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Hello, everyone. Welcome to the Metap anatomy series. Today's lecture is on the anatomy of the back and the spine and it's going to be done by Mr George West who is currently a CT one at Great Ormond Street Hospital in London. Um, this series is sponsored by the MDU and 10 Hub. And, uh, at the end we'll have a feedback uh questionnaire. If that, if you complete, you'll get a certificate um, of attendance to show that you've been at this anatomy session today. Um, and yeah, we'll start and I'll hand it over to. Lovely. Thank you, man. Um, hello, everyone. Uh Thanks to Medi Perth International for having me. Um, it's great to be here. Uh, just before we start, there's just a little pole that's been set up so I can find out what year of medical school you're currently in, if you could submit, that would be great. Just so I know what to tailor what level, uh what slide to. Um, and also, er, while we're on it, if anyone in the chat could just type kind of 1 to 3 words of what scares them about kind of anatomy as a whole and specifically the anatomy of the back. And that would be really helpful too and hopefully we can address them concerns today. Um, but I will start. So, er, next slide please in ra Dr 10, I'll look on the chat. Is anyone some of the guys need you? What scares you the most about anatomy? A lot of second years, which is cool. So, while you're setting that up again, I'll just talk about what I will and won't cover so we can get through it. Um, so I'm gonna be talking firstly about, er, brief discussion on essentially the function of our vertebral column, the sections of the column, er, the anatomy of the single vertebra, um, and how they vary depending on where you find them. Uh I'm gonna talk about the spinal cord, I'm gonna talk about some ligaments, they're important and then we're gonna delve into some clinical scenario. Um, uh I'm not going over the muscles of the back today if you want to read up on them, please be my guest. Um, I recently sat um, a postgraduate exam. They weren't questioned on off or asked to be learned about. So don't, I don't think you'll get asked about them at undergraduate level, but it's good to know them if you have a keen interest or wanna go into spinal surgery. Uh, next slide, please. Um, we can see the slides. Thank you, Rio. I appreciate that. Er, so I did this slide a few weeks ago when I was teaching about the upper limb. So, anatomy is hard. Um, I appreciate, you've got so much to learn in med school and med school is a marathon, not a sprint, but I found anatomy easier to learn, er, by going over it and over it again and layering that knowledge. Um, so what you see today is only gonna be the tip of the iceberg, um, depending on what level you're at, whether you're first year, final year fy one or two ct one would depend how much you need to know about it. Um And obviously, the best way to learn anatomy is to see it in the fla in the flesh. So if you can get to a dissector room, um get to a theater and see it in real life. Uh Next slide, please, Jerome. So we touched on this again, uh the last few weeks in this anatomy series and it's just getting to grips with kind of how um we speak about planes in medicine and surgery. So knowing that the front is anterior, the back is posterior, um away the away from the midline is lateral and towards the midline is medial and don't forget about dorsal and ventral too. Um This can be quite hard, I understand, but it's good to know because when communicating with colleagues um in the medical profession, they wanna know clear and concise information of what you're explaining. So do learn it if you can uh next slide, please. So I'm going to assume that everyone has a basic knowledge of the Spri of the spine um and the vertebral canal, er, but just to touch on the building blocks of the vertebral column, which is in the vertebra, we'll dive into those of the c spine, t spine and l spine of a bit. But I just want you to understand that the vertebra is basically the building block. It provides a structural support and protection for the spinal cord. Um Each vertebra will consist of a body which you can see which is the round thing. Um the vertebral arch and then various processes. Um the vertebral arch is what is gonna include a enclosed, the vertebral foramen. Um And through which way your spinal cord is gonna go, um the processes uh will include the spinus process, the one that goes posterior towards that and sometimes you can feel. Um and then you've got your transverse processes which are out towards the side uh towards the side. And these are what serve as the attachment points for muscles and ligaments. The vertebra we discussed today are classified on where they're found. Um And all kind of exhibit features depending on where they're found. Um So this is an image from teach anatomy. So you can see the body, you can see the body connected to the lamina by the pedicles. You've got the spinus and the transverse processes. Um and the lamina um that's kind of the basic and then where you find the vertical body will depend on kind of what uh structure it exhibits. And um yeah. So next slide, please jerome at any point. If anyone's got any questions, please do ask them. I'm happy to answer questions as we go along. Er So just the vertical column as a whole then, so as you can see, some people call it the spine if you're calling it in layman's term, but it's just, it's our structural support of our human body. It's crucial for support protection um of the spinal cord. So, it's composed of 33 vertebra, uh which are made up of cervical thoracic lumbar and then a few sacral and coccygeal regions, um Primary function is to maintain posture, facilitate movement, um absorb shock. Um You've got discs situated between the vertebra which we'll speak about later that um will aid in flexibility and cushing. And then you've got the ligaments and muscles surrounding the spine um which will increase our stability, but also help us in our range of movements, going forward, back, side to side, um et cetera, et cetera. Um Just to make a note, there are 31 pairs of nerves but 33 vertebra. Um and if anyone knows why and can put it into the chat, um I will be most impressed. It's quite an easy answer but might as well get some interact um interaction going in the chat if we can. Um next slide please. Dr Thank you. So let's delve into the cervical spine or as we like to call it the C spine. So it's comprised of the first seven vertebra of the vertebral column, the C 1 to 7. Um So these vertebra are uniquely adapted to support the weight of the head um but allowing for a remarkable degree of mobility. Um So I'm sure you will know er that the first two are known as Atlas and axis respectively. And these are really unique in that they have specialized structures that facilitate unique movements. Um The things that you need to know about this will go on into the next slide. But I just want you to think now while you're watching what's causing you to nod, just think about that before we go into the next slide about Atlas and axis. So, functionally, the cervical spine will support the skull and protect the delicate structure of the spinal cord within your neck region, but it will allow movements of the neck and head. So we've got flexion, extension, lateral bending rotation. Um And these things we use every day without even thinking about. And obviously, as mentioned earlier, the cervical spine is a chondroit for our spinal cord towards the rest of our body. And you've got nerve roots emerging in your c spine and probably the most famous one that you've er gruelingly learned through med school is your brachial plexus. So, a typical c spine vertebra uh will feature a small oval shaped vertebral body um with superior inferior vertebral notches uh for articulation with the adjacent vertebra. Um One thing to note that makes ac spine vertebra, ac spine vertebra is it if it spinus process process, if you look on the image and it's kind of like two fingers on the end of the spinus process. If you're given that an exam, you know, it's ac spine, vertebrae, they're also much smaller um than say a lumbar vertebra. So the transverse processes as well um extend laterally and they serve as attachment sites um for the muscles and ligaments. Um And we've also got the, the for the foramen and you also got the frame and transversarium in which our vertebral arteries um will extend from C six to C two. There are one thing to note uh is that there are eight pairs of nerves but only seven um vertebrae and the C spine. And that's because they exit above uh the vertebra as opposed to below. And that's what causes um and that's what causes the kind of not matched up number to vertebrates, pairs of nerves. Um Next slide, please join. So this is really important to know they love to test it in anatomy, within medical school, postgraduate exams if you're doing an orthopedic job to understanding the difference between atlas and axis. So it's a synovial pivot joint um that helps us essentially not only hold the weight of our head up but not in shaking your head and shaking your head. Ok. Um So the things that make them unique and that you should be able to recognize in your anatomy is the Atlas actually lacks a vertical body and instead consists of a ring like structure um with anterior and posterior arches. Um It will articulate with the occipital condyles of the skull and that's what allows for this kind of nodding function of your head. Um And then you've got the axis underneath which is C two which is your has instead of er the er vertebra has your prominent odontoid peg or odontoid process or also known as the dens. Don't ask me why there's three different um words for it, but just pick one and know it and it extends superiorly from its body and articulates with the Atlas. Um It acts as a pivot er in which the adolescents and the skull can rotate um enabling for rotational movements of the head as we've mentioned earlier. Er Also, it's good to note that the axis possesses a large vertical foramen to accommodate the dens um and the transverse ligament that holds this dens in place, er which we'll discuss in a bit more detail in the next few slides. And it's really important to know the anatomical functions of er and the kind of structure of the C spine um parts uh this axis, like I said, cos they come up in exams all the time as, as you can see from the images, they are very different from the rest of the vertebra. Next slide, please. Dr And no questions, which is good. Uh So here let me just get back to the slides. I can't see the slides. Can we see the slides? Mm Sorry about this. I can't see this. It's all I apologize. It's fine. I don't know. It's any questions in the audience. Guys. Let me know when you, yeah, guys, if in the orders you can see the slides, let us know and I can talk about. Has it gone down for you? Dr Yeah, it has. Um, it's just the system, it just, it seems to be a uh issue at this moment of time. Well, let me. Ok. Is the back, it's not back for me. Well, what about everyone else? Cos it seems to have come up for me at this moment. No, it's not back. Sometimes. There's a bit of a delay when you put it up. Jeromy to us. That's what I found last week when I was watching TIMS. What about now? Not doing nothing. No, there's a chat. We can't see the slides. Thanks for, we'll try and get it back up. Um, if I share my screen doesn't work, can you see still can't see anything right? OK. Hold on. We can. Yeah. Ok. Hold on. Unfortunately, it seems to be a technical issue with metal. Let me just figure it out guys. If there's any questions about a anything any ask me questions, I'll try and answer to the best of my ability while we're waiting. Um OK. Thank you. All right, Doctor. Mhm. Happy to answer any questions about practice and method in the UK. If there's anyone, any questions or surgical applications or come on, would you mind on your? Yeah, give me one second. I was trying to, my powerpoint is not working, so I'm trying to get the powerpoint open if you just upload it as a PDF through um that section. So when you click present now and then just go through, share a PDF, I'll send it to you as a PDF, but it quite seems to be a mental issue. Unfortunately, apologies to the audience. What are the best resources to study anatomy? So, the best resources I found, er, so I started there are, how did I start? So the best thing I started was some youtube videos. Um Ken Hs quite good. We're very lucky that in London we have anatomy teaching each week. Um There are groups, various groups or courses you on. I think MRC S Sellar has a textbook that's very well distributed. I don't know if I'm allowed to say that Gray's Anatomy is a good textbook. There's a brilliant, brilliant, brilliant anatomy textbook. It's called um Clinical An Anatomy for junior doctors and it's written by the guy who writes the MRC S anatomy exam. Um and it's by him and Harold Ellis Fish and I had a and Harold Ellis read that book back to front and that'll do, um, remember that anatomy is equal amount as pathology. So, don't neglect your pathology when studying for the MRC S exam too. So you need to read the pathology textbook too. There's some great youtube resources. I followed a guy called Abdullah Mansour and subscribed to his channels and watched his videos as well. So I'd highly recommend him. But practicing with someone finding a study body and practicing for the MRC S part B exam is what you need to do. Part A is just learning, learning, learning and getting an early subscription to E MRC S and going through all the questions is all I did. OK, I can see it here. Is it working for you? Now, George slides slides are about fantastic. Cool. So thank you everyone. Thanks for your patience. Uh Thanks for joining, for sorting that. So this is just uh an image that I quite liked from the textbook that was just showing a real life uh axis and Atlas. Um That's just one more question. Thank you. The slides about fantastic. Um If you wanna learn your anatomy, it's good to go through pro sections. I don't know if your universities do have pro sections, but just sometimes in my exams they'd hand you a vertebra and say, tell me what this vertebra is or where it's from. So have a look, you can see the way that the, the dens or the odontoid peg articulates and allows that synovial pivot joint movement. So it allows so nodding occur, people think nodding actually occurs by flexion of your c spine, but it's not nodding occurs at the er C one C two joint. So if you learn anything, learn that fact today. So next slide, please, Jerome. Uh So as you can see my slides have minimal on cos I want you to try and take the images and learn from it. I know it's a lot to take in and this is a lot for your level. I don't think you need to know this, but it's good to know. OK. So the ligaments between C one and C two. So between the Atlanto axial joint um connect the ACL Atlas to the axis, they play a crucial role. Pardon me? Sorry, in maintaining stability and facilitating the movement of the C spine. Er So the most significant ligament is the transverse ligament that we mentioned earlier of Atlas, which holds your dens or odontoid peg as I like to call it um of the axis in place, preventing from its anterior displacement. And so it ensures proper alignment. You've also got the alar ligament uh which attaches the dens to the occipital condyle uh which provides further stability. Um during rotational movement of the head. But if someone, your professor asked you what's the most important ligament? The C one C two joint, it's the transverse ligament. Next slide, please. Dr So this is just a radiograph um of ac one C two joint. It's taken by an open mouth, ap x-ray. So you'd have a patient with an open mouth like this and they'd take an X ray of the C one C two joint. Er commonly you'd get this if you suspect the C one C two fracture in which you'd see displacement of that odontoid peg. If you're a medical student, you don't need to do this. If you're thinking about MRC S and you're at that level, you probably need to be able to recognize the structures as seen on this radiograph. OK. I'm not gonna delve into it any questions about it, messing the chat. But next slide, please, Joan. So we discussed a typical structure earlier of ac spine with its bifid spinus pro c spine vertebra and it's bifid spinus process, it's quite small as well, but the odd one out is C seven. So if you got asked in an exam, tell me three vertebrae, the c spine that are atypical, you would say C one C two C seven. So the C seven has a er distinguishes itself um where it's really prominent and long spinus process and that's what you can feel at the back of your neck that hard is yours, is your spinus process of your C seven. it's elongated, it's palpable. Um and it's not bifid like the other spinus processes that we mentioned earlier. It's a crucial landmark, er, used in spinal surgery or assessments in orthopedics. Um, and lets you kind of work out where everything is by counting upwards. Um It's also your transitional point. It's your last vertebra in which we then go into the thoracic vertebra and it's distinguished different from your c spine to your t spine. Um, although it has your transverse, the, er, the kind of transverse foramina, the little circles that you can see next to the body, it does not itself transmit the vertebral artery. I've not gone into detail, the vertebral artery, but I do mention it later. Um, but the vertebral artery is a major artery that comes off the subclavian and supplies your spinal cord will go on. Now, next slide, please drone. So I've delved into a bit of different here. Cos surface anatomy is really important when knowing your anatomy and knowing where structures are cos if you've got someone with pain somewhere, we should know what anatomically lies there. These are good to know, but you don't need to know them. So, the level of C six just above your, er, your kind of prominent, er, spinus process is a point that's commonly tested in exams and there's six common things that happen there. And so that a level of C six are just around here. So it's the termination of the pharynx and the beginning of the esophagus, termination of the larynx and the beginning of the trachea entry of the vertebral artery at C six where it's the vertebral, like I said, don't go through C SEVEN. It goes through C six. the tendon of the MRI across the uh across the car sheath, the middle thyroid vein emerges from the thyroid gland and the inferior thyroid artery enters the thyroid gland. These are landmarks that I expect you to know post graduate, but I do not expect you to know undergraduate. Next slide please. That's fine. Sorry, that was just a patient. Go. No, that's fine. So we're now going on to the thoracic vertebra. So the thoracic vertebra, our next point of our t spine made a 12 vertebra is distinguished er by their unique anatomical features. Again, this is because they have a role in supporting the rib cage and they're facilitating our respiratory function. Er Each thoracic vertebra possesses a vertebral body um er with Demi facets um er on the lateral sides and these are what articulate with the head of the adjacent rib. Um Their spinus processes are really long and slender and they, they, they slant inferiorly. Um and then they overlap of that with the vertebra below which makes our kind of distinguishable pattern of our spinal cord that you may see and say more slender people Thank you. Um Additionally, er the thoracic vertebrae have costal facets on their transverse processes uh which give an additional point of articulation for the ribs um which will just keep stability and mobility to the the I'm sorry, take away stability to the th er so increase stability, decrease mobility to the spine. So the the movements of the thoracic vertebra are somewhat limited, I guess as we spoke about to the c spine. Um but we still have some essential movements of this area. So you can still flex extend, rotate and lateral flexion. Uh But it's somewhat constrained compared to the rest of our spine. Um You, we spoke about costal facets earlier and these are what are located on the side of I've got, yeah, I've got a pitch in the next I we won't go yet, but we just want to talk about it. Um And they've got these kind of line depressions which articulate with the head of the rib. Um They're quite, they're, they're a, you're able to distinguish these and sometimes in exams, they may hand you a rib and a vertebrate and ask you to articulate them to be aware of how to be aware of how to um there are some atypical vertebra in the next slide, please. Dr Sorry. So these just a picture I just want to talk about some atypical vertebrae in the t spine um which are t 110 and 11 and 12. Um I wouldn't go into detail about that, but just know that at spine will have Demi factors and costal facets that will articulate with our ribcage to provide that really strong, stable strut towards our ribcage for our respiratory function. Next slide, please. Jerome. So we're moving on to kind of if we're talking about building blocks of our vertebral canal. This is kind of our foundations, our lumbar vertebra. Um and they're characterized by their really robust structure, um reflecting their role in supporting our weight of our upper body, but facilitating movement of our bending, lifting, twisting. Um Each vertebrae will possess a large kidney shaped body that you can see just at the top of the picture. Um and their spine's processes compared to the other vertebra um are really short and blunt. Um and they project posteriorly to serve to attachment for our long muscles of our back and our ligaments um the transverse processes will extend laterally. Um and they will er again provide attachment for more um muscles involved in the back. You then between like the rest have your vers discs that we will touch on. I promise later on in the slides. Um but they're thicker here in this region because they're essentially our shock absorbers of our spine and allow flexibility of the lower back. Um We've got a wide range of movement in our lower back, uh more so than our T spine. Um So we've got flexion extension, lateral bending and rotation, er, and knees will enable us in our everyday movement to lift, uh lift objects, lean backwards, lean forwards, uh twisting the torso. Um and it's these kind of robust building blocks and our muscles that allow these movements. Er One thing to also note is the triangular shaped verte uh vertebral for and I know I've already spoke about the kidney shape, er kidney shaped body. But if given an exam, um uh uh a lumbar vertebrae, you should be able to easily er distinguish it because of its size, this kidney shaped body and um the kind of tria foramen. Next slide show guys, if there's any questions, please do ask or if you want, let's go over anything, please do say. So let's go on to these kind of crucial part of our spine, the vertical discs and they, they consist of a tough outer layer, which is the annulus fibrosis. And then you've got er which are they like constrictive fibers, uh fibrocartilage, they're really kind of layers, concentric layers. And then within this, you have the kind of gel like nucleus pulposus, which is really rich in water, er proteoglycans. And this is what provides the cushion and flexibility. Uh It's these unique structures that give us our spinal movement, but also our shock absorption. It's the changes in these discs um which are called D gen or hernia herniation, which lead to our pathology, which we will touch on in a bit um but also it's these disc generation that results in reduced disc i loss of elasticity. And er you, this is what kind of shortens the spine. But also if we do get this, this is what leads to um herniation, which I don't wanna go into too much cos we're gonna speak about later, next slide later. So this was just kind of back to a bit of neurology really just knowing what comes out of the intervertebral foramen in which kind of the two articulations of the vertebra and the disc. So it's the six things that come out and it's the root of each spinal nerve, the dorsal root ganglion, uh the spinal artery and the segment of the segmental artery of of that region. Um the communicating veins um between the internal and external plexuses. Um the recurrent meningeal nerves and the transforaminal ligaments. This is something that's expected to you. You might be asked the six things in say an MRC S exam. But again, I don't think they'll ask you at undergraduate level, but just to be aware, it essentially serves as a conduit for important structures and to exit um to exit out of this column for the spinal cord to communicate with the rest of our body. Next slide, please. True. So, ligaments are important to know because they provide massive structural support to our spinal cord. And there's ligaments that are present throughout our vertebral column that you need to be aware of. So what you can see on the image is an image taken and teach from the anatomy and you've got the anterior and posterior longitudinal ligaments. Um and these are long ligaments that run throughout the length of the vertebral column and they cover the vertebral bodies and intervertebral discs. Um your and uh you then have your ligamentum Flaum, which you'll know is the tough ligament that connects to the lamina of the adjacent vertebrae. And you may remember this er from learning about a lumbar puncture and the layers you go through and that we'll discuss on the next slide. You've also got the interspinous ligament that runs um from and connects the spinus processes of the adjacent vertebra. And then you've got the supraspinous ligament that connects the tips of the adjacent spinus processes. Um These ligaments that sur I'm sorry back as slide, sorry, jo um the ligaments that surround the spinal cord er provide crucial support and stability um of this vertebral column. Um It's the anterior and posterior um that run along the length of the spine, as I mentioned earlier. And these are the ligaments that stabilize the vertebral body to limit over excessive movement of flexion and extension. Um The flavor as mentioned connects the adjacent vertebral lamina. Um And you've got the spinus and supraspinous ligament that I've already touched on. You do have ligaments that are unique to the thoracic spine. Um If you so wish to go over them. Please do. I'm not touching them on them today, but I just want you to be aware of these ligaments because the next slide, please drain, you will be asked on them about the layers that you will pierce when obtaining a lumbar puncture. And I'm sure we're all aware. A lumbar puncher is a very useful investigation to do when we er consider um a central nervous system or a certain pathology such as an infection um within the CSF or a bleed within um uh within the brain. So one exam question that's commonly asked is the layers, you will pierce with a lumbar punch needle. So a lumbar puncture will occur at the level of L4 5. And you can find this spot on surface anatomy and anatomically by locating the patient's posterior superior spine, a meeting at the midline of the spine. So you would do this aseptically, uh probably an test um or your medical registrar was performing this procedure. But knowing the ligaments you pass through um is a commonly asked exam question. So you would pass through skin um then subcut fat and fascia, then you'd go through your supraspinous ligament, your interspinous ligament, your ligamentum flavum, which commonly comes with a pop, as people say, um and then you go through the epidural space, the dura mater, the arachnoid mater and the CSF we will touch on the layers that surround the spinal cord coming up, but just to be aware, some medical schools may ask on this, uh, where I went, they did actually ask this. I had to learn it, but it's also a commonly asked question in the MRC S exam. The next slide later. Yeah. So we're gonna touch on the spinal cord a bit now. Um, just it's anatomy, um, what's surrounded in the meninges, its blood supply and then we're gonna go on to some clinical scenarios. Um, But if you anyone's got any questions about the vertebra, er, please do put them in the chat. So the spinal cord is what makes up our central nervous system travels inferiorly. Um And it's a vital conduit for, for transmitting our sensory information and motor information from our brain to our body. Um It's very complex, it integrates and processes temporary inputs, coordinate reflexes, function movements. It's got a vital role and autonomic function such as heart rate, respiratory rate, digestion. Um and it is composed of white and gray matter. Um Our spinal cord terminates at the level of L1 and that's where you'll get your core equina um which we'll discuss on in a bit. Um But just to know a common question they'd like to ask is where it ends in neonates and it ends in L3 and that's because we obviously grow. Um So I thought I'd touch you on a bit of boring embryology just so we can touch on the development of the spinal cord and during the embryology development, er the spinal cord will originate from the neural tube, er which is from your derm, er neural crest cells will uh contribute to the development of the spinal ganglia and associated nerves. And then by the fourth week, you'll have distinction into your distinct regions. Um and it'll then keep going further specialization and growth and you're in the process of urination differential which will lay the layers for the formation of your central nervous system. Uh Next slide, please, John. So you've got your, your spinal cord is surrounded in meninges and there's three membranes um that surround the spinal cord. And you've got the dura mater, the arno mater and the pia mater. And this is what surrounds the brain too and they contain your cerebral spinal fluid which act to support and protect your spinal cord. Um So kind of more distally the meninges form like a strand of fibrous tissue. And then at the end of the spinal cord, that's what makes you kind of f your film terminale, which I should have pointed out. I should have used the image previously on this slide as well as a part. Uh Pardon me? And that's what anchors the spinal cord and meninges at the end. And so the three layers are eura your arachnoid appear. Um So, e dura is the most external extends for the Foramen magnum, which is at the top of the hole in the bottom of your skull and extends down to your fin uh terminal and it's separated, separates towards the vertical canal and the epidural space um has some loose connective tissue in it that has your internal vertebral venous plexus, which we will touch in more detail in a bit as the spinal nerves exits the vertebral canal. They actually pierce the dura mater. Ok. And then they pass in the epidural space. Um uh and it's this er out connected tissue which is the epineurium. Er we then have the arachnoid mater, which is a more delicate membrane which is located between the dura and the pia. Um and it separates um the subarachnoid space which contains the CSF itself. You then have the pia mater, which is the inner most meninges and it's a really thin membrane that covers the spinal cord nerve roots um and their blood vessels. Um and it fuses with the film and Seminae that we mentioned earlier at medical student level. I would expect you to know the layers um at MRC S level, I was just tested on the layers. I wasn't tested on specifics about them. Next slide, please. Jerome. So there's a distinct venous plexus that surrounds the spinal cord that they um and the vertebra, the vertebral column, er just be aware of it, don't know it off by heart, just know that there's a kind of, I mean if you're gonna be studied for the MRC S do know it, but I don't think you need to know it at the undergraduate level, but um just know that there's an anterior um external vertebral venous plexus, um which is around the vertebral bodies. You have the posterior external vertebral venous plexus, which is around the vertebral processes of the back. You have the anterior internal venous plexus, the vertebral venous plexus that surrounds the length of the vertebral canal. And then you have the posterior internal vertebra venous plexus, which is the length of the vertebral um canal posterior to the dura. And this is what drain the spinal cord. Next slide, please. Jerome. So the primary arteries and the supply of the spinal cord is the vertebral artery that you mentioned earlier, which is the second branch of the subclavian artery. Um You also have the segmental arteries that come off the aorta and the radicular arteries. Um the vertebral arteries um like I said, then give off uh which comes from a subclavian which I really want to stress. So you can know that and they supply the anterior and posterior spinal artery, the segmental arteries um that originate from the aorta contribute to the spinal cord. Um and radicular arteries er supply specific segments of the spinal cord. I just want you to know from this lecture that the vertebral artery supplies the anterior spinal artery and the posterior spinal artery. And these are the fundamental blood supply of the spinal cord. Next slide, please. So the corda equina is the end of your spinal cord and it comes from the Latin for the horse's tail. And it's the collective term given to the nerve roots that distal pardon me to the Conus Medalis, which is essentially the end of the spinal cord. As you can see in that picture, it's contained within the fecal sac and suspending the CSF, as we mentioned earlier. Um, and it supplies all the distal um, nerve roots, er your pelvic organs, your internal external sphincter of your bladder, uh your perineal sensation and of course your lower limbs, it's a massive clinic called significance, which we'll discuss later. But I, what I want to stress is that the spinal cord itself terminates at L1 and then begins the Conus meds and the corda quina, your spinal cord does not go towards the end. I as a foundation year two was once presenting a trauma conference and uh they, uh a professor of spinal surgery asked me where it ended. I stupidly said L5 and I have been made to feel like an absolute idiot for the rest of my life. So I should know that it's L1. Next slide, please, Jone, right. Let's get clinical. So I want people to pipe up in the chat now, please. Um, there's only three cases and then we're finished. So we will finish on time. There's no excuse. Uh, next slide, please. Jerome. So I um the orthopedic sa Jo on call. I've been asked by Ed to review a 45 year old male, er, sudden onset back pain, er, with episode of urinary incontinence. But he's otherwise well in himself. No past medical history, no drugs, regular drugs, no family history, non smoker, non drinker. He's a boring office worker. He's got this sudden onset back pain. Uh, I examine him, he's got bilateral leg weakness. Two out of five, he's got paresthesia in all dermatomes. Um My pr examined him with a chaperone and he's got water sensation. What's the diagnosis? Yes, Novik, well done. This is indeed called a equina syndrome and is something that should never ever ever be missed. Next slide, please Strome. So this is the MRI showing a complete cord equina syndrome. You can see at the level of L4 5 and the disc bulge uh disc bulge, herniation of the disc has caused um loss of translation of the spinal cord, the corner equina. So it actually corner syndrome refers to a kind of collection of symptoms and signs result in severe compression of the descending lumbar and sacral nerve roots leading to uh some onset back pain, bilateral leg weakness, paresthesia, uh altered um perianal and um genitalia sensation. It's acute, it's an emergency and it is a surgical emergency in which you'll be getting the boss at, in, at 23 in the morning to urgently decompress them whether that be a laminectomy and removing the disc. Ok. But all I want to stress is that when your junior doctors, if you get back pain, you must ask them about urinary incontinence, fecal incontinence, altered perianal sensation, er, altered genital oration, er, bilateral leg weakness, bilateral sciatic, I need you with your thinking these symptoms, you need to rule out called requiter failure to treat. This will result in um loss of bowel, bowel dysfunction, of course loss of mobility in the lower limbs. And I worked in a spinal injury center and I seen patients and it changes their life massively, they're wheelchair bound. They need to intermittently catheterize their life has changed forever. So please always have it at the front of your brain. Next slide, please. Dr So it's a busy day and you're, now you're in the GP somehow and you've got a 55 year old now who's presenting, uh, with lower back pain. You take history, you know, you do full history 10 minutes in and you found out that it's actually worse on downhill walking and it's relieved by uphill walking. You also take a bit of a social history. Uh, you find out he's got a bit of erectile dysfunction too. Um, his only past medical history is that he had an M I 10 years ago and which he's on secondary prevention for, er, no family history. He's a smoker drinker and he works as a builder. Um, on examination, he's got slight right leg weakness, um, with sensory changes over L4 and five. What's your diagnosis? Get the shot going. This is a bit more difficult to see, but come on out guys. So I must know Jerome. Do you know the answer? Um Kind of? Ok. Well, let's see. Wait, let's see the chart. Yes, well done thorough one. So, yeah, lumbar canal stenosis. So common causes are, and the most common cause is degen disc degeneration of your discs. Um You'll get central canal stenosis which can arise due to narrowing of the um anterior, posterior, transverse or combined diameter, um which may occur as a consequence of disc, heart reduction bulging, um or hypertrophy of the facet joint and um the ligamentum flavum um commonly uh if I've seen this, people go for vascular tests too to rule out location of um of buttocks. But um be aware comes up in Mr CSI actually had it in my examination and history. Um So just be aware of it. Next slide, please. Er Oh yeah, and this is just um an MRI image of it. Next slide should have said that. So you're back in Ed, you've got a 65 year old female presenting um known previous breast cancer but had the all clear and went under a bilateral mastectomy three years ago and she's presented with sudden onset back pain. You examine her, she's got bilateral leg weakness, hyperreflexia, cos you've been good and you've actually done reflexes and she reports an episode of bowel incontinence. What is the likely pathology? This, this should be another textbook. Go ahead and definitely, especially where we used to work. Mm Exactly. This is a really common uh interview question clinical are in, in kind of the clinical side whose previous cancer in this in this situation, you kind of need to kind of look at lower mo motor neuron signs versus upper A. Uh So I come into my office, Mets the spine. Yes. Nice. Spinal lesion is well done. So, if you've got someone in the history that has had a previous cancer and have got these symptoms of spinal change, you need to be thinking is this a spinal net or primary to a proven otherwise next place drug. So, Mets to bone, the most common site is spine. And I want you to think about that. How would you approach this? I would do a four, a two E in the patient. I'd make sure I'd image them. We need to think about going to the MDT staging grading via biopsy, finding the primary, doing the tumor markers. Um and ensuring this patient is staging graded correctly. Um spinal meds are really common among cancer patients. Um they occur when cancer cells obviously spread to the spine from pri um or from primary tumors. Um there's they can spread to primary tumors at from primary tumors of the prostate via Barton's Plexus, which is just the kind of venous plexus around the pelvis and obviously, diagnosis will be MRI or CT and stage. Your treatment aims here will be to relieve the pain, stabilize your spine, but preserve neurological function stage and grade the patient chemotherapy treatment or combination. Ok. You cannot rule you. You should always have this at the front of your brain when thinking about the differentials. Um Next slide please. Dr I believe that is it. Um Thanks guys. I know it was brief. I just didn't want to go into too much detail. I'd rather you learn a few bits. I hope that was helpful. Any questions, please go away. We've got about 10 minutes or sorry, don't go away. Please answer away uh question away and um we can answer them if we can. I hope it was helpful. Please give feedback. Um Thanks to Meath for running it. Um They did a brilliant job. Yeah, this is your time to ask any questions. Um If you would like uh we'll uh wait. Thank you, Ellie. Wait around for a minute. Um Again, thank you so much for joining in. Um It was a wonderful lecture again by Mister George West. Recently, Mister Might I ask. Um this is your last lecture for, for, for, for the anatomy series, correct? It is. But I probably will just jump in um and watch Matt and Tim. And if there's any questions, I hope it was helpful guys, I tried to keep it brief cos upper limb was too much I wanted you to take a few things away and I hope that the kind of vertebra stuff is what you took away from it. Um Please leave feedback but yeah, yeah, perfect. Um Yes, please do fill in the feedback uh after the session, um the email uh feedback form and after you complete it, you will get a of attendance. Uh Once again, we are sponsored by Ken Hub as well as the MDU. Um And please do join in next week for the next our next session. Um kind of content will also be available in the next couple of hours. So if you do wanna go back and review some of the information Mr West has taught you, you, it is always available to you. Thank you so much for attending this week. Uh Hopefully we see you again next week.