Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

see me that obviously we're recording it, and this is going to start from the beginning. So, um so welcome to everyone. Thank you very much for letting me talk to you again. Hopefully, I'll be of some interest. I'm This is just a little background about me. I know some of you may have seen me before lecturing on this program. Uh, I'm going to talk to you about spinal cord lesions and particularly from a medical student perspective. I'll explain why in a minute I'll also explain why I've got this slightly cheeky title in and around Thoracic Park. I will explain that this is me. I'm an associate professor of teaching at the Queen Square Institute of Neurology. And also, I'm an honorary consultant neurologist at that building with red brick in the picture, which is the National Hospital for Neurology and Neurosurgery at Queen's Square. I've been a neurologist in the UK for over 20 years, and I hope I won't bore you today. So one thing I do need to add there, please don't post the images. You're obviously free to use the lecture. I'm going to give for your own educational purposes. I'm allowed to use the images I've used, but I always have to be careful about that. I don't know how widely there could be subsequently used. So I'm going to get on now and tell you about in and around Thoracic Park. And as I'm doing this Hannah, please let me know if there's any problem with the screen. I think it's only because I've got the toolbar on front. I'm fine to go on. Um, so is that okay, Hannah the you can see the full screener. Yes. Yes, it's great. Wonderful. Okay, so in and around Thoracic Park. Well, what am I talking about here at medical school, often spinal cord lesion's and in particular, How you recognize them are often not taught or not taught much at all. The problem is, you then become a doctor, and the danger is that these can be missed. Now, I'm not talking about once in a career type things. These things are common and they don't always come with red traditional red flags. It's all around them and the dangerous. Of course, if you miss it, and if it's got a structural cause, that patient may miss the boat for surgery. so it's a really big deal. This is especially true for thoracic Cord Lesion's, so you all know the next cervical spine. Thoracic cord is kind of that big bit of the bit in the middle and then lumbar sacral spine at the bottom of lumbar sacral, uh, spinal spinal spinal cord, which may be missed if you only do a cervical spine MRI or a lumbar sacral spine MRI. Let me give you a scenario, which I promise I've seen quite a large number of times. A patient comes in with new bilateral leg weakness. Maybe they've got brisk reflexes as well an inexperienced physician, and I'm not blaming. We've all been there. At some stage. I've been a medical student myself may report when they examine the patient that they had normal leg reflexes. But just possibly if the patient happened to be an older, perhaps a longstanding diabetic, it may have been that they're normal was actually very suppressed reflexes. And sometimes with spinal cord lesion's, you can either get brisk reflexes or diminished reflexes, becoming apparently normal. So just a little catch there in this type of scenario, an emery scale of the lumber sacred spine maybe the only thing that's ordered Sometimes an MRI scan of the lumbar sacral spine is exactly in order. For example, if the patient complained of new onset perineal numbness around the genital area, numbness and weakness in the legs of new onset and bladder disturbance Absolutely. You need an MRI scan of the lumbar sacral spine. What I'm saying here, though, is very often people seem to stop at the MRI lumbar sacral spine when people come in with leg weakness or numbness of recent onset. And then the final point I'm making there is sometimes this translational error can slip slip in. So sometimes the next day suppose the MRI scale of the Lumbosacral spine only is done. Suppose it's normal. The next day may be the consultant is told MRI spine was normal. You see the difference. The lack of one word makes and then, quite reasonably, there, say, Oh, fine, the whole spine. We don't need to worry about that. It just seems that I've seen that so many times. It's worth pointing out. So what about the corny title to my talk? Jurassic Park. Obviously, obviously it's a bit a bit older, but I know There's been so many, uh, Sequels to that. You're probably familiar with the term. Well, let's consider. And I promise I'm not going off down a paleontology route too far. It's only take a minute or two. I think it's quite interesting. This is one of the oldest known thoracic vertebral injuries that I'm aware of. Although in this particular case, the whole spine was eaten. Um, so I hope you'll excuse me for using it. There it is. Thoracic vertebra of a dinosaur. 93 million years ago, it was gobbled up by this extraordinary creature, which is a crocodile, a form from modern day Australia. Uh, final point before I get off. Dinosaurs, technically, 93 3 million years ago was actually Cretaceous. Not Jurassic. But I'm allowed to say so because nearly all those dinosaurs in Jurassic Jurassic Park were actually from the Cretaceous period. OK, enough of around about dinosaurs. Let's get back to what we're really talking about here today. Weakness? Let's think about how we think about weakness now. It's very easy when we start thinking about things like weakness to start saying, Oh, yes, it could be caused by this or could be caused by that. But rather than thinking about why it's important, we start thinking as neurologists about where the classic thing in urology is. Try and localize where the problem is, then work out what it is. Let's think about weakness. It could actually be not weakness at all. It could be. The patient's in pain so they can't exert full power. It could be that they've got a problem with their muscle or muscles, perhaps a myopathy. It could be as the next level up the neuromuscular junction. Important point here. Myasthenia gravis classically causes fatigue, a ble weakness. So almost any weakness you see anywhere in the body just possibly could be related to myasthenia. And if you suspected, it doesn't take long to test for fatigue ability. If you're looking at the eyes and they seem to be a bit weak, but it all seems a bit complex, get them to look up at your finger, maybe for about 10 seconds and see the weakness get worse with myasthenia. If you think they've got some unusual weakness that seems to change a bit in that arm, try and get into flex for about 10 seconds and see if the weakness gets worse. Okay, so myasthenia. At one point going up, it could be a problem with the nerves. Or where the nerves or coalesce at like at the break your plexus or lumbosacral plexus, or the nerve roots where they come out from the spinal cord. Maybe those could be compressed or possibly even affected by inflammatory conditions like Guillain Barre. Then people often skip straight up to think about. Well, weakness could be the brain stem. Maybe it's a tumor, or it could be the brain. Maybe it's a stroke. Or maybe it's a systemic problem, you know, low low potassium, low calcium or general illness. But it does seem that quite often not enough attention is paid to the spinal cord as a potential cause of that weakness. So let's think about this. So this is a typical view of a mid cervical cross section of the spinal cord. You notice I've referred. This is from the wonderful, extremely senior Lionel Ginsburg, a very famous neurologist who actually put this paper in practical neurology about 11 years ago. Now the first thing I want to say is, don't worry about all the small print you only really need to bother about the stuff that's on the right of this picture and a top on top of the picture and below. Let's start with on top of the picture and below, because one of the first things you may notice is this is the way we always draw cross sections of the spinal cord. But posterior is on top. I'm just saying it because certainly to me, at least in the past, that always seemed a bit counterintuitive. You think? Well, anterior should be on top. The reason we do this just look at me for a moment. Imagine I bend down now Imagine my cord in cross section. The top part is actually the back, the posterior of my body. So that's important to get that nomenclature, right? First of all, only looking now on the side of this diagram on the right hand side, let's quickly go top to bottom at the top or the posterior, the top of the diagram, the posterior part of the spinal cord. You have the dorsal columns. These are where your joint position, sense and vibration sense fibers travel, so sensation next down lateral corticospinal tracks. This is where the power goes to move your muscles in your arms and your legs next down. Still on that right hand side, we've got the spinothalamic tracks, so that's sensory, and that's where we understand where pain or temperature is. I'm going to mention this again at the at the end, but this is about the only one that actually crosses over when it joins the spine. So most of these fibers just sit in their lane in their lane of traffic, all the way up to like the brain stem. And then they start crossing over if they cross over. But not so the spinothalamic pain and temperature jumps across to the other side straight away. I will explain why that's important. A little bit later. Let's start by thinking of a general process like the whole cord is pretty much being crushed or squashed. For example, imagine that that's a disc and intervertebral disc prolapsing very common. This is actually where the disc would come from, by the way, so that's the anterior part of the cord. That's where the disk comes from. Let's imagine it's compressing at a common site for this C 56. So what we can do then is think about what we might see with the patient because we're not going to know when they walk in the door that they've got a C 56 prolapse. They're probably just going to say I've got a bit of new onset weakness or numbness in my arms and legs. So what you can do is go through the neurological examination sequentially to look for evidence of where the lesion is. That's localizing so tone with time. If you have a an upper motor neuron lesion like spinal cord compression with time, you would expect spasticity to occur at or at least below that level. So that means in the lower arm and in the legs. In this example. Note that increased tone can also occur with Parkinson's disease that's called extrapyramidal, but that is different. Extrapyramidal increase in tone, like Parkinson's, is like a lead pipe. However quickly you move it, it's always about the same stiffness with a stroke that causes upper motor neuron spasticity. That's different. If you move the arm slowly, it doesn't seem too bad. If you move it quickly, it suddenly seems to resist you. That's spasticity. Now let's think about this. C 56 example. You may remember from my neurological examination talk a week or two ago that the biceps is C 56 level. Now it might be that this has been affected at C 56 by this disc prolapse It might be it's just kind of made it through, so that might be slightly weak. But when you get down to the triceps muscle elbow extension, you would expect C seven to be weak, and therefore already you have been helped. You've already got the idea of a level just based on the strength testing. It is true to say, of course, with time, you may well find that the reflex has become brisk, and usually it's quite quick. If there's an acute spinal cord injury, maybe within a few hours of that there may be a lot of reflexes, but typically after that, the reflexes become brisk or so at the site of the injury. Here C 56 You may get a loss of reflexes, so in this case you may get a reduced or absent biceps reflex, but a brisk triceps reflex again that helps localize. So let's think now about dermatome so we've looked at motor. We've looked at tone. We've considered reflexes. But what about sensation? This is an example of dermatome. As you know, from the kind of neck down, you can map out specific patches of our skin that correspond to different levels of the spinal cord. Now, in this case, obviously we're thinking about C 56. So you might expect maybe C seven to be reduced, and then all the other levels below that on the body to be reduced. You test dermatome is with a pin prick or light touch. So joint position, sense, vibration that's slightly different. You still test for those. So remember, as I said, you try and get a level not just with power, not just with tone, not just with sensation, but with each aspect of sensation. So pin prick. You can use a pinprick and go up until they can feel it's normal. Remember, start at a normal place. Can you feel it sharp? Yes, keep going up their legs or even arms until they say yes, and then you can get onto joint position sense and then get onto vibration. You need to do this on both sides because the lesion could be asymmetrical. Now I know many of you probably thinking straight away yet power. I get it. C 56 reflexes. Yeah, sort of. Get it? Biceps C 56 sense sensation. I've been shown the dermatomes. I want to tell you something that I learned when I was a junior neurologist. And it's always stuck in my head about how each one of these can contribute to the localization. A long time ago, when I was a junior doctor, I was studying neurology. At the time that I was a junior, some of my colleagues and I were told to get a patient ready for us to be taught on by a senior member of the team. We spent about 45 minutes and that patient also had a C 56 lesion, and we worked it all out. We worked out the power testing and the reflexes, and we were quite pleased with ourselves. And then along comes the senior professor. He was seemed very old then, although sorry, perhaps I'm not far off his age now. And he shuffled in and we were all kind of looking at each other and said What does he know about neurology? And he started off by saying to us, Is this only one lesion? And we said Yes, because we knew it was a cord lesion at C 56. Then he went over to the patient. And in a very loud voice, he said, Are you in any pain? And the patient said no. Then the senior professor grabbed both the patient's hands and shook them up and down like this. My name is Professor George Harwood. How are you? And we were looking each other like, Who is this guy? You know? And suddenly the professor turned around to us and said, Now we know where the lesion is. We have to find out what caused it. And we were all thinking, We've spent 45 minutes working this out. And then he explained that he was doing this business to work out differential tone. Okay, C five. That's okay, because it's above the lesion. C 56. Possibly. Okay, C seven stiff. See eight stiff. Now, I know that's a bit showy, but it makes the point. You don't just depend on tone, but each aspect of the neurological exam can help now. Key thing is that if you have any suspicion at all of a spinal cord injury, you need to check the abdomen. Now. I don't think I was ever told this in medical school, but it's really important. What I mean is the sensory level. Sure, you can use pinprick and go over the Dermatomes. But importantly, spinal cord lesion's often give you a sensory level of the on the abdomen. If they're the thoracic level or cervical level, let me explain. This gives you an approximation of the typical dermatomes covering the abdomen again. It doesn't take long pinprick. Obviously, you know, make sure the patient's covered and is aware what's going to happen, and all you've got to do is start with the pin prick. Start somewhere central. Can you feel it sharp? Yes. Then start from L1 there and work your way out. Tell me as soon as you feel it sharp. If they feel it sharp straight away, it's fine. If not, go up until they say yes, just above the tummy button, that would be t nine. Then you do the same on the other side only takes you probably 10 15 seconds but a sensory level on the abdomen is strongly suggestive of a cord lesion in thoracic or cease by. While you're at it, you can test abdominal reflexes. Abdominal reflexes are not the same as deep tendon reflexes like the biceps. Deep tendon reflexes like the biceps and the knee reflex and the ankle reflex tend to be exaggerated or enhanced and become brisk with spinal cord lesions above that level. Abdominal reflexes, however, tend to become absent till they don't become brisk. What an abdominal reflexes is if you imagine you'd use a little orange stick that's traditionally what you use. You could use the end of a tendon hammer if it's clean an orange stick. By the way, it's like a little mass catch. It's called an orange stick because it's supposed to be made out of orange tree. Would you just flick lightly and you'll see the muscle actually contract underneath? That's normal, same below and same on the other two quadrants. 15% of people don't have them at all, particularly if they've had surgery, however, particularly if it's lost on one side. That side they're lost on may well have a spinal cord injury. It could be old, but it might be new, then, finally, and you would never initiate this as a medical student. This would require a more senior doctor to ensure it's required and explain it etcetera. But if you think it's a fairly acute spinal cord lesion, someone needs to consider a per rectum examination to test and document anal tone. And also perineal sensory loss, because these can be impacted in, um in spinal cord injuries and can have a significant impact if you're thinking about their long term ability to recover. But remember, even if a senior doctor says, yes, you can be part of this, you shouldn't initiate this yourself. Remember, until you're qualified, then it still requires explanation, a chaperone and consent verbal consent, because that's quite an intimate exam, and we often forget about that with patient's right. So, again, this main emphasis if someone comes in numb or weak, especially if they have spasticity. And remember I said that stiffness, which is worse when you move it quickly, then consider a spinal cord lesion, especially if it's a recent onset. You know, if they've had it for 10 years and it hasn't changed, that's different the patient may not come in a wheelchair with very brisk reflexes. An upgoing plantar like this example. They may be walking. So remember, not all of these spinal cord injuries shout themselves out. Sometimes they do. My doctor might Sorry. My late father was a doctor. He was an anesthetist. And he told me that one day a patient managed to stagger into the emergency room with a wooden stake right through his chest, coming out the back right by his spine. What had happened had been on a bike, A lorry in front have been a break, and the pole went straight through his chest, unbelievably managed to walk in jail, stagger in. And I think he was okay. In the end, that was an obvious case because you had a poll right next to the spinal cord. But also often it's not that obvious. If someone comes in and you know that's a TLS routine, they've had a car crash. Of course, we all think of the C spine, but not so much if it's insidious. If someone has just been going off their legs, we often forget it could be a cord lesion. So let's go back to the cord and start thinking about incomplete cord syndromes. Remember, I started by saying, Imagine the whole thing is kind of squashed just to make it easy, but they don't always come like that. Sometimes they come in like packages. The Communist incomplete cord syndrome is so called central cord syndrome, and this is often caused by trauma in the high cervical region. The key thing here is that the arms tend to be more affected than the legs, but there may be bladder involvement. I'm going to show you why. Look, imagine a disc is coming through from the anterior and pushing back to posterior. Look now on your right hand side of your screen, halfway down to lateral corticospinal tract. Remember, that's where the brain tells the muscles to move. Now you can see that there is actually a separation between leg and arm fibers. So if you have something pushing in from the anterior side backwards and pushing in from the center backwards, the first fibers they're going to hit our the armed fibers rather than the leg fibers. So that's a classic feature of this central cord syndrome. The next thing I want us to consider is the syrinx. Now, technically, a syrinx is a small, fluid filled or expanded, fluid filled section. Now I want you to look in the middle here, and you can see the central canal of the spinal cord. We often forget that there is even one. It's so tiny, but sometimes it expands for us to think about that. I want us to remember what I said about the Spinothalamic tracks, so these bring pain or temperature sensation from the periphery. But remember what I said earlier? Those pain fibers cross over as soon as they join the spinal cord, and then they go up on the other side. So what actually happens is when they cross, they go very close to the central canal. If you can see that, so imagine if you then got a central canal that pushes out one of the first thing that gets hit. So those crossing spinothalamic tracks. So the classic presentation of someone with the Cering X is that they will often present with a loss of pain and temperature sensation over their hands and fingers, and sometimes also over the back that so called shawl distribution, like they're wearing a shawl and the power will be intact. The joint position sense would be intact, but if you use pinprick, you'll say, Oh, hang on, that's gone down. I remember seeing someone with this who actually presented because they started burning their fingers on their cigarette, and they haven't noticed it because their pain and indeed temperature sensations were being reduced by a syrinx. That syringe X can sometimes be caused and often associated with an Arnold Chiari malformation you may remember from I talked previously on headaches. That's where the back of their brain, specifically the cerebellum, can sometimes slip just down below the frame of Magnum. And that means you can almost have a piston effect when you do valsalva maneuvers and almost build up pressure within that Central canal. Now we're looking to a classic from about 180 years ago, when Brown Sicard actually first described this. This is the half cord syndrome. What I mean by that is just imagine the right side of the cord has been completely taken out. This may well be trauma, for example. Sadly, it could be a stabbing. Now, when that happens, remember again what I said about the spinothalamic tracks. Now, pretty much everything else you can assume is on the same side. So let's take motor. For example, the Spiner the you've you've got the corticospinal tracks. Then those will be affected, so there cause weakness on the same side. Remember, it's right side damage in this example. So look at the picture of the whole man. The right side of the patient is, of course, on our left side because they're looking at us, Remember? So the right side of this patient is in the lighter color and on that side that you would expect to see weakness. You'd expect to see brisk reflexes. You'd expect to see reduced joint position, sense and vibration. But the pin prick and temperature sensation has jumped over to the other side. So in this example of a brown sir card syndrome in the high cervical region, you actually get the loss of pin prick and temperature on the other side to the lesion. So again, that's a classic partial cord syndrome. We've nearly finished. Actually, there isn't much more to go. This now is the anterior court's syndrome, another incomplete cord syndrome. This is typically caused by an infarct or stroke of the anterior spinal artery with the anterior two thirds affected. Remember, the anterior is kind of when we're looking at it like a picture looks like the bottom bit. You can see the visual aid there tells you which part of the cord is affected with the anterior cord syndrome now because the anterior two thirds are affected. This will affect the corticospinal tracks and the spinothalamic tracks, so you can have weakness on both sides with brisk reflexes with increased tone and also reduced pinprick and and temperature sensation below that level. But see what spared the dorsal columns, so this patient may well have intact joint position, sense or vibration sense. Typically, these are caused by a vascular event like the anterior spinal artery, but rather strangely even in this day and age. These are not typically treated the same as strokes in the head, so, you know, stroke in the brain. Time is brain. You get them as fast as possible to the hospital. Ideally, if there is possibility of using thrombolysis or even thrombectomy. But with spinal cord strokes, it's much more difficult to diagnose. They often present a bit later because it's not always a presentation just like this. It can kind of be a stuttering start. And unfortunately, even with imaging, it's not always as easy to spot a stroke with MRI as it is with the brain. So the up short is, I'm afraid many of these have managed symptomatically or conservatively. By that I mean, you know, if they've got any pain, you treat that you look for vascular risk factors like high BP or atrial fibrillation, and you treat them as secondary prevention. There are other causes of this. It's unusual, but you could get other causes of this. For example, you could get this with inflammation. It could be a transverse myelitis seen in multiple sclerosis. I'm obviously focusing in this talk on not missing structural causes, compressing the cord. But there's a whole host of other things that could cause it. Once you've excluded that structural cause now we'll come onto the posterior cord element. I think this is actually the last one I have to present. So this is the kind of the reverse. Here you have only a third the posterior third of the cord involved. You see what this affects it affects the dorsal columns. So if you think how they're going to present, they would probably have good strength and tone and normal reflexes. They would probably have normal pinprick and temperature sensation because all those tracks are preserved. So how would they present? Well, they might feel some general numbness. But there's another classical thing that you may well note even before you start testing joint position, sense and vibration. That's the Romberg test now. I don't know if you know this or not, but that's so often I see it misunderstood. If you'll forgive me, I want to talk you through it again. So Romberg describe this test to distinguish between cerebella problems and problems affecting the dorsal column. Let me give you an example. Understand up so my face will go out of you when we stand up. Okay, suppose a patient standing up and they've got a posterior cord syndrome. They may be able to stand up and be very fine without any problems until they shut their eyes, and then you may see them sway or even fall over. That's a positive Romberg test, and it's important because it's not a sign of cerebella problems. It's a sign of a problem with the dorsal columns. How so When we stand up, close our eyes, maybe in the shower or washing our hair in the shower. We don't have our eyes to tell us where we are in space, so we rely on the joint position, sense of our feet of our toes and our ankles. If that goes, then when someone shuts their eyes, they fall over. That's what a Romberg sign is Now. Pasta record syndrome is not common. There are a number of causes of this. It could be trauma, but the classic cause is B 12 deficiency. Now. It's also true to say you can rarely get it infarct just the same way. With the anterior cord syndrome, the anterior spinal artery could be affected. It a posterior spinal artery, could be affected sadly more frequently nowadays, with recreational use as a drug of nitrous oxide that can classically cause this as well with the excessive use, Um, and that seems to be via a mechanism a bit like B 12 deficiency in the past should always classically see very, very longstanding. Syphilis can also cause this now. Finally, although throughout this talk, I've been emphasizing how you don't want to miss a spinal cord lesion. There is a very rare example of how someone might present with what seems to be a spinal cord lesion, but it's actually caused by a brain lesion. So what I'm talking about is imagine. A patient comes up with a slowly progressive history of weakness in the legs, brisk reflex, increased tone in the legs and bladder problems. So they've become incontinent. Well, that's an absolute red flags all over the shop for spinal cord problem, however. Very rarely you just need to remember that if that MRI scan of the whole spine not just number sacred spine is normal, it still could be something in the brain. This is a classic cause. It's so called Paris sagittal meningioma, so sitting there in the middle, slowly growing. What it does is it hits out on the on the motor tracks on both sides who get bilateral leg weakness. But in addition, that's near the micturition centers in the brain. So how we go to toilet so that can be affected, too. It's a real rarity, but worth just putting in the back of your mind. It's also fair to say that even if an MRI scan of the whole spine is normal, there still could be something up. It's worth remembering that rarely, sometimes something could be going on that the MRI didn't pick. For example, it could be a spread of neoplasm. It could be metastases. It could be maybe a neoplastic or Paraneoplastic syndrome. It could be a form of transverse myelitis, like you see, an M s, which is so called MRE negative. So just be wary of that. And finally, one other thing. It's actually quite unusual, I think, particularly older people to get a normal MRI spine because very commonly there'll be wear and tear, and this is really commonly particularly in lumbar sacral spine. So I always tell patient's beforehand that I'm expecting to at least see some wear and tear, because if otherwise, you say good news, it's all normal. But I found this and that. The patient, to be honest, may not believe you. They may think, Well, that that's really serious right now. I did promise that I would finish early, and I think this is the last slide. This is just a glimpse of all the other kind of things that could be going on. If there's a spinal cord lesion, however, first assume, then exclude compression as a cause of spinal cord lesions. Then effectively, you have more time to think about all these other type of things here. I'm not going to dwell on it because that's almost another talk. Just to say that I've been emphasizing strongly, not missing spinal cord lesions and then emphasizing this because you don't want to miss compressive lesion's. Because surgery might then be indicated. So thank you very much. So, um, I do have 10 minutes left for any questions. And if there were any questions, Hannah, please do let me know. I haven't seen any questions in the chat so far. So if anyone wants to write something now or someone's raised their hand yes, I can see. Yeah. See, um, assets raised his hands. Uh, yes. Uh, So you said about the anal reflects, uh, anal reflects test. We have to do with the, uh the patient is showing, uh, haristeas or numbness or weakness in the abdominal region. But, uh, like, as you said, it's very intimate exam, so it depends upon the gender as well. Who does the exam like? A. If it's a lady, then a lady neurologist has to do. It's a man, then it doesn't matter who does it. Is that the case here? Yes, it's a very good point, as you actually correctly picked up and what had emphasized. I must be honest that when I was a medical student and I think it's totally wrong. You know, in those days people are just marching the Romans. So here's some medical students. They're going to do a P R. A new per rectum exam, and that's totally wrong. You know, probably many of you. I've been a patient in the hospital. It's just not correct. It's not the right way to do things. We need to be sensitive for many patient's. They haven't got a clue why someone putting a finger up the bottom, basically, and the reason it's important, firstly, is because if they have got reduced anal tone so literally, put the finger with some ky jelly after you've got consent and as you say, chaperone and make sure they're happy and if need be, make sure it's gender compatible. But when the finger is inside the anus. You get them to press down, to bear down to make sure that they can do that. And then you also, ideally with cotton wool, just test around the perennial area for for sensitivity. That's that's important for several reasons. Firstly, if that's gone and it's an acute presentation and there is a surgical sign suppose there's a there's a disc prolapse, then that could be a really emergent reason to seriously consider a surgery. If there's a lesion to cut out, particularly when you're thinking about Korda Equina. So that's slightly different. That's where a lesion gets the nerves at the end of the spinal cord, so it's below the spinal cord. There's another reason, and I'm afraid it's slightly defensive medicine. Reason. I suppose they're going off for a surgery, urgent surgery, and they come back from surgery and for the first time, then someone says, Oh, now we can relax. Now let's do a PR exam and test sensitivity. Oh, it's all impaired. Someone could claim that they could say, Well, actually, that's because of the surgery. I mean, it's it's very unlikely, and I don't want you to have to think too defensively But it's good practice to not just test something once but ideally tested again, and particularly before you do something big like surgery, it's really important to get as accurate a picture and document that in the notes as you can. So that's the reason I was quite quite put quite a lot of emphasis on that. So thank you, Assad for that question. But you're right. You have to be very sensitive to patient's. Explain yourself fully and wherever possible. You know, barring urgent situations, then you should ideally make sure that it's gender compatible, if at all possible. Another question, uh, regarding the posterior column, Uh, one of my professors told me, like, uh, other than vascular, the mostly the symptoms of the posterior columns or the occurrence of the posterior columns are very late because the posterior columns, uh, due to the white methods, very cushioned, like and compared to the other, we can get these symptoms very quick. But the posterior columns, either we delayed or sometimes we know very later compared to the other other columns. Yes, supposed to do. A column is very late to find out you're absolutely right. So as it was making a very sensible point when I agree. By the way, if your professor 100% that all those other kind of syndromes of incomplete cord lesions they typically, you would hope present pretty quickly. And that's fairly obvious because a lot of them concerned weakness that most people are going to note or clear numbness in the leg. But the dorsal columns don't actually cause a classical numbness, so to speak. They just cause this gradual assuming it's a slow process, reduction in your ability to feel where you are in space. And sometimes people accommodate for that, or they just say, Oh, I'm a bit old old. I felt a bit giddy in the shower, so you're quite right. This can progress, and particularly because often it's not a vascular cause. Often it's a slow cause like B 12 deficiency that might have been rumbling on for years, so it can be a very slow process. But do remember what I said about the Romberg's test? It's a classic. For some reason. Everyone always gets that wrong. They think if someone keels over when they shut their eyes, it must be a cerebella, cause it is not a cerebella cause it's actually because they can't feel where their feet are because joint perception has been affected, typically by dorsal column involvement. Incidentally, of course, if you're gonna test of Romberg's test, make sure your hand is in front and behind the patient so they don't fall over. So, yes, I don't know if there were any other comments, Hannah or any other questions at all. Yes, someone asked in the chat if you could explain what a spinal shock is. Yes, so spinal shock. I did allude to this. So what? What happens when there's an acute event? Suppose you look off a bid someone has got, you know, a sudden injury to their spine particularly, you know, maybe upper spine. Then what actually happens initially is not what happens in the long term. So we all think about spinal cord injuries, and we think, Oh, yeah, the reflexes are going to be breast. The planters are up going to be up going, and actually, initially, when this happens in perhaps the minutes to hours, then you might find actually, there no reflexes at all. It almost looks more like a pattern you might see with very sudden onset G on Barry syndrome or something like that, you said? Well, actually, the reflexes almost absent. And then after a period of time, pretty quick, Usually within hours, the reflexes come back. It's almost like a tsunami. So the reflexes go out, and then they come back even bigger than they were before. But it's just worth set noting that which again goes to show when someone is acutely ill. You don't just examine the once and say that will do until they're discharged. Things can change rapidly. So someone like this with a suspected spinal cord lesion usually examine them first time. And if anything's at all off, they should be examined again in a few hours. Or, of course, if they deteriorate. So thank you for raising that schemes. Proofs. Excuse me. Process. I've got a question. Yes, Yes, please. Yes, yes. Uh, you mentioned about, you know, some of the autoimmune conditions, uh, making similar to, you know, central card and the anterior cards and symptoms. Um, if we see patient's especially, you know, uh, INR oral settings. How do we approach that? Do we have to send the patient regardless for spine MRI and our X rays and everything I can. We progress in a much more, you know, investigate. Do all the blood tests and, you know, antibody checks and everything before we. Yes, it's a very good question. And thank you for raising that because, of course I started. And perhaps I should have said, from the luxury of assuming that I had an MRI at my hand. And it's not always possible. Of course. You know there are lots of places, particularly more oral settings, where it's a really big deal, and maybe the patient themselves might be putting pressure them. I said, I can't do that. I can't do it too day and I'm busy and I've seen that before. I've seen people with barn door called syndromes. That was one that springs to mind, said No, no, I've got I've got a running race to do next week. I was thinking, you know so but you're right. But I think the key comes down to the history with the examination. So before we start worrying about autoimmune causes and things, as I say, the first one on the block is it compressive because that's the thing that is most likely to cause harm if it's missed. If someone tells you you know what, They've had this weakness for years. It hasn't changed recently, but their their partner has finally persuaded them to seek medical attention. Medical attention. Then there may be some justification for a slightly slower route. I personally would say, though, if in any doubt these should always be treated as urgently as possible, you know, I mean, if it's as I say a year, nothing's changed, then that's fair enough. But you know, if they've come to you and things have been getting worse over weeks or even or sorry days or even weeks, then I would say every time. If there's if there is neurology that you can find on the exam, then that would be an acute setting. And to be honest, even if it's over months and have a very low threshold, it may be, of course, that someone comes to you and say, Yeah, I've got numbness in my arms and legs. It's been going on for weeks and you find nothing at all. The examination is totally normal. You still have to be very careful with those cases because we all know our body better than someone else will, even a doctor. So what I'm getting at is sometimes these very same patient's you start thinking Hang on is all just functional. You have to be worried that there could genuinely be something going on. So with some of that will come with experience. And another thing you should hopefully have a resource for is hopefully you'll have someone you could chat to over the phone, maybe a neurologist, ideally or an acute admitting physician, who you might be able to at least talk things through with to actually give you confidence and also to be fair backing to make sure that you have made the right choice. I appreciate it can be difficult. I'm very cautious by nature, so I always tend to suggest sort of being, if in doubt, going on the side of caution. Thank you so much. Thank you. And I might Are there any more questions, Hannah, Because I think it's probably good timing for me in the next couple of minutes. Unless there any other questions. There's nothing right now. If anyone wants to add something quickly. Well, thank you, Hannah. Well, thank you all very much appreciate you listening to me today. Hopefully it wasn't too boring. Um, I promise. I'm talking today thinking from my many years ago as a medical student and certainly for me. And I doubt it's very different these days. We really Yeah. Sorry. Um, police was, um like I I thought that, um I text trying to differentiate between Hey, I realize my tropic lateral sclerosis and cervical cancers on you spondylotic mile a party. So I don't really understand the concept of cervicals on the, you know, tic Milo party. Right? So So cervical, cervical spondylosis Was that against? Was that against a less Is that right? Yes. The current detect was trying to differentiate between the two, but I didn't really understand the concept of cervical spondylosis Tick myelo party. Yes. Now, the reason that can be difficult, as I'm assuming als motor neuron disease to keep things simple. Um, the reason this can be difficult. Firstly, motor neuron disease is not obviously caused by a spinal cord lesion, but it's caused by a lesion in the anterior horn cell. So there's the junction between the central nervous system just before it goes out to supply the muscles in the periphery could be anywhere in the spinal cord or even in the bulb a region. But the reason is difficult. Is that motor neuron disease? Classically, you have upper and lower motor neuron signs. What I mean by that? I've talked today all about upper motor neuron signs, so that's when the cord gets crushed. You get spasticity, you get reduction of power. You get also brisk reflexes. Upgoing planters. Those are all upper motor neuron signs. You can get them with myelopathy squashing of the spinal cord. You can get them with MND, motor neuron disease, or ALS. The tricky thing is, with ALS. You also get lower motor neuron signs or you do eventually. Now that's almost the opposite. With that, you get wasting of the muscles you get for sick. Yelena Asians often of the muscles. Maybe you'll see it in the tongue. The tricky thing is, though the reason they probably use that differential is if you think about cervical spondylosis iss to put it into plain speak. Where and tear of the cervical spine that you can not only press the cord, you can sometimes press the nerve roots if you press the nerve roots there in the peripheral nervous system. So those 2 may give you for circulation and wasting, in addition to if you're squashing the spinal cord upper motor neuron signs. So you're absolutely right. And the simple thing is, if someone's looking to diagnose motor neuron disease, they will be doing almost always, I'm sure an MRI scan of the cervical spine. And indeed, probably the whole spine as well. So you're quite right. That's an example where things can be difficult to tear apart. But still, the first thing to do is to exclude compression. So hopefully that was some some help. And thank you for that question. Um, I might need to actually leave at this point. Please forgive me. I've got another presentation I need to give. I'd be most grateful if you could leave feedback. And I really appreciate all your time today, and I particularly like to say a big thank you to Hannah for your great help. Um, supporting me as a moderator for this. So thank you, everyone very much indeed. And sorry. I should actually stop sharing here as well, which I haven't done yet.