muscle? That's it? It is. That's how you treat it. You, you do, you, you, you go in usually through the base of sternomastoid and you detach it from either initially the sternal head. And if that's not enough, you can also detach it from the clavicular head. You literally just peel it off from the muscle, there's a bit of bleeding and um, and then you just ensure it's all released, you move the head back into its normal neutral position and you put them in a hard collar six weeks. Ok? That is a treatment that is a surgical treatment for torticollis. But you need to be careful because there is carotid artery vagus and other nerves and a few bits and pieces around there, you gotta be careful of, that's all. But if it's done cautiously with good hemostasis, it usually works quite well, very good. So, um when they're in that position, you're usually expected. And if you asked to do movements is to start asking them, but I don't know why. II think I've got these slides of someone else. It was a presentation I um helped create with somebody else, but for some reason, this person's insisted, sorry about the Inoke, uh insisted on using a sketch of Arisi soak as the patient as far as I can tell. Um But um, so you've got your hands on his neck and you're following him moving forwards and backwards and you can see there, he's got a good range of movement, which is usually about 100 and 50 degrees. It's usually a pretty good range. Um And when they're in maximal flexion like that, you can often ask if you worry about myelopathy, if they've got any tingling or numbness in their upper limbs. What who described that clinical sign? Does anyone know maximum cervical extension in the presence of cord compression in the neck, usually in the axial spine which results in involved results in an exacerbation of their upper spine. It's known as le hers phenomenon. I don't know if you've heard of it le Hermes because what you're doing if you think about it in the lumbar spine, if you're testing for stenosis and claudication, you can sometimes get a stenotic to stand up straight or even lean back and they say, oh, I'm getting my leg symptoms, my claudicant leg symptoms and the reason for that is the neural space, the neural canal in the lumbar spine, just like it does in the neck reduces in size when you extend only by a very small amount, usually less than a millimeter or more. But that's enough to exacerbate the stenosis in the lumbar spine and reproduce the leg symptoms. The same thing happens in the neck. When you move into extension, you're reducing the neural canal space, you're pressing on the cord a bit more and they get uh exacerbated. Now, some of them even get electric shocks down their arm and their torso and into their legs, which is really bad. That means their cords very compressed. So it is a helpful examination, but you just need to make sure they do it gently. Um This is uh lateral, um lateral flexion and it's the usual thing of bring your ear to your shoulder and you can go left and right on that. And it, you can either describe it in moving in 25% and 50% or 100% in terms of range of movement. And this is the rotation where you look from above and it should normally be 90 degrees both ways giving you the foot of 100 and 80 from side to side. Um These are the sort of tools you should look out for. If you're at a uh clinical station in the exam that should be lying around, sometimes they don't make them apparent. But you should say, oh, I'd like now to test sensation with a neurotips, sharp and light touch. That's what that little nobbles is for the light touch. That's the sharp. And then um if it, if it did ask you to do that, you should always ask for a neurotips, they're made not to pierce the skin, but obviously, you always warn the patient and there's your tendon hammer, you should look out for that. Um your dermatomes as you know, um I more or less agree with this, I would say C five is a little bit more over the anterior, the shoulder than he's got here. But the rest of this is right in as much as it covers the thumb and the inside half of the index finger. And then you've got C seven covering those three fingers and then the, the medial half of the ring and the whole of the uh little finger is C eight coming a little bit out the side of the forearm about halfway down the forearm. T one takes over T two. And that is pretty much how it is. And you've got to compare both sides and you can use the neuro tip and so forth to check what I tend to do is if I think it's ac six or possibly ac eight radiculopathy and I'm not sure or a my, not usually myelopathy but radicular picture, I'll sometimes test it um with either a neuro um or, or light touch. And sometimes that helps establish which nerve is more affected. And that enables me to target a CT guided nerve injection. That's the sort of thing I'd use it for. Here's your myotomes. So just basically remember C five is your shoulders abducting upwards and you just test the power comparing one side to the other. Then I tend to keep their arms with the bent elbows in position, arms up in the air, grab hold of their forearms. And I say, pull me towards you. And I'm really resi just saying resist me and I'm trying to extend their arms and they're pulling in and I can really feel the biceps both sides objectively get an assessment of the power, then push me away and that's your triceps. You're getting out of a chair muscle, lifting yourself out of a chair, muscle. Um And um that's a good way of assessing if there's weakness, either side, we should always expose adequately to look for some wasting. There often is some wasting frequency frequently of triceps, particularly with the C seven insult. Um And then you've got the foot long forearm flexors, which I do as a power grip. And then you can do variations and further tests say for C six of asking them to um extend the wrist or flex the wrist. As you can see on that top right hand corner, there's sup you can test which again is a combination with C six and S pronation is seven and eight. And then you've got the finger flexion which is long flexors of the forearm and that's mostly C eight. And then you got T one which is the in intrinsics, which you're into oss as you know, very good. And the other thing you should always do on a cervical spine examination is, what else do you test for anybody? You must mention it at the end of that in your clinical case? Yes, we're gonna come to reflex. What, who, what did someone say you would examine the shoulder as well. Yes. Very good. Examine the shoulder. If that doesn't show anything. Sometimes they've got pain around the forearm but no pain radiating down from the shoulder or the neck. I often frequently test for, um, tennis, elbow, lateral epicondylitis and golfers, medial epicondylitis. Um I will look for that. Um, it'd be a bit unfair to have that in the exam because it's very painful. There's di veins as well, but that's incredibly painful. I'm sure they won't have that. You must test, someone's just mentioned it for compressive neuropathy. Um Usually at the wrist, either with Des Phelan's and Tel or a combination of all three, you can mention it as well as ulnar tunnel neuropathy. So you must mention that that you would also test for that, particularly the myopathic picture where you have some tingling and numbness. Here's your basic reflexes. Um I gen generally C six is dominant for biceps, C seven is dominant for triceps. C six is dominant for smas. You really only need to do biceps and triceps, in my opinion. Now, that little diagram in the bottom right hand corner, if you uh don't know it, I love that way of doing uh triceps. Um As long as they've got no pain in their shoulder, it's a brilliant demonstration because what you can see make my cursor work, you can see the hand move as a pendulum. So even a small amount of flexion here from the activation of the triceps, reflex results in quite a hang on quite a wide mark, mark of movement in the, in the hand and you can see it move. These are the things which you've mentioned already to look out for in myelopathy. These are some of the tests. Obviously, you've got the up the Babinski that goes up. II, I've put two beats of clonus. Some neurologists told me that four beats can be normal. But I think anything more than that or anything that's sustained is certainly abnormal. I wouldn't go to town on probe, receptive tests in the foot themselves. But you've got Romberg's and Gates analysis looking for ataxia as an important point at the beginning of the examination when you're still doing the look bit, I've mentioned Le Hermes and of course, there's Hoffmann's, that's the way, the way the guy's doing it there is the way I like to do it. Usually my fingers just illustrating here across the distal pharyngeal joint and I flick that nail and I look for movement. Hang on. I look for movement in these two fingers here. The hand and the forearm must be relaxed. That's all about you creating a good rapport with a patient and getting them relaxed. I think that's it. Any questions or have I just sort of clubbed you to death with all that information.