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Examination of Spine and Neurological assessment by Dr Ansab Mahmood+Mr Vivek Deshmukh

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Summary

In this on-demand teaching session, medical professionals will learn about conducting neurological and spinal examination, strategies essential for diagnosing and creating treatment plans for patients with spinal injuries or disease. The presenter will provide an in-depth review of spinal anatomy, examination techniques, and special tests, before moving onto a comprehensive examination of neurological conditions; including cervico, thoracic, lumbar, sacral, and coccygeal spines. Attendees will gain an understanding of common anomalies such as scoliosis, kyphosis, or lordosis and learn how to identify these in their patients. Key topics to be covered also include how to accurately measure spinal curvature, determine leg length inequality, and examine postural assessments. This session will provide essential knowledge for all medical professionals looking to enhance their expertise in spinal and neurological health.
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Examination of Spine and Neurological assessment by Dr Ansab Mahmood+Mr Vivek Deshmukh

Learning objectives

1. Understand the importance and purpose of spinal and neurological examinations in diagnosing and managing diseases or injuries of the nervous system. 2. Review the anatomy of the spine and comprehend the functions of its various components, such as the vertebral body, intervertebral disc, associated processes, and articulations. 3. Perfect skills in executing examination techniques, including postural assessment, identifying leg length inequalities, observation and inspection of the patient's gait, balance assessment and palpation of the vertebra and paraspinal muscles. 4. Learn and be able to apply several special tests like the Spurling test, Hoffman's reflex test, and finger escape sign used in diagnosing specific neurological condition such as cervical radiculopathy and cervical myelopathy. 5. Develop a comprehensive understanding of how to conduct a step-by-step neurological examination, recognizing abnormalities and analyzing their possible implications.
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I see please. Ok, so today's topic is uh neurological and spinal examination. Uh introduction, there are many slides. So I need to go a little quicker. So introduction about the why we are doing it is about the importance of spinal and neurological examination. It is essential for the diagnosing and managing purposes. Helps in understanding the extent of injury of the disease, helps in managing the making the treatment plans and the interventions during the examination, we will review a little bit of anatomy examination techniques, special test and finally the entire neurological examination including the dermatomes, it's locked again. You can. Yeah. Yeah, like it's not going there. Uh No, just just open. How are you today? So which one this one? So anatomy of the spine? Very quickly. Review of spinal anatomy is composed of 33 vertebrae, seven cervical thoracic file number and bicycle which are fused for coccygeal. Again, there are f and intervertebral disc. They act as ac between the vertebra acts as a shock absorber. Each vertebra consists of anterior anteriorly. There is a vertebral body posteriorly. There is a arch which is composed of medical followed by laminas, transverse and spinalis pass intra and mammillary process. Articulation includes the intervertebral disc and the facet joints. However, the diagram for that. So that's in vertebral body, intervertebral disc. If you go on the cut section, you can see the intervertebral disc periphery is the less fibrosis and inside is the nucleus pulposus which is mainly a jelly and uh behind that is, which is attached to the body is pedicle followed by transverse process and then the laminar on both the sides which they join to form spinus process. And this is cervical thoracic lumbar and sacral and coccygeal spine. The function of spinal column, you know, it supports the body weight and protects the spinal cord. Then spinal cord normally extends from from in magnum to lower border of L1 divided into cervical thoracic lumbar, sacral and coy elements, spinal examination, postural assessment, good on inspection. Uh about the postural assessment. Observe the patients standing in the sitting posture, look for scoliosis, kyphosis or lordosis. There is a normal cervical lordosis. Normal range is between 20 to 40 degrees. Thoracic kyphosis average is 35 degrees, normal is 20 to 50 degrees. Lumbar is normally range is 20 to 80 degrees, average is 60 degrees. This is a healthy spine followed by later spine spine that is there is a convexity of lumbar spine anteriorly and convexity of cervical spine. Anteriorly, kyphosis is concavity of thoracic spine, anteriorly flat back, is strengthening of the lumbar spine or loss of lars and drawn back. That is a thoracic um all the inspections. So first you, you need to expose the patient and ask the patient to stand. Look from the front coronal balance. Look for the symmetry of shoulder height and the waistline, especially in the cases of uh scoliosis. Look for any muscle wasting and muscle wasting, especially in myelopathic cases, skin marks or freckles which uh happen in neurofibromatosis. Look for the pelvic balance in scoliosis from the side. Again, look for kyphosis of thoracic spine or hyperlordosis. That is excessive lordotic of cervical or lumbar spine. Possible causes are fixed flexion, deformity of the hip or spondylolisthesis. Uh The weakest way to find out on examination um is the Adams forward bending test for scoliosis. We ask the patient to stand and then bend forward where to go at the level that your eye exam. This eye should be level at the, at the level of back and seeing how is the, how is the thoracic thoracic uh or rib hump? And when you see the rib hump, that means there is a rotation of spine towards the side of rib and also the scoliosis. And most important it indicates the structural changes, that is a permanent change in the cervico uh permanent change in the spine, which is same as a structural curl. So any curve which has got a permanent changes in the spine is that indicates a structural curve. This test is commonly used for school screening if it is more than seven degrees on a scoliometer, it is considered to be abnormal and then the patients are brought for checkup in the hospital. Now, leg leg length inequality, that is the next step. You have to check whether the leg length is right or not. If there is a shortening of one leg or lengthening, then you might get functional scoliosis. That means there is no structural or any changes in the spine. But still, you will find the scoliosis as a compensatory mechanism. Next is a red spots. We get it in neurofibromatosis, midline skin defects which include hairy patches, dimples of nevi. This is a sign of spinal dy dys, spinal dysraphism is nothing but i it various uh abnormalities of the spine like distoma that is a double spinal cord or you can have filum terminal uh or cord syndrome, which is the cord which fails to ascend with the hem development. Uh and with the growth and it just gets attached to the tips of the coccyx by means of a fibrous cord or you can have it. Uh there is uh malformations like Meningomyelocele or meningocele. So, midline hair, uh midline skin defects are important to look for scoliosis. Uh You have to look for shoulder height differences in the rib prominence as I explained you with the Adams uh bending test which uh shows the rotational deformity and the scoliosis of the spine in the spinal dysraphism. We already discussed was asymmetry and the pelvic tilt. Now, if you ask the patient to sit on a table, then, then, then whatever leg in equality is there will be, will be removed. And actually, you can then see whether the scoliosis is functional or whether the there is a structural scoliosis. That means if there, if there are structural changes in the spine or not, then another one is uh springer deformity that is uh congenital. It's a congenital thing with the scapula where the scapula is hypoplastic and it fails to descend and you get the weaning of scapular. So that sort of deformity is small, scapular, it fails to descend and with binging is the splenda deformity. Uh then the flat lumbar flat back is uh decreasing in the lumbar gliosis. And the possible causes are compression, fractures, ankylosing, spondylitis, scoliosis, surgeries. When we distract and correct the scoliosis, it can lead to lumbar uh flat back syndrome that is blackening of the lumbar spine because of distraction with the particular system or Harrington rod, which was used initially earlier days. So don't other messages, don't forget to look at the hands and the feet uh for CVS or clawing. And it is important because it can suggest a neural axis abnormalities and may need MRI scan, then look for the gate of the patient on inspection. Is rat wide space gate, unsteady gait or shuffling gate with increased chance. You can get it in the uh when there is a myelopathy, you can have perceptive neurological disturbances as well. With that and gate or meddling, you can have with the L5, you know involvement L5, root involvement, you can have meddling or 10 and gate depending on if there is one side or both sides. So you'll have bilateral involvement. Whereas and bugs that is a unilateral involvement, get you get it uh in the cerebral palsy patients uh which is commonly the flexion of hip flexion of knee and dorsiflexion of the foot. So patient walks with a sort of a pouch po posture. It's called pro gate stiff. Gait is because of the foot drops, uh because the patient has got a foot drop, he cannot put foot normally on the ground leading to the stiff. Then you look for the balance assessment. One is the one important thing is a plum line and that is for the Coronal assessment of balance. So what you do is you can see on the diagram, see seven spinus process, make a tape measure and let it hang with the gravity down and see where it reaches the a a at what level it uh it it and see how it reach to the gluteal fold. If in a normal patient, it should go through the pass through the center of the gluteal fold. Whereas if there is a scoliosis of the spine, naturally, it will be on either way depending on the scoliotic curve on the sagittal balance, you look for when you start from the spinal sclerosis, it should the posteriors and the superior aspect of the cyclin. And that is what normally on the s balance you should have. But if it is going anterior to the sacrum, if the baby is going anti to the sacrum, it is called positive B balance. And if it is going posterior to the sacrum is negative balance, she can you hear me? Can anyone tell me? Can you hear me? I can't hear any anyone talking? 200? Hello. Can you hear me? OK. This is the next is a spinal examination on palpation, palpating the vertebra and paraspinal muscles so gently palpate each vertebra for tenderness. First is the spinus uh a palpation of spine for any abnormalities. Then for the paraspinal muscle spasm that is on the side of the spinus process, you see a cord like. But if it, if there are in spasm, then palpate the spinal and the sacroiliac joints processing uh to check for any tenderness, identifying the tender points and the deformities with the spinal. So to confirm what you see on inspection with the palpation, spinal examination, a range of movements, cervial spine movements. So normally you get about 50 degrees of flexion, 60 degrees of extension. Later flexion is about 45 degrees. Rotation is about 80 degrees from side to side. Then normally you can touch chin to the chest on flexion. Look at the ceiling on extension. That is what we roughly do touch ear to the shoulder on later flexion without lifting the shoulder up and look at the shoulder for rotation range of movements uh of lumbar spine. Then same flexion. You can bend forward extension, bending backwards, later flexion and rotation thoracic movement. Mainly there is a rotation in thoracic spine. They are broadly restricted in spondylitis. Now, coming on to the special test first is Spurling test. Uh that is to diagnose uh cervical radiculopathy pain. And it is done by simultaneous extension, rotation of head to the affected side, lateral pain and followed by vertical compression which produces which uh uh reproduces the symptoms of radiating shooting pain in affected arm. And then the narrowing of it is because of uh in this position, there is impingement of the root in the introvert foramina causing exacerbation of the symptoms, cervical myelopathy examination. So there are few tests you should be doing in a myelopathy examination. First is a Hoffman's reflex. That is a reflex of index figure flexion with sudden long finger distal fells, flickering. So when you flicker the distal fs, there is you can see the second diagram, there is a sudden flexion of index and um that's a Hoffman's test of pulse reflex. Se second is a R test. This is for cervical myopathy. Again, the patient has a patient to stand with arms held forward and eyes closed, loss of balance consistent with the poster column, dysfunction, finger escape sign. Ask the patient to hold the fingers extended and adducted. You'll find the small finger spontaneously abducts due to weakness of intrinsic muscle. Hi to, to, to hill walk. Uh the patient has difficulty in performing. Go to hill walk arm sign. This is a test which is not normally done in the examination in the your exams. But you just tell the examiner that uh with the extreme flexion of cervical spine, it leads to electric shock like sensations which radiates down to the, down the spine into the extremities. But remember, you never do this test in exam. You can just orally tell the examiner because it causes a lot of pain and problems to the patient. Spinal examination. Special test is a straight leg raise test that is to assess uh the lumbar root involvement. So in this test, the patient lies and examiner lifts the leg up with the knee extended and the angle at which the pa um examiner elicits the pain is the angle of straight leg raise test. So if you normally from 0 to 30 degrees, you should not have pain for the uh for the um lumbar root involvement as the sciatic nerve starts stretching. A there is a tension in the sciatic nerve after this level. So normally it should be between 30 to 70 degrees is the range where normally you get straight leg risk positive. If it is below 30 degrees, it can be something else and you should be looking for the cause about 70 degrees. Again, it can be because of, uh, sacroiliac pain or other things. There are various, uh, SLRs which are described, it is mostly, it is parity of uh, uh, whether patient needs an operation or, or needs a surgery or not. If you get the SLR pain radiating from back into the leg going post along the course of sciatic no into the foot. That is classical SLR with the shooting type of pain. Usually this clinical finding, um if the patient has this clinical finding, they usually have a good result with the surgery most sensitive, it is a sensitive test to look for between the central and the peripheral nerve pathology. Now, something about the cross SLR you should know is basically done for axillary disc which you will come to know later on. I will show you the diagram after this slide. The important aspect of the SLR is a LASIK test. That is if you get, for example, pain at about 40 degrees, you lower down the leg by 10 degrees to relieve the pain of the patient and then slowly passively with your other hand, dorsiflex the foot. And if the pain comes back, then it is a positive test for sciatic, uh positive test for the radiculopathy. If it is negative, then the pain probably might be because of hamstring tightness and not because of radiculopathy. Don't forget to examine abdomen for AAA aortic aneurysm or perianal sensations and an to power. No, I was talking about the axillar disc. So there are various types of disc, lumbar spine, and cervical spine. I will briefly let you know how the disc prolapse causes compression on the roots. So if, if uh there is a l this is a L4 vertebra and below is L5 vertebra and in between is L4 L5 disc. So now this relapse can happen in various directions. So the one which is shown is a paracentral disc, that is, it is mainly if you see the root, which is coming out, it is not between the, if it is outside the road, that is if it is not between the spinal cord and the root, it is called as a shoulder disc presentation and compression of that leads to if you, if you look at it, L4 L5 is prolapse happens with, this is called paracentral disc. And if there is a paracentral disc prolapse, then it causes compression on the L5 root as you can see with anatomy. But if it is a far lateral disc, that is if you go more lateral and if the disc is coming out far laterally there, then it might cause compression of the root, which is above and not at the same level causing compression of L4. So this, you need to bear in mind when you examine the patient. The third is about axillary axillary disc that is in between the spinal cord, which is not shown here. But this is between the spinal cord and the root. You get a disc in between which called axillary disc. And in that case, which is pull the sciatica on the other side, that is if you do the SLR on other side, if the disc is on this side, you do the SLR on the other side, all spinal cord will be pulled and you'll get irritation of this ro because everything will be pulled against the axillary disc. So you'll get what we call it as a contralateral SLR. So contralateral SLR is, if you have a disc on the right side, you will get SLR, which is when you start raising the left side, not the right side, but the left side up, you'll start getting radiating pain in the right leg that is called as contralateral or something about the cervical spine. If you look at basic difference between the lumbar and the cervical spine, if you look at these are round things on the pedicles and these are the pedicles of lumbar spine. So if you see lumbar spine, L4 pedicle, there is L4 root which goes below the L4 pedicle. Whereas in cervical spine, which is, is this is ac five vertebra with ac five pedicle, C six root goes below the C five radical. And that is what is called as a mismatch. And because below the C five, we expect ac five root rather than C five root is ac six in cervical spine. Whereas in lumbar spine, below the L4, you get L4 root. So that's uh this right. So if you see here, if you get ac five C six root compression with the C five C six disc, which is same as the lumbar spine. Because the roots in the cervical spine, they go more horizontally than in the lumbar spine where they have to drive a certain distance and go down. Then the femoral nerve stretch test that is for L2 and L3 S to identify the femoral nerve involvement position of the patient. You put the patient in one position, then flex the knee to 90 degrees and then extend the hip joint. And finally, planar affects the patient's foot. If you get pain going across the thigh or an to your side, it's a po positive femoral nerve stretch test. The hepatic test also known as fiber test, which is flexion abduction and external rotation test. So in that test, what you do is ask the patient to lie to fine and then ask him to flex his knee and put his ankle just above the contralateral knee as shown in the diagram. And then slowly start and, and what you have to do is to hold the contralateral, I rest with the other hand or stabilize the pelvis with the other hand, and then slowly bring the knee down. I if you get pain anteriorly, basically it or in the groin, it shows that the patient has got intra hip lesion or pain. This is basically patient gets pain or in the groin. If the patient gets pain located posteriorly, then it is probably a psychic disease or a lesion. The other one is a shower test that is basically done for stiffness, especially in in closing spondylitis. So what we do is uh uh we mark the spinus process of L5 vertebra and go 10 centimeters above in the midline and go five centimeters below, mark these two points above and below and then ask the patient to bend forward as much as possible. And then again, measure the distance between this proximal point and distal point. We mark about 10 plus five is 15 centimeter distance which will increase to more than 20 in a normal patient. Whereas in ankylosing spondylitis, it will be less than 20 centimeters. And that is a positive SARS test. Neurological examination. Purpose is to evaluate the nervous function and it includes uh mental status, cranial nerve, examination, motor system, examination, sensory system, reflexes. So peripheral nervous system, it has got a cervical, well, thoracic file lumbar bicycle and one coccygeal and no. Ok. Hey there, I uh I'm my name is one of the clinic fellows in A&E of the hospital. I will talk about the neurological examination. So today, we were talking about the spinal examination. So uh so we are going to skip this the central nervous system and uh we'll focus on the peripheral nervous system for the exam for the examination. So for the peripheral nervous system, we the spi we have 31 different uh spinal nerves which are divided into different regions uh with the cervical, thoracic lumbar, sacral, and coccygeal. So the main functions of the cervical uh for the nerves are is to transmit the sensory information to central nervous system and to carry out the motor commands from the central nervous system to muscles. So when we are going to uh when we are going to do the examination, neurological examination, it has different parts. One is the motor or you and sensory part. So the first of one, we will focus is the motor one. So for the examination, we'll start with a muscle strength assessment for that. We are, we normally use the MRC scale which range from 0 to 5 and we are going to test every major muscle groups in that. We'll talk about it later in the slides. And the other thing that we are going to look for is a tone and bulk evaluation. Then for that, we are going to uh assess the, for assess the muscles for the specialty and uh uh flexity and also for the muscle atrophy and hypertrophy. And uh the uh and the next one is the coordination test that we normally perform uh finger to nose and the heel to shin test. And we also assess for dysmetria and ataxia. So, talking about the power, normally, we use the MRC scale and the MRC scale range from 0 to 50 for when uh zero is for low contraction. And we can see that in paralysis and uh and five is a normal power. And we, when we are using uh when we are assessing the power of the muscles, we normally uh focus on the one muscle group. On the one side, we stabilize and isolate a relevant joint for each assessment to ensure we can accurately measure and compare the muscle strength as a result, we assess one side at a time. And when we assess that one side, for example, we are assessing the um muscle groups like Cordy on, on the right side, then we will assess the same muscle group on the, on the other side. Also, normally we u use the MRC and but I like to use the modified MRC Great. When I'm, when I uh when I'm assessing the patients in uh in the ed, it gives us more information and the neurosurgical people really like it. Yeah. So for the uh for the myotomes, uh there are different myotomes and these are the um uh main myotomes that we are going to focus today for the shou uh for the shoulder abduction deltoid is the C five when we assess this uh deltoid muscles, we are assessing the C five. now and the elbow flexion biceps is C five. We can ask the patient to bend the elbow and don't let them straight uh and let us straight straighten it. And uh for the C six, normally, we can u uh uh C for CSI is the wrist extension. And uh we can uh we can ask the patient to move the wrist up. And uh for the C six is a brachy radialis. We asked the patient to for the risk, risk, radiation deviation. And for C seven is we are, we are assessing the triceps for it and we do it by the elbow extension. And for C seven is the wrist flexion. And for C eight is the finger flexion. And uh for T one is the, is for the uh when we are assessing the T one, we uh we ask the patient for those fingers abduction or we can just ask them to send their uh fingers apart and don't let them, let us close them for the lower limb uh myotomes. Mm For the L2, we assessed the uh hip flexion and for the uh L2, we or we, I can also assess the hip extension, hip A adduction and we are assessing the different muscles for that. So if we do the, for the L2, you can see that L2 is that uh we are assessing IOP for in the hip flexion and for the maximum maximus, we are accessing for the hip extension. And uh in the same way, we can assess the quadriceps by the knee extension. So you can ask the patient to bend, uh to ask the patient that you are going to bend the knee and don't, and they are going to resist that uh resist that force. And for the uh L4 for the, uh we can assess the foot dorsiflexion and uh lift and we can uh tell the patient lift your foot up towards, towards us. So L4 is a foot inversion. L5, hip ab abduction. L5 also is a big toe dorsiflexion and the S one is the new flexion hams. And also for the S one is the foot plan of flexion. Uh And S one is also the uh cranial uh uh foot inversion uh for the S two, S 2 S3 and S four. These are the, uh these are the movements that we are going to conduct and check the follow on the, on the MRC scale. Normally we, we for the S3 and S four, it's normally done for the Cor cor and uh we'd normally do the uh the pr examination or also the uh prevoid and post void uh bladder scan for it. For the bowels, you can do the rectum examination and also you can ask the patient if the, if uh they are incontinent or if there was any episodes of incontinence in there for the sensory examination, for the uh for the sensory system examination, we are we have different things to assess it. Like the light touch, two touch, pinprick, warm and cold and vibrations. So when we are going to do this, we are going to use every dermatome and we are going to assess uh right side to the left side. So we are going uh bilaterally to and uh for the vibrations and pro sections, we are going to use a tuning fork for the vibrations. So w why we do the spinal uh the sensory uh examination because we are assessing these tracts of the spinal cord for the dorsal columns. We are uh when we are assessing the deep uh prosection or vibrations, we are assessing the dorsal columns of that, of that uh dermatol uh and also for the pain. And when we are assessing the pain and temperature, we are assessing the later spinal elms. And when we are doing the light touch, we are assessing the ventral spinal thic rac. So these are the uh this is the whole map of uh different dermatomes. Uh But I'm going to show you these ones which you can just assess these things and these points and you can assess the whole dermatome. I'll, we find it very easy to do that. So um for the, for the C five, we are going to use only the deltoid region by the shoulder, shoulder, uh muscle region where we, we can assess the all the sensations there, like the uh light touch, blue touch, you know, uh and every other sensation we can touch. Uh we can assess it from there. And for the c sake, we can use the distal palli of the tongue and C five. The middle finger, C eight is the ulnar hand, uh ulnar side of the hand. And the T one is a medial elbow, medial side of the elbow. And T two is the axilla T four. For the uh we can assess the nipples. And uh for T eight, we can assess the Z system for T 10. You can, we can use the um uh we can assess the emblica. Uh for L1 is a groin region. Again important for the Cornum L2, for the anterior thigh, L3 for the knee and L for the medial medullar. For L5, we can use the dorsum of foot and the first web space. Uh first web space between the big toe and the uh and the uh toe with it. S one is a later foot and little to S two is the posterior medial pie. For the S3 is the E and S four and S five is the final region you can ask the patient or uh with, if you have the or you can assess it with the, with the chakra the next part is are the reflexes. So they are different reflexes. The deep tendon reflexes, superficial reflexes and some abnormal reflexes or pathological reflexes. For the uh deep tendon reflexes. First, we are going to assess the the upper limb reflexes. Then the lower limb reflexes for the upper limb reflexes, we are uh assessing the C five nerve on the with the bicep reflex. So for that, we ask the patient to first, we have to uh assess where the tendon of the bicep is normally is in the cubital FSA. And you put your, you put your uh put your thumb there and with the ham hammer, tendon, uh uh tendon hammer, you can put the force there and you will, and you will see the contraction of the bicep and the flexion of the, of the elbow, the same on the baker radius and the tricep muscle and the patella is the is in the lower limb and the achilles is for the S one reflexes, we normally scale these from 0 to 40 is like you, you don't see any activity on it. And from 1 to 22 is the normal reflex and three is a breast, but four is the breast reflex with clonus. The clonus is the, is the, is the uh tremor like thing you see like ther flex but with the tremor of or fasciculation of the muscles for the uh superficial reflexes. The Elvan Premier reflex use lightly stroke, the superior and medial part of the thigh and normal response is the contraction of the premier muscles that pull up. The test is on the, on the same side. We normally also use uh the cremasteric reflex and the testicular to. And also. So for the abnormal signs of uh reflexes of the pathological reflexes. The most, one of the important ones is the bins or plantar reflex. When we with the, with the tip of the ham, uh tendon hammer. When we, when we scratch it from the heel laterally to upwards, the normal response is the big toe go down. All the, all the muscles try to go down, uh sorry, all the toes go down. But if the extension of uh if there is an extension of the great toe, then it, it can identify upper motor neuron and the other ones, uh superficial reflex is the abdominal reflex. And uh with, if there is any abnormal uh abnormality in those reflexes, it shows the spinal cord abno abnormalities. Syrinx, we can as uh we can as uh we don't normally assess this reflex on the all the four quadrants of the abdomen. The um above the blockers is T seven t eight, T 10 and the below blockers is T 10, t 12. But uh in the end, we normally also assess for the uh for the position for this. We ask the patient to lie down in the spine, uh spine position and uh ask them to close their eyes with a big, we uh we, we ask the patient to close her eyes and we do the flexion and extension of the big toe at the distal joint. Normally we do it on the uh on the distal fell, uh distal interphalan joint. And then we asked the patient, if that they, if they can assess in which position their to is if they can assess it, then it means that it's uh it's normal. But if, if you don't, then it's an abnormal position sense with uh in the end, we also do the vascular examination because the vascular examination uh play uh plays a huge part in, in the uh in, in the sensory uh sensory examination also. So this is the ace chart when we are doing the exam and the the spinal cord. And when we are doing the neurological examination of the spinal cord injury, we normally fill this up and it has a l all the dermatomes that we can assess and uh with the light touch, pin prick on the, on the, on the both sides and we fill it up and it gives us a lot of information about it. So, yeah, if so the takeaways for today's presentation was the importance of the spinal and neurological examinations and uh some of the tests and techniques for the accurate assessments and the significance of the findings of those tests. So, if you have any questions feel free to ask and we, we wake and I are both present here. So to answer them, I guess you, yeah, it was a big presentation. Anything and they were all this. Yeah, because it was a spinal. So that's why it was no, you know, I'm not saying I'm not giving the name. I'm just saying that it is a lot from you. OK? I think. Yeah. OK. Thank you guys. Yeah. Don't forget to provide the feedback about this presentation. One important bit is the back because every uh small patient comes in, you can get it online. You have that and then take a photocopy and just put it in the next day morning when the the and the that's uh thank you. We don't do so many tests. You can do nothing more than that, isn't it? And there is a, that is what exactly most of us. But in A&E there are a lot of different things going on because of the uh with the stroke thing with the thing with the Yeah. And uh those three out there.