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Stop it one second. It's, I'll let you know it's recording. Ok. Yep, it's, it's on live now. It's recording now. Ok. So, uh, so this is Case 14. So we've got a case of back pain. So, uh I'm, I'm a third year medical student and I'm one of the uh CSI crash, crash sleeves. So let's begin with back pain. So the first thing I've got here is your IV at, so your case four team, if you look at here, are you guys able to see my cursor? Uh I could see your cursor. Let me see if the track could see your cursor. I could see it, but just in case respond to see if he could see his CASA mm PC and I can see it. Ok, that's fine. Um The most important thing is this is worth 9.375 percent of your grades. Case 14. So we need to make sure that you, uh you do as well. Um I remember something like most of your marks come from the actual part two. So part one and part three, I guess less emphasis, but we need to have more emphasis on our uh part two. So this is an outline of the part two you've had. So you firstly went through task one, which was ascending pain pathways. Then you went through the signs of referred pain, then you went to spinal cord development, then you the autonomic nervous system, uh then you went to the red flag systems in task five. Then in task six, you went through communication and clinical records. And from what I remember, Task six, I think it became quite important later on. So, so take, take bad at mind. So uh back pain. So why is this important so often back pain? The cause is quite unclear. So the reason why it's important is even though we get this a lot, we need to understand. And as af one as any clinician, you're gonna, you're gonna see a lot of this. So you need to, I guess, know how to rule out the more severe things and kind of be happy that, you know, they've just got a common mechanical back pain and nothing, nothing really to be worried about. Another issue with back pain is that it self limiting. So it affects people's dai daily life affects um their sleep, their, I guess their work. And also, as you can see over here, there are 10 plus million six days per year due to back pain. So it does affect the economy a lot. Um acute is chronic. So first of all, you've got chronic, which is greater than 12 weeks. Uh But most is acute. Um And the good thing about acute is 96% of acute cases of back pain, they resolve itself. So, another important thing is that we need to be able to differentiate um back pain. Once again, I've mentioned mechanical and pathological. You need to remember that the mechanical is probably more like musculoskeletal. But you uh oh, so my, my nephew just walked in, fell, fell. So, um anyway, um um you can also have like psychological reasons. So I remember in our first few cases this year, we talked about the surgical shift. So it's important to think about this sort of thing. So like, you know, you could have psychological, you could have stress but um so stress could cause back pain. Um So that's, that's quite uh important to think about all these multiple reasons, but also like the most important thing to take from this is always think worst case scenario, what whatever it is, you know, it's, it's all like to be an optimist. But when it comes to medicine, you always think the worst case scenario. So preventing back pain, I'm gonna gloss over with this slide. Uh Just cool things are just like staying active, taking care when you're like lifting like dead lifts and that sort of thing. Um Not, not being too, um I guess staying at home too much, that sort of thing. But uh you can read this in your own time. I don't think something like this would come up in your exam. Um So, yeah, like, like we mentioned before, um, 96% of cases improve within six weeks. Uh, most improve within a few days. You've got common reasons. You've got, uh, you know, sometimes that's what the NHS says and you've got your other things. Um, so the TS and the things, so, you know, you need, you need to stay active, you need to keep, you need to strengthen your back muscles and your posture muscles, otherwise you will get back pain, uh, your anti-inflammatories. Um, so you can, you can have Ibuprofen. Um, another thing the NHS website noted was do not have paracetamol by itself. Um, I mean, I don't really know the exact reason for it but that is what, what it said. Uh, then you've got cold. Um, so, like, you know, put an ice pack to reduce swelling and pain, then you've also got more, uh, you know, quite hot packs. So, for example, uh, this will relieve joint stiffness and, you know, that muscle spasm stuff. Er, you're also also doing exercise and stretches. So, you know, swimming, doing yoga, Pilates, that, that sort of thing will help. One thing you should never do is stay in bed for a long period of time because what this does is it weakens your back muscles and it becomes a problem when the muscles of your back can no longer support your back at all, worsen your back pain. Uh, this is when to get help. You know, this is just, you should probably get GP advice if you see one of these things. Ok. Now, uh, in this slide, uh, you've got your red and you've got your black. Uh, the ones I've colored in red, they, they are things you should go to A&E for and call 999 whilst the black ones, they're just uh things you should get hot from GP or 111. So uh let me just explain a few of them. So the first. Mhm uh I guess it's a bit of a spoiler for what we're about to do which is Spoiler Kind syndrome whilst the fifth one, chest pain. So with chest pain, once again, worst case scenario, you've got chest pain, it's tearing to the back. Uh See if one of you guys can say if you've got chest pain and it's, and it's going to your back and you, you hear you, it feels like a tearing sensation. What's the, what's like worst case scenario? What are you thinking of? OK, let me see if anyone puts in the chart. OK. Someone said m I let's see if anyone else agrees or disagrees. Someone said a OK. A lot of people are saying aortic dissection, aortic tear. Yeah, that's, that's perfect. Yeah. Um So yeah. Um and once again, that's another big emergency in back pain. I'd say there's like three. Yeah, I'd say like there's two very big ones called equina and aortic dissection. These two are very important for you to think about as clinicians. Um The other ones are like high temperature, unintentional weight loss. So for example, uh this, this is just your main cancer sort of screening uh serious accident. I forgot to mention this. So this is more like fracture stuff. You, you can and it can become quite a big problem or flip. No. So uh and swelling or deformity in your back. So that could think it could be something like sacral edema. So that maybe like heart failure or something like that. So maybe that's something to see your GP about urgently. Um Pain is so bad. You're so you're having problems sleeping, um sneezing, coughing or, or peeing. Uh that could probably be um a herniated disc. So when you sneeze and cough, you might, you might feel a bit worse and the other one is pain is coming from top of fla. OK. This is one of the, one of the one quite a big red flag is um thoracic back pain coming from the thoracic vertebrae because that's directly in contact with your spinal cord and we do not want issues there. Anyway, let's carry on. Um So this is the first question or can you put out? Yeah, I'll stop. Yup. I play in the pool. Let me I'll let you know when you're getting some responses. Do we have two responses for option D B D? The last one. Let me see. Ok, we got six responses for D one response for a, ok. Um, ok, again, um, ok, I'm guessing a most, most people are paying D and one person's put a, one person's put c ok. So, uh, yeah, so most of you got it right. It's d uh, constipation wasn't on that list. Low temperature wasn't on that list and high BP wasn't on that list. Um Yeah, so let's just move on. So uh back pain, special history. OK. This is just slight issue. II have a look at uh something interesting. Um radiofrequency denervation. Found this quite interesting. Uh It's just, you will basically cut uh it's like a procedure where you cut off the end of your nerve. So let's say you've had back pain for such a long time. This is unbearable. You can just cut it off and you will never have those pain signals again, which I think is interesting and quite scary at the same time. Uh So signs of pain. So we've got three main concepts. Um The first one is somatotopic arrangement. I don't know if you guys remember from the other s you had your homunculus. So, and that kind of showed that different areas of the brain kind of have more sensation and different areas of the brain. They kind of, they're in charge of different parts of the body. Um I think that's your soma arrangement. So I don't know your right hand is in charge of a part of your brain. So for example, your left in your left middle part of the the vein, um your next bit would be contralateral arrangement. So for example, your right hand will always be on the left side of your brain, the somatic sensory cortex, your left hand will always be on the right, your right leg would always be on the left part of the brain. Your left leg will always be on the right part of the brain. That's contralateral arrangement. And if you guys remember Decca and be honest. So this is when it crosses over, we're gonna go over that, but that's something to bear in mind. Final fingers are effective Neurosciences. So this is more like I just, you can see, for example, down here, you've got uh the reticular formation of a. So what it is is that it's kind of like your your brain regions that when they're stimulated, they will, they will kind of form like an emotion or some sort of response. So for example, if your reticular formation, let's say you've had dull pain, what could happen is that it's gonna cause arousal. So you're going to er stay awake at night and you just like you just can't sleep, you just feel that pain. So that's, that's an example of a effective neuroscience. Um, OK. So, soma, so if you're on the, the ho er, thing I mentioned, it's gonna come up soon, I think. But you've got one. So one would be your, uh, I'm not gonna test you guys on this cause you probably, I don't think it's fair. So one would be your first and I just tested myself, to be honest, two would be your hip, uh, three if I remember correctly is your hands and four is your face. And I think something interesting to note, I just, I just figured this out is the more in the middle, it is the more lower part, the the more lower it is in the body. So for example, your foot is a right bang in the middle, then you go more laterally, you go to your hip, which is a bit higher up and you go even more laterally and it's your hand and if you go even more laterally, it goes to your face. So if so I guess if you get something like this and it goes like, oh, what's this? What's number three? You'll probably like you can kind of estimate that it will be your hand if you can't remember something like this, especially something like this. I could never remember something like that. But good luck of any video. Um So decussation. So, decussation is when you've got a synapse or a new one. So here you've got a sign up if you can see my cursor and then it will cross over to the other side. So let's say come it, let's pretend. And OK, let's actually, you know what, let, let's go a bit. II need to mention this before. You've got your dorsal column pathway and you've got your spinothalamic pathway. So your dorsal column pathway is more sensation and touch whilst your spinothalamic tract uh and that pathway is more of a pain pathway. Um So let's go with, let's start off with the dorsal column pathway. So let's say you're touching something what ends up happening. We we take the dorsal column pathway. However, if you're in pain or we'll take the spinothalamic tract, very important. Touch, dorsal column pathway, pain, spinothalamic tract, very, very important. Make sure you remember this. So uh we're gonna explain more about it but er you just something to note the crossover for touch is the medulla oblongata. So the medulla here, whilst the, the the crossing over bit for the er spinalthalamic tract for pain would be at the dorsal horn at the spinal cord. Ok. Very important. And then there's a little um pneumonic here, disc, dorsal ipsilateral, ipsilateral, meaning it that it's going on the same side. So it stayed on the right. You uh yeah. So it was staying on the right and it goes all the way up to the right and then it Decca at the, I guess the brainstem whilst contralateral means it swapped over. So it went from right to left. OK. Here we go. So I guess this is more helpful knowledge. So, um if you remember N BRS Neuroscience, uh you got your ascending pathway and you've got your descending pathway. So descending would be going from going to your body whilst ascending pathway would be going from body to brain. So, sensation like you've mentioned. So that's more movement. So I guess you er deciding to watch this lecture. That's a that was for your descending pathway, ascending pathway. You know, you, I don't know, touching something. Um So you got your corticospinal tract uh uh is for your descending pathway from brain to body. Whilst your body to brain, one would be your dorsal colon pathway and spinal thalamic tract that we've mentioned. OK. So this is the most, I think this is one of the most important things to learn in your lecture uh from, from your CSI lectures. But uh just gonna skip past for a second. OK. So we're, we're gonna just do it like this. So your dorsal colon pathway, as we mentioned is more touch. So fine touch, perception, vibration and it will take this green pathway. So it goes through the dorsal column. So let's say you're touching something with your right hand, uh it goes through the dorsal column. Uh you got your medulla oblongata. So it's say IPs actually. So it's the right hand, it stayed on the right hand side of your, of your uh spinal cord, then it goes to the medulla oblongata and then it swaps and it goes contralateral. It dec and then it goes up to your thalamus and then it goes to the somatosensory cortex and it will go to the bit where it's to do with your uh to do with the right hand. Now with your pain, however, it goes, let's take this. Uh So the I'll quickly say this. Now, the red one is for um I guess like sharp pain, whilst the blue one is for dull pain. So with your sharp pain, this, we're gonna take, we're gonna use that one as an example. You go to uh you get, you get a stimuli, your mechanoreceptors, you get stimulated and then your new one comes and it gets activated, action potentially goes to your dorsal horn, but this deficits straight away. So it goes, uh it doesn't go ipsilateral, it goes contralateral straight away and uh your dull pain will go to, er, will have reticular formation whilst your sharp pain will just er, will kind of bypass that and it will go to the thalamus and it goes to the somatosensory cortex for the exact location of your right hand. Uh on something to know would be your, the, the sharp pain would be a much quicker response and it's much more specific. So we'll know exactly where. So like let's say you got a pin and we'll know exactly that it was at this part of the finger that I touched, but with dull pain you might get, it's, it's less focused. It's, it's a less focal, focal, er signal. Ok. So, yeah, crew touch pain, temperature. Uh, to be honest, I was confused what crude touch meant and then it turns out it's actually like it's like an itch or a tickle. So that's what your re touch is. Transduction. OK. So transduction. Uh So at the bottom here, you've got like lists of stimuli so called, uh I know you're gonna try to pronounce that uh chemicals, heater, stretcher. So what happens is you've got your transducer uh uh change these uh molecules here. And what it does is that it's gonna, it's gonna, II guess they're like, they're like channel proteins, something opens and it leads to depolarization. So your new one becomes er, positive leading to an action potential. Um And this is a no receptor, meaning a pain receptor. Uh nociceptive new one. Yeah. Uh transduction is literally just a stimulus of, yeah, it's just a stimulus turning into an action. OK. Hey, guys, if I'm going too fast then with or like something you guys don't get, just, just make sure you just put it in and chat and I'll try to explain it further. Um There, there are things to know the ones on landing green T RPV one T RPM eight and PO two. But I'll, I'll be honest, I don't think this is coming up. But um this one's so cold, uh this one would be more like keep like mechanochemical and this is stretch uh like a thermal chemical. That one and then this one would be me. So spinothalamic tract. So pain. So you see how I mentioned how there's dull pain and sharp pain. You can now split that up. So sharp pain and dull pain. So, so your sharp pain, if you, if you noticed it didn't go past that particular formation, honestly, make sure you remember this. Um this is a very important slide and I think it will come up. So you've got your sharp pain. So you've got your mechano receptor. So let's say a pin in your right hand, like you said, it will go, it will be activated. And if you can see you've got alpha fibers, see alpha fibers, they're myelinated axon. But in your doping, you've got C fibers, these are nonmyelinated. So it won't go as fast. So uh and so it goes to your dorsal horn once again and then from there after the vesicular formation, everything is the same but it will go to different, I guess um active new neuroscientist. That's what it was school again. Yeah, all go to one of them different parts of the dream for different, I guess, emotions or motivation, er responses. Uh So yeah, just like I said, alpha delta and C fibers. OK. Now um mhm is there anything else you should probably know from this? Yeah, just, er, the Decca happens at the dorsal, right after the dorsal wor, at the spinal cord. Very important that it does. It decss straight away. So I, so that's another very important thing to bear in mind. But, uh, yeah, that's that any questions, please let me know. Uh, but we're gonna do this question, question to, hopefully I'll put it in the chart now. One OK. So, mm we haven't got any responses. OK? No, we've got five responses. Three people pick E and two people pick C mhm. That's actually really good. I'm, I'm actually happy about that. Um This is most people are picking E OK, I'm happy about that. So um it's good you noticed this? So the first thing you do is this is doping. So first thing you think? OK, this is pain. Let's, let's rule out this me oblongata ones cos that's the deal of touch. Forget like there's no chances it will be. Uh, so it's good. The answer is you. So yeah, no chance. No, no, no way it can be A or B the next thing you do is you look at er, the region is ignore the hip. No, it's not meant to say it. But anyway, um it says less than matter sense for you, right? Like first thing you said is everything is dec so it will be contralateral. So this is at the right list So it has to be at the left part of the brain. So we can rule out D and F. Um Now we have to compare between C and E. This is doping. One of the most important things. Like it's the one of the main differences other than the fibers and like specific speci speci how specific the pain is uh would be in, in, in dull pain would be the reticular formation. So, reticular formation is one of the big differences. Other than that, I can't even say this word specific is or um uh or like how fast it is in the myelination in the fiber. But yeah, I'm happy. Uh So just go to the next one. Question three. So, yep, I put question three in now stop pulling it later. OK. Good. OK. Let's give it a second. We have one, we have one response for C so C two. OK. Yeah, we have two now for C uh we have three for C. OK. I think everyone's going for C was all six. OK. Well, that, that's good. Cos that is the correct answer. Um I guess the first thing that we need to rule things out is this is sharp pain, sharp pain means that there's no way it can be ac fiber. So that rules out A and B immediately. So the reason why it's not D and it's C it's if you remember the pathway. So it firstly goes to the mechano receptor, then eight would be alpha delta. OK. That's the same. Then one. OK. That's the dorsal wound. So what happens after the dorsal wound? Remember we get decussation in C it shows de decussation but in D it says uh what do you call it? It's nine which is ascending, it doesn't ascend first, it decorates, then it ascends. Another issue with D is if you look at the right, at the end three, it goes to the right cerebral cortex. Remember if it decussate, it needs to be at the contralateral part of the brain. So if it's right foot, it needs to go to the left part of the brain. Um Yeah. What's that? Let's go to the next door. So uh if there's anything about the pain that you can't understand all that, all the, like the new, the new one stuff just, just, just put it, just put it in the chart and I'll, I'll put the answer. Um our next uh patient history. So we've got Paul Bennett. So this was a presenting complaint. Uh I guess you can have a quick read of that. He had a history of presenting complaint uh of that. And he's had a past medical history of this. So the reason why you basically common, he's had lower back pain for quite a long time, but this time it's gotten worse. He's, he's waking up more at night. He's becoming overbearing. He's having a baby all day. And he's had pins and needles in both legs, right? OK. OK. The third thing OK, guys, you need to follow me here. So whenever you have pain inside your body, let's say you've got a problem in your heart, it's not going to uh you know, you're gonna say like it's not, you're not gonna exactly locate it at the heart or, or come out like a skin like a, it will be at an external stimuli. So your skin um and this is because your internal organs will synapse at the same vertebral level as external surfaces like skin. Um So your brain, your, it's just that your brain kind of gets confused. So let's say you, let's um your brain's very used to external external stimuli, like touching things of your skin and like you wearing clothes right now, it's, it's things that it knows that is most likely if, if so if there's a stimuli, it's from your skin. But so it just kind of gets confused that if something internal happens, they could kind of associate it externally. So let me give you an example here. Uh You can see over here your heart, I hope, I hope you can see my cursor. Um It, it's showing that your, that your, your left arm. So the top of your left arm shoulder and it's going a bit down. This is because your pain fibers supplying the heart synapse the same level as the derma tumor as your left arm. So that's why you, you, you feel it in your left, your left uh left arm, here's the mechanism. So pain stimuli sent from viscal tissues, uh acting potential, the sensory afferent up to the spinal thalamic tract to the brain convergence, sting vessel sensory neurons can converge with the somatic sensory neurons as well. And stimulus that was from a vessel tissue is perceived by the brain as normal from the skin or muscle. Ok. Now, things to rule out. So this was like some sort of differentials that they gave in your CSI session. So they first went like vertebral spinal cord, nerve roots, lumbar muscles, aorta, kidney pancreas. Um So, II guess let's let's just firstly rule things out. So aorta you would have had a tearing pain that we mentioned before, from your chest ripping to the back. But we don't really have that here with uh pool. So we can rule number five out. Six kid kidney pain is more loin to groin. So we can rule that one out. And the pancreas would just be more like central and abdominal, probably be more anterior. So that's probably a uh another thing we can rule out here as well. Um See a lot, the re the reason why we probably won't think this is so lumber is because he's also had like um I guess like sensations around his legs. He's also having like, I guess pins and needles or paresthesia So, so that's why he can rule out solely lumbar muscles. So that's why we, we will, uh we will go to, we'll say it's, we'll say our differentials kind of turn to number two and three. OK. Now, what about your anatomy? Um There are 31 nerve roots in your spine. Remember it starts from, that's above C one. So that's why you got eight c, eight nerve roots at the C level. You got 12 at uh the thoracic level, you got five at the lumbar five at the sacrum, which will and then you've got your coys, they're actually four vertebrae but they're all fused. So any accountable one. So if you add it all up, it ends up being 31 vertebral, uh 31 nerve pairs of nerve. That's because, you know, you go right and left, show him. So something to, I guess um look out for your nucleus pis and your annulus fibrosis. This is actually where most of your disc herniation issues come. Um Think of it like your annulus fibrosis. This is like a, this is like, it's like a, it's like collagen, it's like, it's quite thick. And whenever if this bursts, you've got this kind of, it's, this is kind of your nucleus pulpous, is kind of more free flowing. And then what happens if there's like a gap, it just literally like enters through it and then it will, it literally presses against your, your nerve roots or your nerves um and it can go laterally. So if it goes laterally, it might just affect a part of the nerve root. But if it goes medially, so right down the middle, it will go right down to the spinal cord or your corinum. Um And yeah, so that's that uh once again, yeah, this is your disc and inside that there will be your nucleus forces. Yeah. And yeah. So anything else uh negative? They're gonna show you this but maybe like in and you've done this where your, your qui it kind of looks like, I guess if you, if you've had like if you've taken spaghetti right outside the packet and it's just like it spreads out. That's, that's what your chin looks like. It's just little like like little wires, all kind of like strings that are just all spread out and they kind of, they look kind of singular and I'm pretty sure you guys have already seen it and then your back pain causes. Uh So this is, there are different ways to do it. Uh You've got your vertebral lesions, spinal cord, lumbar muscles and nerves. Uh The things I've highlighted, they're, they're common, the things that are read, they are all emergencies. Uh OK. Um Let me just uh and if you look at this image again, that's what I mean by your, the one on the top of like you see, you see how this, this fiber, how it how like you kind of, it kind of opened up and it caused a leak of your n nucleus pulposus and that's kind of thst onto your uh your, your, your spinal nerves. So uh so it's a really, really big issue. So now let's go to task three. So, endoscopy, you were given three differentials from, from what we had mechanical back pain, radiculopathy and cord kind syndrome. So let's, let's just rule this out. So the reason why we know it's not mechanical back pain is uh if you can read this uh what it does, but mechanical back pain shouldn't have any pins and needles and you should retain your urine and you should not have numbness in mechanical back pain, radiculopathy. The reason why we know it's not this. So this is when uh let's just go back and slide, see your nerve roots. Uh This is going back to here. Radiculopathy will just be on one side. It will be more lateral, but in quarter quino. So you, it'll be right medial, it'll be right in the center. So it blocks and if it goes right in the middle, then it'll block both left and right. So you get more bilateral um bilateral symptoms. So the reason why it's not radiculopathy is because he's having um bilateral er sciatica and he's having bilateral symptoms as well. Uh And uh yeah, so that's why we've kind of come to the conclusion that he's got quarter a in you. Now, this is the development of the spinal cord. Um So, so this is quite long. But um how, when you're a baby, basically, uh you, you, your bone, your bone grows but your spinal cord will never grow. Um And what, what this does is you've got your nerve roots here. So let's say you've got this one going to S one. So it will, and, and that will remain for the rest of its life. Like you'll have a S one nerve root coming from your spinal cord. OK? Now, this is basically this, this whole thing will be how the coquina forms and it, by the end of this slide, you guys should hopefully, should understand it. So what happens is um your, your bones will grow but like I said, your spinal cord doesn't. So by 24 weeks, like you can see the bones have gotten bigger and have grown, but your spinal cord is not grown. So it's becoming shorter than the actual vertebral column. And you see you see over there how your s one's still going to from, from that place to there, it's gonna carry on doing that and not only s one's doing that, you have ST doing that, you have S3 doing that, you have S four doing that and you'll have S five doing that. And then you've got to, and then uh you know, you go to neonate and you even go to an adult and you end up. Uh yes. So your bones are still growing and then you will literally have this nerve root literally going to that S one region and have one, going to S two and have one going to S3 and they all go down and this is what forms the call equina. Um And yeah, er, that's how it does. Uh another thing to note the thing at the bottom of the corner, we call that the Conus medullaris. But um yeah, your spinal cord ends at the Conus medullaris which is at L1. OK. Uh Hopefully, hopefully that does make sense. Um If it doesn't once again, put it in check. Uh So I guess you've got this slide to do with your nerve, which OK. So over here, uh you can see we've taken Amri uh which is basically the, the main form of imaging for Corinna. Uh The most common sites is L4 L5, an SA L5 S one for uh nerve compression in equina syndrome. This is because it, it carries the most support and has the most movement. So therefore it becomes like the most prone to injury. So, yeah, in the uh once again, we've said how L1 is the end of the spinal cord. So that means L2 must be the beginning of the quarter final. Um And yeah. Ok. So now we've got uh the, like we've got the red flag symptoms for quarter equina, we're gonna split it into three. You've got pain, you've got weakness and you've got incontinence, um, sciatica that, uh, that, that comes more from the sciatic nerve. We'll go into that pallesthesia pins and needles. Um, any other words, uh, micturition, that's more process of urination and, yeah, let's go. So, pain, bilateral sciatica. Um, here you go. So this is your nerve, pain in the leg caused by an irritated or compressed sciatic nerve. Why is the bilateral? Remember when I've shown you this, this disc herniation, you've got your nucleus corps, uh it's going right medially. So it's gonna affect both nerve roots, both on the right and the left. So you'll have both ways. You're gonna have uh sensation coming through the right and coming through the left pain going down your leg. Um So that's that. And then there's the, yes there, the pathway there. Why is the sciatic sciatic nerve? I told you it's come from the word sciatic nerve. Uh It's a combination of motor and sensory, motor and sensory fibers from spinal nerves, L4 to S3 L2. This is your weakness. Um So, so bites. So once again, bilateral neurological deficit in lower limbs. Once again, we it's, it's kind of is basically similar to this. Now, your second one, saddle palaestes. Uh this is pins and needles because sensory pathways that transmit touch, pressure and peripheral resection are being affected, laxity, laxity of the anal sphincter. Uh This supplies nerves, nerve roots, er, from, uh, I think it's s 2 to 4 if I remember correctly and these control your pelvic floor muscles and include anal sphincter, which is essential for maintaining continence. But the cor equina can impair this and then your final thing would be erectile dysfunction. Um, once again, uh, erectile dysfunction is from your cavernous nerve and this is from S 2 to 4 and this will affect your s um another thing with, I actually, something I forgot to mention your laxity of a sphincter is, uh, that's why one of the exams you do is apr exam for. Uh this is because it will affect uh I guess like the, the, the anal tone and that, that sort of thing. So, yeah, uh they covered it. Uh yeah, cytopenia, uh something to look at for copalia and some of these symptoms sometimes have a look at dermat and just see if it kind of matches up. And it usually, sometimes it does. Uh, yeah, and then for your incontinence. So your L1, 23 stops you from peeing because they're sympathetic nerves, you s 2 to S3 to 4, they're para sympathetic nerves and that makes you pee and then you've got, uh and a quarter qui it tends to happen from L4 to 5 and L5 to S one. So, parasympathetic function would be impaired, but sympathetic function usually preserved. Therefore, you can stop pee, stop, stop peeing but you can't pee uh this is that why you have retention, but this later on leads to incontinence because let's say your bladder ends up being full. So then it has to go somewhere. So then you get incontinent, so you might have a leak, leaks and that sort of thing. So, and that's what overflow you anyway, incontinence uh also know with the Pudenda. So ST S 2 to 4 keeps the three ps off the uh off the floor. Um And here, once again, this is to do with the contradiction where one allowing, allowing the function whilst one is not allowing for the urine function. Um oh, just, just to go back um over here, remember, this does affect uh over the laxity of the anal. This will also affect your um you, you're moving your bowels. So you might feel like uh I guess inabilities and like frequent incontinence as well. Uh Let's go to the next one. So, investigation and treatment. Um So you OK, you're gonna do an MRI straight straight away. Um Your contraindications of the MRI will probably be stuff like metal wiring um and that sort of thing. And in that case, you probably do myelography should be a CT CT myelogram. Uh You do it within 48 hours. This is a very important if, if you delay treatment in um called a equina, you, it can lead to lifelong complications. So, like lifelong loss of bladder control, lifelong weakness, lifelong saddle pain or like lifelong, like just chronic pain. So it's very important you get this right. And this is why like a lot of lawsuits which we will go into later occur because of quarter final. Um, these are your red flags. So just keep these in mind. These are your red flags. Um, definitely try to me, uh, memorize these. Remember these, uh, just do it in a way that you can recognize it if it comes up as an SBA Q. OK. Question four. We pus and let me put the question on for them. So I, I'll put the question on for them. I'll let you know what they say. Also in the meantime, if you guys have any questions, you want me to re like re say anything, just, just put it in the chat. There's nothing in the chat so far. I'll give you a few more responses. So if only two people responded, uh, it's 5050 between A and D with the A and de the, uh the first and last option. OK? And when I was in second year, I made that mistake where I thought it was B as well. It was actually a um, remember it if tier 11 is blocked everything below it blocks as well. OK. So you, so you, I, so you'll get all the symptoms and, and that's basically just something to remember. Take note of this. I think it might come on your exam. If, if there's a block in T 11, that means all every everything below blocks as well. OK. Just make sure you remember that. Uh OK, this is a feedback. Um Yeah, just guys, if you can fill this out, it will be really helpful. Um And in the meantime, if you got, if you have any questions or want me to explain anything further, just uh let me know there's no question in the chart so far, but I'll let you know if there are. Yeah, I'll just, I'll just leave this here for a minute and then I'll um, wait, they want the feedback in the chart. Let me post that the chat. Give me one second DT and then there'll be, uh, there'll be more questions and stuff and there'll be one last task and then we have the questions at the end. Yeah, let me just put a link in the charts. OK? I put a link in the chat that this should work. Yeah, it's working, please. Yeah, up to you when you wanna carry on. OK, just give it like 20 seconds in case there's like a question that pops up. Yeah, that's fine. I'll let you know if there is one, no questions in the chat. Ok? Ok. Let's have a look. So this to six is just about communication. Um It, it, it's, it's more so to kind of cover your back and also the patient might not understand what what you said, are you, you're not gonna ask a patient, do you have bilateral sciatica? It's gonna be like unle unless they've got some sort of, I guess background or they kind of know what it is, then they'll probably go like, ok, yeah, I've got it. But you need to go, like, do you have pain going down your leg? Is it both? Is it one so that you need to ask these sort of questions uh in a clear and way that a patient is able to understand it? Um And yeah, it also says it's confusion as well. Uh Yeah, this is also quite important as well. Um Like I've mentioned a lot of lawsuits happen because of qui and pa part of the CSI case is trying to avoid that, er, as in the future when you guys are clinicians. So, er, the ways you do that is you document everything, er, make sure it's legible and you record at the same time, the events happen, not like two weeks after, at the same time it's happening. Um uh Yeah, make sure you keep it securely or maintain confidentiality and there's other stuff. So you mentioned the relevant clinical findings. So like if there's a red flag, you say these are the red flags I found and you have to specifically don't say there are no red flags. You say there was no bilateral sciatica, there was no fecal incontinence, there was no er, foot sensation, there was no, er, um, loss of anal, like you have to specifically say what the flag it was and you also have to say who, who it was that, that made the record, uh, why, like I said, it's for, uh, legal reasons, um, because these are, the tips is given, uh, I guess just, just some interesting facts. Um, a delay in referral can lead to 100 and 30 k claim from injury alone. And if they've had like a nice job before where they've earn, they, they've been earning a lot of money and it's affecting their career progression, then you can even get even more from that. Uh, the MDU spends 350,000 lbs a year in legal fees because of Gordo Kinner and 8 million, er, last year or actually now 2023 was given in settlements. All right. Thank you. Make sure you call and make sure, uh, you do everything right. Uh So statistics questions, uh, you need to recognize straight away. You, you're gonna get one recognize straight away that just a statistic one. I know that's, that's not really hard to do. Don't panic, just kind of just take everything in and then all be easy. II usually skip them and I do them to the end, but whatever your style is just make sure you, you stick to it, re read the question carefully. Be careful of negatives. The reason why I've said this is if someone's got a negative pain score and it's become more negative, that's actually a positive thing that's happened because they're now in less pain because that's a negative pain score or like they, they've got a depression score and if the depression score is becoming more negative, that could be a good thing as well because that less the plus in the or that the plus score is less. That's another important thing to think about uh time management. And uh practice. Also remember anything that doesn't have ap value of less than 0.05 is not significant. So that's another thing to bear in mind. But now we've got questions coming up. Question five. Yeah, I'll put it in the chart now. OK, I'll wait until we get like five responses and then let you know. OK, most people, three people who have voted I at sea. Oh, ok. Ok. Three people could see one person could be OK. So, uh the answer is actually c like I've mentioned, first thing you do look at your P values. OK? Uh It is 0.04. This is a significant result. This is 0.01. This is a significant result. So we'll just look at these two. So quality of life plus 0.1 plus 0.2. OK. Quality of life has increased. That tells me uh one thing has improved. Uh Also make, make sure you look at the top extended intervention and brief intervention, maybe they will be flipped around. You don't know, make sure you look at it. Next one, you look at depression. Remember when I told you be careful of negative figures, negative 3.6 depression going to negative 7.6. So their depress depression score has decreased, which is overall a positive change. So therefore it's actually two and not one. OK. Next question at what vertical level does the spinal cord end? Let's see, six people are per A and one person is per B but once it a stay as a member and also try to remember that spinal cord development is L1. Next, what investigation does a patient with? What kind syndrome require urgently? Yeah, let me check now. Um five people. OK. Six people put B2 people up with C OK. The answer is MRI, the reason for that is um you, you, you, you any of the CT MRI is contraindicated. Like I've mentioned, for example, you've got metal work in the body but remember it's MRI why? Because it depicts soft tissue pathology really well. Um and stuff like aortic dissections or uh spinal infarction. They, they can kind of mimic in CT S but in MRI S, you've got, you've got very, very accurate. So and CT S aren't like in terms of literature. It's they, they, they haven't been really well defined to, to treat quarter final syndrome. But B is the correct answer cos it could depict soft tissue pathology, pushing it. Yep, I'll put it in now. Ok. Um We have, give me a second majority of people. Upper option D Yeah. Is that correct? Uh Number S 2 to 4. Uh and that cause sympathetic nerves to your bladder uh promotes detrusor contraction and internal sy organization. Questions. Nine. OK. I'll put the next one in. Ok. Do you? I'll wait for a couple more responses. Um Let me see. OK. Most people have put b actually see uh to be II, this is, I very much doubt this would come in the CSI. But if it does, um because it was in your prereading uh one based chemical and thermal, right? Uh Question 10. Which if he has good. Yep, I put it into the chart, I'll give her a couple more seconds so more people can respond. Two. OK. Majority of people have put d all done. Uh, back pain is kind of important, uh tends to happen within the age of 30 to 50. Um Yeah. And remember it's bilateral and final thing, just final advice for SP AQ, there might be answers that are slightly correct or something, but you always choose the best answer. Uh That's why it's called SBA case. Um Final thing. There's like a checklist just uh it's not exhaustive. There might be other things. But if you can get this, I'm sure you'll, you'll, you'll, you'll do well. Uh are there any questions. You do not see any questions in the chat and we will put all the slides and recordings up right after this. Ok. Well, that's, that's, that's me done to see you. And, uh, thank you very much for listening. Thank you so much for let me stop recording, stop podcasting.