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That determines whether or not you get ankylosis or you get absorption and lysis. Um and that rank pathway that balances osteoclastic and osteoblastic activity seems to be a crucial one. These people come to us because they have pain or they have deformity or they have fractures. Uh and you just need an approach, how to, how to approach them. I hope you get your um I hope you get Mr Stelle sorted. Sorry, I just have one question if you don't mind, of course. Um Like clinically, I I, you know, from my experience, I think I know the answer to this but you said with a bond, you have to look for a fracture until you find one, but it's not the same dish. Is it? I think, I think dish is very, very similar tom if you have a dish patient, but bear in mind what you have is an ankylo spine and they have the same high risk of fragility fractures. Again, if you have a dish patient with pain and above and beyond what they normally experience and they've had trauma, go looking for the fracture. I would treat them in a very very similar way. Thanks. Isn't whole spine MRI sufficient for the, for these, for trauma or do you also then need a CT? So, Charlie, I think pragmatically what we do is when, when people come in and say you've got a, and you've had a fall and you've got thoracic pain. What we'll do is we'll ask for a CT scan of the thoracic spine because we're looking for a fracture there. And if that's um if, if that's abnormal, then we'll do an MRI scan and we'll ask them to do the whole spine on the MRI because what we don't want to do is, is, is the radiation. So I think that's the approach we take equally, you're well within your right to say, look, we, we're highly suspicious. This man with Ank spas got a fracture. Can you do ac a effectively a whole spine? Ct I think I would have that conversation with the radiologists in your unit. And what we tend to say is, look, can we look at the area of suspicion? But if we find something, when you, we need an MRI, can you MRI the whole spine? So if the radiologist agreed just to do the MRI because of the clinical suspicion, then you wouldn't necessarily want a CT to help any surgical. I think I, I think I would do the MRI scan. Uh And if that excluded a fracture, that's great. If it showed a fracture and you were referred to the spinal surgery unit. We would get a CT because we need the CT to plan where we put the screws. Sometimes the pedicle caliber is very, very small. Uh and it helps surgical planning. So I if I had to pick one investigation, I would get an MRI in, in, in, in a out out of a spinal surgery unit. And the spinal surgeons will request a CT scan for preoperative planning. if the MRI scan shows a fracture, the reason we get CT more often or not, is it just easier, isn't it? It's sort of practically much more feasible. So, um, but I think an MRI is more sensitive and probably a bit more, um, a bit more useful. Thanks, the reason these people, yeah. So sometimes like discussing with the radiologist on call, sometimes they actually offer the MRI because they, he's actually more sensitive to. Absolutely. And I go for that and what I would say, what's really interesting about these people is, um, they often are neurologically intact. All those patients. I showed this, even the guy with the dislocated neck, he was neurologically intact. Why do you think that is Mike the guy, the guy's neck's broken in half. Why do you think he's neurologically intact? How do you think they break their spines? Do you think they, they have a car crash or how do you think they break the spine? Exactly. So, so low energy. Exactly. So they're low energy injuries and, and they snap their spines with low energy trauma and therefore the thing doesn't displace and so, um, er, people often, II, I think, and I'm sure as time goes by will be proved right that the main determinant of whether or not you have a cord injury is the energy imparted into your spinal column, not what the surgeon does not, what kind of operation you have not, what medication you have not what you know, not what not what blood provision profession you have. Um What matters is the energy dissipated into your spinal cord. Um One of the important things about aon people is in, in primary care and in in prehospital medicine is obviously if they're normally kyphotic, sometimes paramedics arrive at the scene, they suspect a spinal column injury and they try to put these people into a collar onto a spinal cord, that's not the shape of their normal spine. So if you try and force them into a spinal cord, you will paralyze them. Um So you have to say to the patient, what's your normal posture and they need to be cushioned or padded on a stretcher in such a way that they maintain their normal posture. Mr Marm and I were doing a a fixation for one of these the other day and we were using cord monitoring and what was happening is the spine was sagging progressively during the operation and we kept losing the monitoring. So Mr Marm had to grab hold of the spine with two cockers lifted up while we put the rod on because the spine is basically deflecting under its own load at the site of the fracture. They can be really tricky and positioning. These people really does require a bit of, um, you know, real team work. You need to cushions, er, pads, fo er, gel pads, positioning them for surgery is very, very challenging. So, so the operation is probably three hours of screws, but one hour of putting them on the table, um, look out for them when you're on call. That's all. Don't miss the fracture. I shall leave. That's great. Thank you very much, Mister Laman. Have a good evening. See you. Bye.