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Teaching structure note. Um, so I'm gonna try my best to talk about pediatric spinal trauma, uh and pathologies in the pediatric spine. Um, a a as you know, I examined for the FR CSO. Um II think this is a really unusual topic to get. Um, I think it's something you need to know for life as an orthopedic consultant. Um, even though you're not gonna be examined on it, I know a lot about teaching is this is for the exam and that's for the exam. But if you ever come across a child with spinal trauma, it's a really frightening thing. So I'm gonna ask, um, lots of questions. I do try and participate cos I really don't enjoy these sessions unless and, and people tend not to talk. So, so ca can I ask you any of you any of you? Um, have any of you ever been involved in a child? Um, th this is specifically to do with cervical spine, isn't it? My remit is pediatric cervical spinal trauma. I should have put that in the title. Has anybody l er on this talk ever come across a child with cervical spinal trauma or spinal cord injury, anywhere in the spine. Anybody at all, Adan, what about you, Adan can have, have you ever come across a kid with a broken neck or spinal cord injury? Aden's not there, Alex Hartl. Have you come across a kid with a broken neck? David David sick? I hope people are there. I am going to ask and if you I'm going to assume you're not there and mark you absent David Kras. Are you there? Ben? Are you hearing me? Yeah, I've got you. Yeah. So um this is a bit of A II think Dan Dan Wat was trying to answer something. Ok, Daniel. Daniel. Um Have you seen a kid with a broken arm? And I haven actually come across ap patient with any spine injuries so far? Yeah. Yeah. And that, that's it. Thanks for answering. Daniel, thanks for participating. It really helps me. II have to say no. Have I, I've been a consultant for almost 18 years now and um I personally have uh dealt with um maybe five Children in all that time with spinal fractures or dislocations that have required surgery and I have not come across one with a broken neck. Thank God. Um Daniel, why do you think that is, why do you think pediatrics, cervical spinal trauma? You know, it is is relatively rare. I mean, you must have seen a gazillion distal radial fractures in Children. Why, why do you think um broken necks in Children are rare. Um, good questions. I mean, not really thought about before. Um, is it perhaps because the, the pediatric spine is perhaps more flexible or something? So it can withstand more trauma before, before break? That's, that's certainly something that I've seen written about. Um, the kids have, have much more lax ligaments. And, um, one of the theories that I've seen as sp is that when kids have, um, spinal trauma, the energy is dissipated over a much longer length of the spine. Er, and because of the ligamentous laxity, it tends not to, to lead to fractures as, as often as as in adults. That, that's one hypothesis. Um er Dira, are you there de Raj atta? No? Ok. This is most curious. Um George, are you there, George Horton? Yes, I'm here. Good. Um George, why do you reckon? Er, you got any other hypotheses? I think. Um I think um Daniel Daniel's hypothesis. So, sounds sound. You got any ideas why broken necks and kids is um do you think other um parts of the body just end up tending to absorb more energy in, in child injuries because of the mechanism of injury, more likely to injure limbs? Um We see more plastic deformity of bones in Children. So perhaps if there's a degree of more flexibility in bones and all of the vertebra, I got short axis that's less likely to be fractured. I'm not sure if that makes sense. Uh I kind of see what you're getting at. Um, er, but, but no, II II, find it interesting cos I would have thought that we'd see a lot more and, and it occurred to me that is it because, you know, kids are running your own trip over your land on your old stretch and there's a direct application of the deforming force to your distal radius. Whereas if you think about modern seatbelts and, and, and, and kids with four point harnesses, it takes a, a lot of trauma, doesn't it, to, to, to, to dislocate your spine? Um, and I just wonder whether or not it's to do with um modern safety equipment, modern car seats and the fact that the application of force is not quite as direct, but yeah, ii it's, it's an interesting er, thing but it is really, really rare. So, so let's talk a little bit about um, pediatric spinal trauma. Um, this is just, er, for the basic sciences part of your exam, you, you are expected to know about limb bud development as exciting how that is a and you're also expected to, to be able to talk about um, the formation of the spinal column. And um, it, it's not, it's not really that interesting or, well, it is very interesting but I finding a good account of it that makes sense to me was very, very difficult and maybe on another occasion, we can talk about the embryology of the spine. Um but that's not the remit today. So I'm not gonna dwell on it. So, if I said to say you do need to know a bit about it. And maybe in the basic science term, we can talk a bit more about it. Um That diagram on the top left shows er an embryo at the third week of gestation. Um And what it's trying to show is the in the formation of that um, primitive pit, um which is an invagination of cells from the amniotic cavity um into the dorsum of the growing embryo. We won't talk about that today. Um But what I do wanna talk about is, is this and uh this is a bone in a child's neck. Jose, are you on the call? Uh Joe Jose, Augustine, right. What about, um, JJ Raman? Are you on the call? Hi. Hi in the slush when I'm here. Yeah. OK. Brilliant. Brilliant. W what do you reckon? This is? Sorry, sorry. II missed the question. What, what bones this in a child? Uh It's ac two, excellent, excellent. And uh so, so what this shows, can you, can you tell me what that upper picture shows? What I, what is it trying to show? It's got two black arrows, a yellow arrow and a white arrow in a 36 month old baby. W what, what is it pointing out? W which picture are we looking at? There's three of them, the top, the top the top two. Yeah. Yeah. OK. So there's multiple ossification centers of the C two? Oh, excellent. So, how many four, I think? Nah, close you can see four arrows. That's a good guess. The bottom one. So there are five. Ok. Looking at the picture. Describe them for me. What are the five ossifications of the odontoid peg, uh, of the, well, there's a Odonto peg one. Yeah. Yeah. What color arrow is that? That's a yellow one. Yeah. Yeah. Yeah. Um, uh I guess there's a central and two lateral ones. I, what's the central one? The, the, the top right hand picture the white arrow. What's that white two in other vertebrae? The body. Yeah, exactly. It's the body, isn't it? And the two black ones in the top picture? Uh Not sure. Well, it's not the front, it's got to be the back, hasn't it? So, it's the archer, it's the, it's, it's the lateral masses and the, and the posterior arches of the C two body uh of the C two vertebra. And what about the bottom picture? Um That shows that white arrow, that thing's called the ossiculum terminale. And it's the, it's where the, er, apical ligament, uh the ossification center um with the attachment to the apical ligament uh forms. Uh And it's much later on in life at age seven, I see. So, um, so what, what do you think this means for, for, in theory? Therefore, here's a 36 month old baby and it's got this bone with five ossification centers and all these growth plates. What kind of injury should, should this child be really exposed to? I if they had a high decelerating injury, cos it also a Harris type injury more than, I mean, it, it's gonna withstand a lot more force than a, a um an adult uh spine. Yeah. Yeah. And I think, I think that comes back to the original point that we heard that it, that might be due to do the ligamentous flexibility of the spine and the ability of the pediatric spine to absorb more energy a across more segments. So, so the reason these things are important is here's the sci ossiculum terminale in a 10 year old. You know, it's starting to fuse and the, and the picture on the right, the top right here with the white arrow uh showing the tip of the peg. Um You can see this black arrow indicates a fracture of the tip of the peg. So in other words, uh as in many other parts of the pediatric skeleton, it can be very difficult, can't it to distinguish between uh a fracture? Uh unless, unless you know the embryological anatomy. Yeah. Mhm. Good. That, that was well answered. That was really good. Is Nicholas JBs listening. Hi, Miss Limon. Yeah, I'm here. Hi, Nicholas Nicholas. Um that, that picture on the bottom picture uh shows a pediatric peg fracture and tell us why, why the, the, the peg has fractured where it has you see the, the black arrow in the bottom middle picture what's going on there? Uh Well, so there's an anterior, I'm assuming that's because it's going through the growth plate or, or what remains of the growth plate at that at that age. Yeah, that, that's a safe assumption, which is weaker than, yeah. So coming back to this original picture, um that body fragment um fuses to the lateral fragments er at about 36 months at about this age. And then the peg fragment, I think this is really complicated fuses on to the body bit at about six years and at about between seven and 10 years, the ossiculum terminale fuses to the rest of it. So that's a pretty um pretty complex sequence of events, isn't it? And you can understand that that assaulter Harris type one fracture, which is a failure through the growth plate. Um is, is a possibility and, and as we can see on that picture does happen, but it's just extraordinary though. We don't see it more often, isn't it? Um You know, you have these growth plates and um and we sell them ii certainly in 18 years haven't seen a kid present with a fracture of the peg. Um And yeah, do um just thinking about the um sort of damage to the canal. Um Would you, would you be getting sort of neurology with that kind of Antero in a kid or, or they have a more capacious canal. I don't know, they do have a more cappa canal. So we talk about the cord to canal ratio and the cord to canal ratio in a child is much more favorable than an A than in an adult. So there's a lot more spare room for the cord, particularly in the opposite ankle spine in Children than in adulthood. So that's one possibility we don't see cord injuries. So, so commonly. And have you heard of Steel's Rule of Thirds? Has anybody on the call heard about Steel? Steel's Rule of Thirds. Ben? Yeah, I think um Mr Stuart, Mister Stuart ironically mentioned it last week. Um It's about so who else I know? You know it. So, uh because you pay attention, let's see who else is listening? Uh Vran, Vran Hooda. No, uh Sandra o'malley, Sandra. Um Noo Ahmed. No foul. Yeah. Yeah. Do, do you, if you don't know that's ok. You know, you're here to learn. So if you don't know, um, that's ok. Do, do you have any idea about steel? Steel's rules of thirds? I'll give you a hint at the level of the odontoid peg. Steel's rule says that that the, the there are the, the, the distance between the anterior art of C one and the posterior art of C one is divided into thirds. Can you tell me what three structures occupy the spinal canal at the level of C one, one's obvious. Uh the spinal cord, yes. Runs in the spinal canal. Yes. Yes. Yeah. Yeah. Yeah. Yeah. Yeah. Oil, oil and anterior longitudinal ligament and the posterior longitudinal ligament is that, that's, that's good. Yeah, that's, that's uh can we try? Let's see. Um, Frederick, are you on the call? Frederick? Iso? Yeah. What's three macroscopic anatomical structures occupy the spinal canal at the level of C one I can see the uh the Atlas, the Atlas is the boundary. Yeah. And what I'm asking is what three structures occupy the spinal canal at the level of the Atlas. Uh And the answer is the odontoid peg obviously the spinal cord and the other third is empty space. So what that means is the core to canal ratio at the cranial cervical junction is very favorable. There's a lot of spare room. B Ben, what's part of the, the spinal cord? What part of the spinal column is most prone to spinal cord injury because it has the least favorable cord to canal diameter. So it would be the um the subaxial cervical spine. So sort of is it see 4 to 7 there? Interestingly, it's um if you think back to cord injuries and on the fir which cord injuries do you see most commonly if you had to think back about it? So, I of thoracic, it's, it's more thoracic. Yeah. Yeah, exactly. Yeah, it is upper thoracic. Exactly right. So, in the, if you in the upper thoracic spine, you know, yy, your, your cord is carrying all the lumbar information, it's carrying all the chest and abdominal information. So the upper thoracic spine has the largest cord um and a small and a smaller canal ratio. So the cord to canal ratio is least favorable. All I wanted to you to know is you, you should have a vague idea that about two steel through the thirds, there's cord, there's space, there's, there's peg and, and these are Salter Harris type one injuries through the Odonto peg. They're extraordinarily rare. OK. This isn't something that you need to know for the exam. II. Just think you should be able to apply your knowledge to, to, to a more generic situation. Just a quick question. Going back to Nick De that, that all the third, does that apply in Children as well? Or is it, it doesn't, it's even more favorable because the cord is relatively smaller um relative to the size of the Foramen magnum and the upper subvital spine. So, so it's much more forgiving apparently. Um So it does apply uh and it's even more so in Children. So this is a funny thing, this thing called os oidium. Um You might see it sometimes on x rays uh done for, for other reasons. Nobody knows if it's traumatic or developmental. But um one of the, one of the hypotheses, you, you kind of get the feeling that the, the upper peg on the tip of the peg hasn't fused to the rest of the body. Um One of the hallmarks of an oso onium is a hypertrophy of the anterior artery. One can you see that upper picture here uh on the, on, on the right side here, you can see that the anterior artery, one is hyperplastic hyperplastic hypertrophic and this bit of the odonto pig is not attached to the peg. And you can see it's a well decorticated and this is a chronic process. So you, you need to be able to recognize that that's not an acute pathology. That's something that's probably developmental. Some people think it's a, it's a non union, but one does sometimes seek in adulthood. Uh and, and it can cause um some difficulty in interpretation. The lower picture shows you an adult with an oso onto which shows a well corticated lesion and a and a hypertrophic C one and the other image, the one with the yellow arrow on the right shows a fracture. And you can see it's a much more irregular uh more acute appearance. So also odontoideum is something that you should know exists. The etiology is not clear but it's where you have uh uh uh the upper part of the odontoid peg not fused to the lower part. Um You don't need to know about the subtypes. One of the things as a, as a principle that that's worth knowing is most of the cervical um er, primary ossification centers would have fused by the age of eight. So, in the kids under eight, if you see a s spinal cord injury and a spinal, a cervical spinal injury, it's usually in the upper cervical spine. And when they all fuse at about age 8 to 10 and you have AAA broken neck in a, in a child over 10, the, the fracture pattern looks like an adult. Um So that's as a general principle, if you wanted to be really clever and, and have, you know, in the exam, somebody asked you about broken necks in Children under eight, they have a very unusual pattern. Uh They tend to affect the upper cervical spine because of the unfused feces. Uh and in the over eights to tens, it looks more like an adult fracture coming back to why, um why kids should break their necks more often if you look at their facet joints, they're really, really shallow. Here's an adult's facet joints. They have a very steep angle, don't they look, look how shallow these are? But still we don't see kids with dislocated necks, week in week out. So it's quite interesting when one does see it. And thank God, I never have, I don't know if you have, if you shake a baby, we've all heard of that horrible shaken baby syndrome. Not only can, can they get intracranial hemorrhage, which is often why they die. They can also present with a dislocated cervical spine cos you can, you can see how flat their, their cycle facet joints are. It's interesting, we don't see it more often. It's quite, it's quite, um, I find it really interesting the ligaments like, like the, um, somebody suggested, uh, are very lax. I think George told us that and he's right and their muscles are relatively weak. Um, one of the things um that, that people talk about is the relative size of the cranium. The picture on the bottom, right shows a baby's head relative to the anteroposterior dimensions of its chest wall. And the picture on the right is an adult. Uh JIA JIA can, what do you think? Um looking at those pictures, what observation can you make about the relative size of the cranium in a child versus an adult? No response there, David Krstic, are you on the call? Uh Ashok uh Alex Hart. That shock is that you? No, that this is Joe's side. The, the size of the head is much larger as compared to the trunk. Yeah, I in a, in a baby, isn't it? A and, and therefore one would w what, what influence do you think that has o in a child in a deceleration injury? The relatively large cranium, what does that mean? Um More chances of um because the head is much larger as compared to the trunk. Um Yes, whiplash. The uh I think the energy dissipated by whiplash is likely to be higher. I, I'm not inert the inertia acting on the skull relative to the trunk will be more considerable. And you'd have thought that we'd see a lot more kids with upper cervical or cervical spine injuries, wouldn't you? That's a good answer. Good observation. Um, one of the things that you might get called to A&E for, er, and this is something that you do need to know about because it's very common is so called C 23 subluxation. In Children under seven, there's often a malalignment of C two relative to C three. And the way you resolve whether or not that's pathological is you draw the spinal line in a line. Uh You'll all know that the spinal lamina lines runs at the junction of the lamina in the base of the spinus process and all the, all the junctions should be within one millimeter of that line. So, in both of these instances, this is pseudosubluxation. Um It's, it's um it tends to resolve itself er, in Children over 10, but you can often get, you, you, you, you kind of get the impression there's a spondylolisthesis, don't you? Of C two and C three? But if you, if you look at the posterior elements, they're all in alignment. So that's called pseudosubluxation. So I want to um uh present a case note. Um uh who's here? Uh Daniel, you're there, aren't you? Yeah. OK. Yeah. So Daniel um this child was 10 when she came to us and um this was many, many years ago, this, this patient was looked after by my um my mentor, Bob Crawford. Can you tell us what the, so she had a high energy deceleration injury in a road traffic accident and came into hospital quadriplegic. She'd, she'd um gone into respiratory arrest at the scene, I think. Um but, but um I think there was either an anesthetist or, or a doctor nearby. Um They managed to maintain her airway until she was ventilated. And you can see here when the plain radiograph is done, she has uh an endotracheal tube in, doesn't she? It's a weird thing to see these days. You wouldn't expect to see a plain radiograph because we would do a trauma series. But this was many, many years ago. So tell us what the um plain radiograph and CT showed Daniel it today. Um So I can say, is this a bad between the C seven and C eight? I think there's uh Miss Stelle told you. Yeah, there's no C eight C six C seven. What can you say? Sorry, darling. Your, your connection is not great. Can you just repeat what you see on the X ray? Uh So there's a dissociation between the C six and C seven, cervical vertebra. So we don't call it a dissociation. WW What, what, what, what um what's that, what's anterior of the C seven over the C six over the C seven. Ok. So it, it's a, it's a, it's an anterior of C six on C seven. Alex isn't here. Er, David's not here, George, you're here. George. WW. What can you tell us as well? So, that's a good observation. Um, er, George, what do you think, what else can we tell, uh, apart from the fact that there is, er, er, a s, um, a malalignment, there's a spondylolithesis. What else can you say about the X ray? Um I think if I'm seeing it correctly that there might be a facet joint dislocation, I suppose that's an extension of the same thing. Fantastic. What, what is a dislocation? Um So that's a, I suppose a complete disarticulation of a joint as opposed to a subluxation, which is the joint still, there's some degree of congruence in, in a joint? Fantastic. That's a great answer. Great answer. George. What year are you? Uh I an ST four? Ok. So a dislocation is a complete loss of congruency of a joint and a sublocation is a partial loss of congruency of the joint. This is a bi facetal dislocation of the C 67 articulation. Uh Very, very good. Um See anybody else? There's one more observation that I want somebody to make and is Sandra on the call? Sandra o'malley? Ok. Um uh Snick Snick Banerjee, what about RDA? Ok. So, uh Tom Barker, II think they, I can see a small fracture fragment on the CT scan. Yeah. Yeah, that's true. WW what about the relative positions of the vertebral bodies? Um Tom, what do you think's going on there in terms of there's a spondylolisthesis? So that's an anterior posterior problem. But what about in the, in the longitudinal axis? Are they distracted as well? Oh, it's massively distracted. I mean, look at the CT. Yeah. So, so if you had to try and predict what the effect on on the spinal column of the spinal cord's been, Tom, what, what would you think? Um uh there will be a traction injury to probably gonna be compressed in the AP as well, cos it's so that, that's absolutely right. So there will be a traction injury which is probably the worst thing you can do to the spinal cord. Ok? Um And that's evident on the CT scan as well. So, so what this, um what this diagram is meant to show and I showed it last week. Um when I talked about, um, whatever I talked about, th th this picture on the left is a child's disc and the, the picture on the right is an adult disc. And what it's meant to show is that Children have a cartilaginous endplate, uh which attaches the disc to the vertebral body. And that, as that text says, ossifies between six and nine years of age. If you ever do a scoliosis operation on a child and you go through the chest. You can take a periosteal elevator and put it between the body and the cartilages endplate. And you can, you can literally peel it off as a complete separate entity. You can peel, you can almost take the whole disc out as one bit because there's a defined plane between the cartilaginous endplate and the virtual body in a child. And that fuses uh it ossifies between six and nine and it fuses between completely at the end of skeletal maturity. So, have a look at this picture here, Tom, what's happened there that raises the anatomy that we're talking about. What's happened to this kid's neck. Um Well, the the disc has remained completely attached to it's um and uh and then there's a big distraction between the disc and presumably that cartilage at this endplate and the very vertical body. Exactly. So the cartilage at this endplate is still with the disc and there's it peel a clean plane separating the cartilage as endplate from the vertebral body. And you will not see this pattern in adulthood because the bone will break, won't it. But what happens here is this is a failure through the ca the junction of the cartilage in place in the vertebral body. It's quite an extraordinary um injury. So what kind of salter Harris fracture is this George if you had to classify this as a Salter Harris type injury? W what Salter Harris would you give it? Um I would have thought a, uh, a one, a straight through without any extension into the body which, ii, suppose you might call the, you know, epiphyseal equivalent. Yeah, exactly. II entirely agree. II think this is, this is probably a Salter Harris type one injury. Pretty crap injury, isn't it? And, um, and so who's on the caller? Ben? How would you treat this? Um, I mean, after going through sort of its high energy trauma atl s type of thing. Um And, and you might think that what you've just said is, is, is not important, the examiner is wanting you to say that um, if, if you don't say that you, you're on a five, and, and there are times when you know, fall on the old stretch hand, that's ok, you can start talking about it, but, but the crux of this, your six starts with this is a high energy trauma and this is a life threatening injury and there may well be other associated life threatening injuries. What other associated life threatening injuries? Do you think there might be ben? Well, uh potentially, um I intracranial injuries, um, chest uh uh the high energy p possibly pelvic injuries, she may have, she may have associated lumbar spine. Yeah, injuries, noncontiguous spinal injuries, uh visceral injury and vascular injury, cos this is, this is a massive distraction force, isn't it horrible thing? So how would you fix it? Um Yeah, it, well, it needs the the, er, fast or dislocation, assume it's a, by fast or dislocation from the nature of the injury it needs to be reduced. Um, and then, uh, fusion, um, it's difficult given that it's unstable at the front, you probably have to fuse it at the front. So whether you do it, uh, I don't know, in a child, a discectomy and a fusion or just plate with where the disc. Yeah, I suppose if you're treating it like a salter one, you could just plate across and hope that that heals up with that cartilage plate onto the bone. Yeah, you probably could get away with that in a child because it's gonna heal very quickly. And so, so in answer to this question, I think I would expect to say uh I think this needs surgical stabilization. When the child is hemodynamically stable and sufficiently resuscitated, you can do it anteriorly posturally or you can do circumferential surgery. And so this is my colleague, Bob Crawford. You can see he's put a plate on the front. Look at the size of those 3.5 millimeter screws relative to the vertebral body. It, you know, it, it's extraordinary, isn't it? He was extremely, he's an extremely skillful surgeon and then I didn't put it up but he fixed it from the back as well. Um er Ben, because you can imagine this is a three column, highly unstable situation, isn't it? In order to not put the child in a collar, he fixed it front and back. She's now, um, in her twenties and she went off to university and when she goes to, when she went to university interviews, she would go with a whole team of people. She has a van, a converted van in which her wheelchair fits. She has a nurse with her all the time because she has a tracheostomy and she has, uh, a ventilator attached to her wheelchair and she's in her mid twenties now. Er, it's quite an extraordinary story but quite catastrophic. I II didn't wanna say very much about trauma in Children. That's cervical spine trauma in, in Children. That's all I had to say. It's rare. It's surprisingly rare. They should have lots of more breaks than they, than they do given all these factors that we talked about. You know, the, the, the size of the, the, their ossification centers, their shallow joints, their lateral ligaments and their weak muscles and their big head. But for some reason, thank God, they're very, very unusual injuries and, and it may be due to the energy required to dislocate your neck, the fact that the energy is dissipated over multiple segments of the spine and because of modern um modern cars and modern seatbelts and modern child seats and these are thankfully very rare injuries. My colleagues at Cambridge, I have spoken to them from time to time and, and because they're a proper N TC, they have seen more than we have. Um, the last one they told me about was a, a kid in a car crash. Um, and, and bear in mind that kids necks, uh, apart from having ossification centers and the, er, the physeal plates also have this cartilage and the end plate. So you can have a, a AAA sort of Salter Harris type injury. That's all I wanted to say about, um, broken necks in Children. Er, does anybody have any questions? It is a very, very unusual scenario. You're not likely to get it in the exam. I, I've, I've written an, a, an awful lot of, um, questions for the, um, the pathology, viva and stuff and trauma. II don't think this is something that you would be expected to know a lot about except the things that we talked about. You know, there, there's a look at the space available for the cord on, on, on, on, on this X ray. It's massive, isn't it? There's the peg and you've got at least, uh, you know, a, a, another sort of three quarters of the space between the anterior and posterior arch, er, for the cord and for empty space. So there, there's a lot of redundant space there. Um, and, and it surprises me that we don't see injuries in the neck more commonly in Children. So, um, you guys have had a long afternoon and, and um I get the feeling a lot of people have dropped out, um, which is not very good but, er, er, all I want you to, to take away is a few things. Um, we're gonna talk about a few cervical spinal abnormalities in Children. These, this is different pathologies. Now, we, we're done with trauma. Um, you need to know a little bit about basilar invagination. Um, a little bit about C one C two instability uh and a few other things and I'll quickly go through them. Ok. Um And I know you're tired. So, so if they ask you, um who's coming up to the exam? Next? Ben Ben, you got the MC QS, haven't you? I, if you had an M CQ and they said which cervical spinal abnormality is related to X and you had to have a punt pump for C one C two instability or basilar invagination. And you can see why um nearly all the skeletal dysplasias down syndrome, Marfan syndrome. Morquio syndrome, which is one of the mucopolysaccharidoses, isn't it? And J I am most of the time it leads to one or two things. C one C two instability or basilar invagination. Um You don't need to memorize that. I think that could be so that might come up in the MC Qs. But if you, if you, if you, if you're in the um adult, um if, if you're in the viva, the um pediatric viva or the trauma, you know, or the pediatric, the um the pediatric viva and they, they say, you know what cervical spinal condition could you have in Marfans? You, you could try basal invagination but, but the answer is C one to instability. So maybe pump for both if you don't remember um that picture on the bottom left, what does that show? Um Let's try Jose. Um w what does that picture on the bottom left show? Ok. Mr Seal just showed you a picture um similar to that. Um Is it, is it showing the, the width that is supposed to be there? Um Not really Mister Stelle just told you this. So there's a, a yellow line that they've drawn between the hard palate and the, and the anterior part of the, and the, and the posterior part of the foramen magnum. So the base of the occipital bone, that's a, a virtual line that they've drawn. What structure should be south of that line that is sitting north of that line? Anybody? Yeah, the peg. Um Jose should be south of that line. Um So what's happened here is the odontoid peg has migrated north or you could look at it the other way round the, the, the head and skull has migrated south and the, the odontoid peg is inside the forum and magnum isn't it? Can you see how it's hitting the CLS and this structure here, Jose, what's this structure here? That the arrow zone here? What's that thing? Um That's, it's a bit of bone what bit of bone is it? It's the anti R to C one? Ok. Yeah. So, so what's happened is the peg has migrated, uh, north, er, and, er, it's going into the brainstem, uh, the picture George the picture on the, right. What does that show? What, what pathological condition is that? Um, the main thing I can see is what looks like cord compression at the Foramen magnum. It looks to be, yeah, quite sort of pinched there. Um So if I tell you this is anterior to C one here. Yeah, and that's the peg. Why is the cord being compressed? So, so the anterior arch looks very anterior compared to the peg. So that would be your C 12 instability. Absolutely. Yeah. So have a pot down syndrome. C 12 instability. Uh because they got ligamentous laxity Marfan syndrome, C 12 instability, um achondroplasia, basilar invagination. So, you know, um rheumatoid arthritis in Children synovitis leading to instability. So, yeah, that's, that's basically it. Um uh I I'll just run through a couple of things. Um You should know a little bit about atlantoaxial rotatory subluxation um where the Atlas which is C one and the axis er C two, the orientation between the two bones is abnormal. Uh and that's called atlantoaxial rotatory subluxation. C one twists off C two and it can happen because of uh the odontal peg being hypoplastic. You don't need to know. I just thought I'd try and make it in anybody know what clip or feel is. Um I'll pick on somebody. Uh, Jan, are you here, Jihan Ramen? Uh Daniel Te, tell me um what's De Perille syndrome? I think it's the, the syndrome where you get an infusion of the cervical vertebrae. Excellent. Excellent, very good answer. Very good answer. So sometimes the bones in your neck fuse together and that can cause uh rotatory instability and it can happen because of trauma. It can happen after infection or after manipulation of the spine. And you need to know about a, a little bit, you know, you might get a diagram now. So you might have to label it. So this is the, this is the back of the C one C two articulation seen from behind with the spinal cord removed. And this ligament at the top is the er superior long T ligament. This is the inferior long two ligament. This is a transverse ligament. Um uh And this is the ligament here. And uh you need to know about the ligament of stabilizers of the upper cervical spine. You might have to uh label a diagram like that. I don't think that's unreasonable for you to know this is the posterior longitude ligament and this is the anterior longitude ligament. Uh And this ligamentous complex contributes to stability between the C one and C two articulation. Um You might have to have a vague idea about w when we sit down together and when you come and work for us, we can talk a little bit more about this. But what happens with C one and C two? Can you see normally there's C one articulating on C two. And what happens in, in this condition is um the C one C two, articulation becomes malaligned i in a rotational plane and there's lots of calcifications. Um Yy, I don't think you need, I don't think, you know, need to know feeling and Hawkins, but it, it's a nice orthopedic principle. Look at that top left hand diagram. So that's a type one. And what's happened there is the er the transverse ligament which holds the peg in position relative to the C one I is intact A and so the, the, the complex C one rotates with the dens acting as a pivot. The top right hand diagram is where the, the transverse ligament might be injured, but one of the facet joints is injured as well. So the intact facet joint acts as the pivot point. It's interesting, isn't it? It's all biomechanics type three is where both atlan axial joints are disrupted. So basically, there's complete instability and here there's posterior displacement. So in other words, if you're asked about if you're doing really well and you, they ask you about, do you know any, any classifications of Atlanto axial rotation subluxation? You could say, look, II don't know. Uh but I know, II don't know the name, but it's based on whether or not there's disruption of the transverse ligament and whether or not there's unilateral or bilateral facet joint disruption. Uh, and, and, and, and the more anatomical structures that are disrupted, the more unstable the segment. And that's, that's basic orthopedics, isn't it? You don't need to know the name, but if you do know it, that's good. Um, so, er, how we investigate them, we tend to, um, we try to avoid CT but um, II think more and more we have to rely on it because sometimes the MRI can be very difficult to interpret. Um, we'll talk about this a little bit more, maybe in a clinical context. I don't have time, but this is an example of a child who presents with torticollis, er, well presents with Atlanto axial rotation, subluxation and a torticollis posture. Er, we give them analgesia, we admit them, we put them on traction sometimes that requires the use of a halo er, for traction and then they go into a halo vest and this poor girl um after months of traction when she came out, er, she, her neck went back into a, a uh a toto Collas posture. Er, and the reason is you get remo and remodeling of the C one C two. And so even after traction and a halo vess immobilization sometimes, um the, the neck can go back into, er, er, er, this posture. We referred her to Queen's square where they discussed surgery with her, but quite sensibly she and her mum said she didn't want an operation. So there's lots of courses or talk to call us that you can read about. One I would say is if you see a, your age now where you're having kids, um, or you might have friends who have Children. Torticollis is, is often benign. You know, it can be related to things like gastroesophageal reflux or it can be related to an upper respiratory tract infection. But if it's persistent, um there can be sinister causes, for example, um George, what, what do you think? Ocular torticollis means ocular means eye, obviously. Yeah, but it's not something I've come across or red before. Um I'd imagine if there's a visual disturbance in an eye, then perhaps there's a, there's a turning of the head um symptomatically just so that the child can, you know, see better. Um Yeah, absolutely. Absolutely. And what, what, what condition do kids get in their eyes that can cause them to have visual disturbance? Um I'd be, I'd be struggling now. I'd have to think back to a surgical s um which tumor, which tumor? Uh I was having a blank. Sorry. Um OK. That's right. That's right. No, you did. Really? Well, they, they can have retinoblast. So, so, so if, if you have a kid who's previously had a straight head and neck and they present with um a torticollis, I II really get scared quite often. It's a benign thing, but I, I'll often investigate the hell out of them and, and one of the things that they can have is we always get the ophthalmologist to look in their eyes to make sure they haven't got a problem with their visual fields and, and their retina. We'll often get um AAA scan of their brain to make sure they haven't got an occipital cortex tumor. Because if you have something affecting your occipital cortex, it can affect your vision as well. But more often than not, it's benign and more often than not, it's due to um uh a muscular torticollis. Um We sometimes pro fossil tumors are a particular problem and sometimes you can have it in association with trauma. So the child can have a history of a fall and presents with a, a tool type posture and that can be atlantoaxial rotatory subluxation. But in a child presenting um in a young child, you can sometimes have them presenting with a sternocleidomastoid contracture. Um It's often related to breach delivery or in, in about um 20% of patients they've got associated D DH. So congenital muscular torticollis is something that you need to vaguely know about. A and if you sit in front of your computer and, and, and do this, it torticollis, if you imagine your right sternocleidomastoid is tight. OK. Just sit in front of your computer, your right. So Clamato is tight, your head and you should do it, do it. Now, tilt your head to the right. So your head tilts to the right and then turn your head to the left because as your right stenoclada Mastoid shortens, it'll turn your head to the ipsilateral side. So, torticollis, due to a right sternocleidomastoid contracture leads to halted to the right and rotation to the left. I always have to work that out. And, um, because, you know, you gotta think it through and, and quite often they'll have a flat head which is on the same side as the contracture. So here's a kid with a right sided contracture head tilted to the right head turned to the left and with a flat right occiput. So ju just practice that and remember, cos um you know, you might be asked that uh it can happen, nobody knows why. Uh and some and, and the way we treat them is non operatively, we, we stretch them out. Um So this is AAA Stenoclada Mastoid band. We do lots of stretching. We use orthoses and very, very uh rarely, we have to release them. So this is one of my patients. You can see the Stenoclada Mastoid and we do something called a bipolar release. You expose the band distally and you expose the band proximately and you cut them with a diathermy, which is quite a scary thing to do really. Um And then afterwards, they have intense physiotherapy to strengthen their neck and they have a night time, uh, cervical orthosis. Um, so, uh, yeah, that, that's, um, that's a rough idea of, um, uh, what's called, you know, um, uh, a stenoclada, could I ask, Mr? Of course. Yeah. Um, with the, with the congenital muscular torticollis, um, is there an optimal age for such surgery? I, I've seen this once in, in, uh, with a pediatric surgeon in, um, Peterborough and it was a, quite a young child and I think the intention was to try unipolar release. Um, but yeah, I wasn't quite sure what the, what the decision is like. You, I think you gotta get on. II, think it's a good question, George. I think you've gotta get in with it early because, um, the, what, what tends to happen is really interesting. They, they tend to get, um, they get facial asymmetry and, and they get, um, and I think it gets more and more difficult to release it. So all the ones that we've done are they? And we've done about four or five now, have been quite young kids under five, maybe between three and five. Er, and the most recent one I did was mis cha about six months ago again, a similar age. They, they, you need to get them before they get, um, they, they also get, um, facial asymmetry and, and so, and, and the, the first one I ever did, I did a unipolar release and it recurred So I, I've never done that since now. We do a bipolar release every time I think the key is really the nighttime orthosis and getting their mums and dad to stretch their necks um after the release is done. But in answer to your question, I, I'd say between three and five the younger the better. Yeah, thank you. Sure, thank you. Um So who's it? Um Let's try. Uh um Vran, are you here? Yeah. Yeah, I'm here. I think you with your girl. Sorry. II get, hm, when I speak it's coming. Uh, you've sorted it well done. So, so this is a 12 year old kid who presents with a clicking neck. Um, they're neurologically intact but they get pain and discomfort and clicking in their neck and their mum and dad haven't really observed any, any particular problems with the child and their perinatal history was normal and they had some plain radiographs. What do you think of these x-rays Vikrant? Are they normal? Hi, Miss Leishman. I think he's, uh, come off the call just in order to, um, try and get a system to work. I'll, I'll have a crack if you want. Who's this? Uh, sorry. It's Nick. Yeah. So, hi, boss. So there's, there looks to be a sort of, uh, so there's an IBU, so there's a, essentially a sort of cervical scoliosis. It looks like there's a hemi an additional hemivertebra around C three. Yeah, this thing here. Yeah. I agree. Yeah. Yeah. What else is going on? Uh, so I can't say there's an, oh, yeah, there's another one, there's something not quite right above as well. Um, up here somewhere. Well, what about this? Um, Nick, what's going on here? Uh, well, essentially there's, there's, there's excess, there's excess bone on as, as we look at it, the right hand side of the patient's left side which is causing the patient a structural, there's a structural abnormality causing a lateral. Um So, II think there's, I think you're right. I think there's a, there's a suggestion of a hemivertebra. Um some of the vertebrae look very abnormally shaped and there also appears to be a contiguous fusion of several of the vertebrae on the AP and on the left C two looks fused to C three and the poster elements of C two and C three also look fused to substantial. So this, this is a uh probably a congenital scoliosis or, or uh in this instance, um we made a diagnosis of a, a complex, a congenital fusion of multiple cer cervical vertebra, you know, and, and that's called Klippel Feil syndrome. And you can see how, look how C two and C three are fused together. It's really odd, isn't it? Uh And the child had a cervical scoliosis. This is one of our patients and, and the long short of it is you, you need to just vaguely know that there's a thing called Klippel Feil syndrome. It's congenital fusion of at least two cervical vertebrae. Uh And the other thing you need to know is sometimes it can be, it can be isolated or it can be associated with other things. Now, remember we said, if you had to have a pump at what cervical spinal abnormalities are associated with condition X, we would say C one C two instability or Vasin invagination if they ask you um if you have a child with a congenital condition and they ask you what other organ systems can be affected if you have to have a pump pump for heart and kidneys. Yeah. And I'm sure you've all come across that cardiac anomalies and genitourinary abnormalities are frequently associated with other congenital conditions and it's no different to Klippel Feil syndrome. They can also have deafness and they can have sprinkled shoulder, they can present with neck pain, they can present with myelopathy and they can present with scoliosis. So, coming back to you, Nick, um Nick, we understand why they've got scoliosis. Cos bits of the spine are fused. We understand why their neck's painful, you know, they've got crooked neck but why might they have myelopathy? N um presumably the um the fusion is causing some sort of impingement on the court. Is it the fusion? Do you reckon? The fusion is not gonna go anywhere? What's gonna cause impingement on the court? Uh Well, I guess it could be the deformity itself right. If it's um could be, could be, but that's unusual. That's unusual. D Tom Tom Barker. Um I'm gonna have a punt and say either instability or basilar invagination. I like the val evaluation. Why instability? The instability is correct? Why, why instability? Um the fuse bit's not gonna be unstable. What bit's gonna be unstable? Well, if the, the there's gonna be excess movement between C two and C one. So, exactly. So the adjacent segment, so the fuse bit is gonna be OK. Do you get that Nick? But the bits are gonna move more are the adjacent segments and the adjacent segments become hyper mobile and they can cause cold compression. So, so it's not the scoliosis or the few segment, it's the adjacent segment, hypermobility. That's a, that's a really good point. Uh Thank you. Do. Do you? Um So, so you don't get sort of um additional spurs or anything like that? Not, not typically. No, no, that's a good point. N no, that's very, that's, that, that, that is possible but atypical mo more often than not, it's a, it's a benign thing in the sense that um you know, it doesn't cause cold compression of itself. So, so you don't need to know this, but I just found this interesting when I was looking this up, I have to say um I learned a lot about it. Um a single level that's fused is called a type one. That's easy. Um If you have multiple discontinuous levels or multiple fuse level, continuous fuse levels. Um then that's a type two and a type three. And you can imagine multiple discontinuous levels are probably the most commonly associated with myelopathy because you've got lots of mobile segments, haven't you in between the few segments? So, um for a single few segment, you can get adjacent segment degeneration as well. But if you have multiple ones, you can get myelopathy, you don't need to know. That's all you need to know about that. Yeah, you know, don't forget it. Capot Fil syndrome. It is a, is a congenital problem. There's fusion of at least two cervical vertebrae. Uh, sometimes it can be more, um, it can be, you know, you can have, you can just have two together, you can have two, then a mobile one, then two other fuse ones or you can have all, all five or six fuse together. Er, and, and it can cause pain. It can cause scoliosis and it can cause myelopathy at adjacent segment movement. Um, but it's an interesting condition, right? I'm gonna put this one. I'm gonna ask Ben Davis about this one. So, Ben, this 20 this is one of our patients. This child was, um, three weeks old, had gone home, uh, normally with an inability to use its upper limbs. Uh, and as you can imagine, after we cracked ourselves, uh, we did some investigations on this lesion in the kid's neck the kid when they went home, er, was in, was seen to be using its arms and legs and it comes in at three weeks old with paralyzed upper limbs. What's going on here? Um So there's a large what looks like destructive lesion, uh difficult to tell exactly on the MRI but something about C five level um with um significant uh expansion anteriorly and posteriorly from the uh spinal column into the spinal canal with uh spinal cord compression. Um Looking, yeah, looking at the X ray alongside it, there looks to be some well come on to the Mr for a second. Let's be systematic. OK. So you said it's C five, it's destructive. It's expanded anteriorly into the previable space posteriorly into the epidural space and it's causing cold compression. What what else would you say about the, the bit in the middle, the what what's happening there in terms of the signal characteristics? So it looks to be fairly high signal. I agree. I agree with you that I as suggestive of fluid, especially centrally. Yes, I agree. Uh What about the X ray? So X ray shows um yeah, uh I suppose loss of bones. There's, there's no, so two, yeah, 234 CC five or C six is just disappeared with some osteo fragments anteriorly or, or some or some calcification anteriorly probably in line with that uh expansion seen on the MRI. Um What's your differential diagnosis here? Uh So suggest given that it was uh uh nor neurologically normal when he left hospital, the stress is rapidly growing. So I'd be very concerned about tumor. Um or I infection would be top of my differential. Really excellent. And that's all you need to know. I mean, pass past six and let's talk about sevens now. So, so you, you've passed this question and we're moving on but, but I want you, we've got some time on the bell at your last question. So we're gonna try and push you to a seven or an eight. So, so tell me how you would exclude this as being infection be. Um So uh some uh so routine sort of bedside tests. So just making sure observations, checking them within normal limit checking the patient isn't septic and uh blood tests including cultures. So blood tests looking at full blood count crp um Excellent. I'd need someone to analyze them. I'm not sure what the normal is for a 23 year old, a 23 day old. But uh um so yeah, uh blood culture is probably three set as possible. Um Yeah, I ideally a biopsy. Um I think so, but that would probably need to be a highly specialist center that's going to be doing that on a 23 day old child. So, so we needed ap ICU we couldn't deal with this locally. So it went to Aden Brooks and the child had an excisional biopsy and it was Langerhans cell histiocytosis. Um, I with, I'm with you, I thought this was infection and, um, but the child wasn't systemically unwell. Er, and like you say, the biopsies for two fold, make a diagnosis and if it's infection, you find out the organism, er, if it's not infection, you find out what the pathology is and this was Langerhans cell histo which is a rare proliferation of dendritic cells, uh three months to 15 years, but the mean age is about four, it can affect the skeleton in 80% of cases and it affects the spine, about 8% of those and, and kids come in with involvement of the cervical spine if they have pain deformity or cervical spine, suboxic and neurology and um you biopsy them, immunophenotype them and you treat them either by observation. And in fact, the vast majority respond to um non surgical treatment. It is very rare to have to operate by curetting and grafting and stabilizing it. And had we known the diagnosis here, I think this child would have been spared an operation but you needed a tissue diagnosis. And uh I think it was just m managed in a, in a collar or something. And uh this is what it would look like at age 10. So you can see the bone has remodeled and reformed. It's all fused together. But this was Langerhans Cell histo. Now, the the classical radiological finding in LC H before plan where the whole collapses. And in this um series, from one of the pre reference papers, you can see how the vertebra sometimes reforms, which is quite extraordinary. Um And it's a very odd process given the neurological uh weakness is there. Do you get a recovery of that? Yeah, there was a recovery, uh almost entirely. Um, the child recovered and I think um they probably had some systemic steroids. Um And, um, and I think the surgical treatment, I'm not sure because it was done at Adam Brooks II know they biopsied it but I don't think they did like a form of decompression type procedure be because, you know, you're creating a huge instability, aren't you? So this child was managed largely in or orthosis and it, um but the neurology recovered as well, which is great. Yeah. Um the, the last thing I wanted to talk about congenital scoliosis, there are three types of failure of formation, failure of segmentation and mixed. Uh You can read about that. That's all in books. Er, and this is one of our kids, uh one of our Children that we saw, um, she was a real sweetie age of about three or four when she came and she has this complex cranial cervical, um, a congenital abnormality and uh torticollis, apart from muscular torticolis, er, post infective or posttraumatic torticolis can be due to a congenital abnormality. Um, er, the last thing, the last two or three slides, um when we have patients with atypical curve patterns and those of you who have come to our scoliosis clinic, er, know what a normal scoliosis looks like. It's normally convex to the right with a small compensatory curve. This is a, a triple curve with a main thoracic thoracolumbar and thoracic lumbar curve. And this child has this abnormality at the cranials junction. Um um is randa on the call. Ok. So back to you George George, what's this abnormality called at the cranial cervical junction? As is this another example of basilar invagination sort of except the odontoid peg relative to the relative to the base of the skull. The peg is still where it should be. So instead of the peg going into the brain, the brain is coming down into the peg. What's that condition called? Can you see there's the cerebellar tonsils have herniated. What's that called? So, herniation or coning is that there, there's a particular condition? Um Ben Ben Davis, what's this called? Ii don't know it. It's an Yeah, that's it. It's an, yeah. So it's tonsillar herniation into the foreman magnum and this child has uh has that and this is another atypical curve. Most curves are convex to the right, this is a left thoracic curve and most curves in idiopathic scoliosis are associated with a flat back or hypo uh kyphosis. This child is hy hyper kyphotic and has a a quite marked Arnold chiari malformation. So, um what I would encourage you to do if you're coming up to the exam, come to our scoliosis clinic or come to one of our spine clinics at the N and N come and, and, uh, these are very rare conditions. I didn't want to spend a lot of time on them. But I think what I've hope, what I hope I've done is shown you how you can take any topic in orthopedics and apply the general principles of orthopedics to them. It, it really appeals to me. Um, this kind of way of thinking like an orthopedic surgeon, neck injuries in Chuna, often Salter Harris type one. basically, uh a congenital scoliosis is Wolf's Law. Um and, and basically, it's also um you know, a an application of o of the basic principles of, of, of orthopedics. Um So, um this is, these are the references and if I had to, to to point you to one reference to read and I think you should read one thing, read this if you went to cop club or whatever it's called. Last couple of weeks ago. Professor Rajasekaran, er I had spoken at ac if I'd known um he he his unit in Ganga is a very good unit and, and this little thing from the JCO T pediatric Spinal injuries from the Ganga Hospital by Raja Saran is a really good read. II don't think you need to know a lot about Langerhans cells citosis or congenital abnormalities of the spine or even the anatomy of the dens in a child or how it develops. But you do, you should read pediatric spine injuries and that's me done. Alright. And I it's disappointing that.