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OK, good afternoon guys. Uh Thank you, Mister Steel and all the small consultants at Norwich for this opportunity. I'm Warren currently a small surgeon at Royal Derby. Uh We'll start with this uh uh topic of uh immediate management of spinal trauma. It's quite obvious, isn't it? How do you manage a spinal trauma or for that matter, any skeletal trauma? What, what's those, what's so special about uh uh the spine? You, you just have to probably like a wrist fracture, reduce hold rehabilitate, same principles apply. But why, why is it so different? Yeah, uh things we need to know is because when we talk about spine trauma, we are talking looking at two structures, spinal column that is the bone and the spinal cord, the neurology. OK. So spine trauma is like a twin spinal column injury and spinal cord injury. So this makes it AAA special consideration. But having said that, ok, on the grand scale of things, spinal cord is still enough. Ok. Yeah, we get carpal tunnel syndrome because of a wrist fracture. We get carpal tunnel uh or uh a brachial plexus uh injury still, it's not a big deal. Ok. So why? WW, what makes it so immediate anybody? Because the nerve is affected in other injuries. Considering the spinal cord is the biggest nerve in the body. It's, it's ok. Is it not poor, poor chance of recovery if, if it does have an injury and the fact that it's not just one nerve, it's all of them potentially. Well, most of the, yeah. Yeah. II, I think, uh, you're, uh, on the right track It's, it's the quality of life because the it's a high stakes. OK? You are going to lose a lot here and that's where there is a timing important. So for example, as I said to you, if you stick to the principle, reduce hole and rehabilitate and come back. OK? I can't see the check x-ray and say there, oh, there is a little bit of a radial angulation. Do you want to redo this uh uh reduction? I don't have so much time. So when you have to, you have to work quick and you have to get it right first time. OK. So keep in that mind, when you come to spinal precautions, you have heard all these terminologies. Is this correct head hole, dog rolls spines, table mobilizers, able common, common things which we write, why, why do we do this? Is there any reason for this further damage? What is that called? S lope? That's right. I like that. So if you go to absolute basics, it's all about primary injury, secondary injury, you should understand the further damage you're talking Luke is secondary injury. So does anybody know difference between a primary injury and a secondary injury? Primary injury happens at the time of the event? So they, you know, they break the spine and then there's a cord injury at that point and then a secondary injury would be, um, like something sustained during, uh, you know, like during care or, uh, uh, you know, if there was um uh you know, if they didn't have spinal precautions when they should do and then there was a subsequent injury to the court after absolutely spot on. So it's the time of impact, is it not? So this picture shows the different types of injuries you can have, ok, leading to a primary injury, the main thing is you don't have any control here. So the card has had it. That's it, it's the blunt trauma, you just can't control this, ok? Now, the secondary injury or the subsequent injury or the re injury, what we were talking each time you do that, all those hypoxia hypercapnia, anemia, all the blood loss, all those things will lead to a free radical formation and that sets in the second injury and that worsens the prognosis. So our role with immediate spinal trauma management is the reduction of secondary injuries by taking spinal precautions like this picture here from the ed and adhere to the principles of a TLS of airway with oxygen and c spine, control breathing and ventilations, hemorrhage, control and circulation and splinting and prevent any uh hypothermia. All this reduces secondary insults. You clear with that. Mhm. So this is a picture again, it's a diving picture just for you to understand that the picture. And the one is a primary injury where no control picture in the two is the second injury where we are trying to immobilize the spine and take him away and while protecting the spine, we also need to understand the spinal cord behind the spinal in the spinal canal is also getting affected because of that. So keeping that in my background, we need to have an assessment of a spinal surgery or uh of a spinal injury which should be meticulous, has an exceptional qua quality um uh assessment of the spine examination. It should be universally acceptable back with the good evidence and you need to customize uh this uh assessment to the areas where you are, particularly if it is you're working as the on call orthopedic uh trauma in ed or if you are called in the ward, always stick to the basics of your at LS principles and carry out full in line spine immobilization while doing so. Have a little think about what would be the background. How did this injury actually occur? Was there a distraction injury? Was he inebriated? Is he cooperative? Is he complaining of pain? Was there any sensorimotor disturbances and uh I just wanted to ask how many people have actually seen a priapism in ID quite common until we look for. We don't see with the spinal cord injury and people who have patients who can talk, they will ob obviously tell that they had a previous spinal surgery or this, they can, they know they might have a deformity. Ok. And when I'm talking about a full in line spine immobilization, you need to be a little bit careful with what are the specific circumstances like there is no point in going into a PURs and immobilizing him when he's actually able to walk out of the scene. So just have a little look at whether he's self extricated himself. And then once he's on the spinal board or once he's ground, take additional help and fit the collar. Now, the tricky part is it's not box standard. Again, there will be short necks, white necks, people who have deformities and sometimes while enthusiastically, you try to put these calls that can be counterproductive, you will lose airway. So we need to be a little bit alert with that. And obviously just uh keep whatever position comfortable, particularly in people who are agitated, don't fight with the patient that will make it worse. And also Children and stepwise approach, manually stabilize the head in line with the cervical spine, like what they taught us in A LS and also measure, get an appropriately measured color and apply. So for a good log rolling. You need about four people with first person who is in charge of the cervical spine, takes the control and the leader. Ok. Everybody familiar with this. Is it not? Yeah. So special considerations, I'm gonna stop here for a second because special consideration completely deviates from the main topic of spinal assessment injury. I'll come to this at a later in the end. But what I will be discussing there is patients with the deformities or in the Children, how we have to take care of this. So, going after in line mobilization, you need to assess the patient for a cervical spine injury. And the nice guidelines clearly suggest we have to use a Canadian C spy and do a risk stra uh risk stratification. And uh people who are 65 and over having a documented dangerous mechanism of injury, which is uh self-explanatory or with associated parasthesia will take the high risk factor needing immediate uh uh imaging or a person who's actually sitting, communicating, walked out of the scene with a minor injury and uh presents late to d with some or the pain or restriction of uh spinal movements, go to low risk practices and then you need to get further uh im assessment done. Not sure. Oops, sorry. Can you see the last one? The Children in Children? We may have to take a, a little bit. Uh We have to be a little bit cautious when you're doing an assessment because of the reliability and their developmental stage. Ok. While assessing thoracolumbar spine, again, same principles of patients over 65 with pain and documented dangerous mechanism of injury. Also with preexisting spinal pathology, usually it will be the kyphotic spine or ankylosing spondylitis or patients who have a history of rheumatoid arthritis or risk of osteoporosis. And also they tell other uh regions of uh spinal problems that you typically it will be a sacral injury or a pelvic injury. And when you examine them, it will confirm there are neurological signs with a deformity and tenderness in the back. And if the patient is actually able to mobilize, then uh you can look, make them sit or stand and look for the evidence of ecchymosis. And if they are in pain and the symptoms get worse, then immediately make them uh lie down and take full spinal precautions. Again, the caveat is uh just a little bit careful with the child when to carry out a full in line immobilization is when there are risk factors, especially high and low risk factors. Uh and a suspicion of a thoraco luma injury. You have to just follow the rule guideline and maintain an in line mobilization. And, and the opposite of this one not to carry is that if actually they have not tied anything, just go go and uh immobilize the patient for the heck of uh doing it because uh it's a spinal injury So just engage yourself uh while doing the assessment because this is quite common where people you see uh when patients get admitted in the world and unnecessarily, the first question nurses ask is uh oh, is it a head hole and a long road when the patient has a quite stable injury? And that decision can be taken at least 24 hours prior to the admission. So once we assess and uh I think I missed one slide, but uh it will come later. Uh uh I'll uh I'll come to the slide later. I, but uh once you assess that there is a cervical spinal injury or a thoracic lumbar spine injury, then you need to get an appropriate uh imaging and that would be a CT scan and that's a default option for adults. And if it is uh uh and if you have a strong suspicion of thorac or lumbar spine, then you can get a uh CT from vertex to toe like a trauma CT. And if the CT confirms there are some features suggestive of instability or you are a little bit unsure what is happening there. Just straight away order for MRI scan, there should be no delay unless you are in a place where the MRI is not accessible. Speak to a local center. Nice also suggests that if there is a head injury evident, all the patients will get ac spine ct up to T one normally. And as in elderly because of the kyphotic deformity, that section might have to go up to T four Children. The imaging is a little bit different where you do not do CT scans, avoiding the radiation. MRI is recommended and if strong suspicion of other region involvement, probably a hold spine, MRI is the way forward. And if the patient is n does not have a clearcut injury of spine and if you are in a doubt, discuss with the spine consultant on call or uh the radiologist on call, you may have to perform uh x-rays to just make sure we are not missing any other abnormalities. And again, these patients also will get a head injury assessment along with the c spine uh scan and this is what I wanted to say, whole body CT in adults is ok, but try to avoid in Children. So before I go to the bo guidelines, I just come back to the destination of injury. When you diagnose somebody with a spinal cord injury, particularly standard guidelines, are you need to refer to the major trauma center who then have to refer to the spinal cord injury center, not the decal hospital. In an ideal scenario. This should happen within four hours and uh isolated spinal column injury. That is the bone injury. You can refer to the local secondary center or a trauma center, not a major trauma center, but uh um a local trauma unit which has a spine capabilities. This applies for adults and in Children, whether it is spinal cord injury or spinal column injury, everything has to be referred to MTC. Is that clear? Ok. This is the best guidelines on spinal uh clearance in a trauma patient. Everything is box standard nothing which is uh uh uh and uh surprising. Everything is quite intuitive how you have to maintain in line immobilization. Getting a proper assessment, documentation of neurological status, clinical examination, everything, getting a uh ac T scan of T one and if not go up to T four, which all discuss. The only thing here I want to highlight is in 2015. They also mentioned in a patient with unconscious or uh a a patient who's unconscious or who have an unreliable uh examination. A senior radiologist has to review the images and report it within 48 hours and that is considered as radiologically cleared spine. No, after that, the musculoskeletal uh radiology group have come with the latest guidelines which which is not so latest if you see it is may 2021 where they divide the radiology, uh further ac spine clearance into three options in in option one where you have a very clearcut demonstration of a spinal injury affecting spinal stability. You continue protection and inform the clinical team. In the option two, you look for the scans and they are good quality images where you can clearly see no features of instability or a fracture hematoma or any other joint disruptions and they don't have any medical comorbidities such as patient is taking Apixaban or uh Edoxaban some uh hemo uh uh antics. Then a radiologist will report that as ac spine radiologically cleared, that means spinal precautions can be with drawn. However, a tertiary survey must be done to document the clinical clearance and that tertiary survey might take at end of three days, end of seven days or depends upon when the patient is stable and the scenario. And the option three where there is no spinal instability, poor quality CT scans with evidence of uh uh with difficulty in interpretation or with problems of comorbidities. The next best step is to proceed with an MRI scan as feasible or clinical examination, whichever becomes first. Is that ok? Spinal clearance, everybody hear me. Yeah. Yeah, that will make sense. Thanks. Bye. So, Bost also has given a few guidelines on traumatic spinal cord injury. Again, it's very intuitive. I'm not gonna bore on this. The main things which you need to understand is I really the patient should be in a place where there is a 24 hours MRI or or AC T scan are available. Asia chart has to be documented and take care of other systems like urinary tract, respiratory tract. You need to make sure patient is being started on some form of um a management with uh uh with regard to spinal cord injury and usually they should be in a place where a surgery can be done within four hours. In an idealistic scenario, for example, it's a bi fascial dislocation with a spinal cord injury where time is ticking. Patient is in Yarmouth and patient has to come to Norwich, that has to happen within four hours. Patient has to be in theater within four hours and within four hours, they are supposed to contact spinal cord injury center if not four hours, at least by 12 hours, they should document on the notes. And this is the one which is very true. I just can't believe they have written here transfer within 24 hours if the patient is fit to a spinal cord injury center and if that is not possible, at least they need to start giving outreach support for within five days and not for getting psychological and family support. Is that ok? Yeah, transfer within 24 hours is a bit of a stretch, isn't it? But yeah, more like 24 days usually, right. I'll go to the next one here. Remember actually, uh Tom has said earlier, steroids, no role in trauma, especially in the United Kingdom. No role. Yes. Gastro protection. Consider pantoprazole or omeprazole based on what guidance are because they will get a lot of pain management medications that can be a source of uh uh stress as well as ulcers apart from the spinal cord injury itself. Then neuropathic agents, it depends upon which unit you are working and what kind of uh uh support you have. Sometimes the knowledge I think uh the pain team do start on neuropathic agents but the evidence is less, do not forget these basic absolute fundamentals. VT prophylaxis at least try to start within, within 72 hours and then duration can be determined later on based on the patient. Uh what uh what are the other injuries and mobility and bleeding risk? If in doubt, we can always uh refer contact uh the spinal cord injury center, clarify the duration. Uh uh and uh give it and prescribe it. Spinal shock. Do not forget this is quite common where uh where uh spinal cord suddenly loses all the function because it's basically, it's in a shock. So it's an areflexia at that time. All the motor sensory power, bladder, everything goes into shock. You just can't do and that can happen for days to weeks previously, it used to be said within 48 hours. And uh they decide that the end of spinal shock is when the bulb caver uh reflex uh is returned, but that might not happen within 48 hours. Can I just ask you how do you check for BBO mule? Uh PR and tug on the catheter? OK. How do you do APR in a trauma patient? Um So with log roll and head hold um typical. OK. That can be one option if uh or you can um you have to do this pr every day. So you're gonna do that. Uh No, no, it, it is possible that's, that's uh that's probably the standard, right? But the other thing is remember, you can do a uh this is just for checking a bulb of awareness, uh reflex. You can do apr in supine position like a lithotomy. OK? Until, unless the patient had a femur fracture or a tibia fracture and you can't do, then that's fine. You understand, I it's not a big problem doctor. Main thing is do it and document it. Ok. That's it. This is one of the common scenario where this spinal cord injury patients will have bradycardia, which is one of the common dysrhythmia. Usually position change or suctioning can induce it. It is quite uh intermittent and self resolving. But if it continues to be a problem, then we need to consider some medical management. Do you know why bradycardia happens in a spinal cord injury? It all depends on the level of the spinal injury. But if a high spinal injury, then they get um neurogenic shock. Yeah. Correct. That's right. Absolutely. Then also remember people who have high spinal uh cervical cord injury, they will need ventilatory management. So they might have to go to itu first tracheostomy. They might consider maintaining it for uh quite a long time and sometimes it might be the only way to keep them alive and they will need long term support, especially when they have C one, C two injuries. I think I had uh come across 23 injuries at Norwich when I was a fellow. And do remember patients have acute autonomic dysreflexia. Do you understand what that means in exam? It, they, they might ask you ask you to draw a quick diagram on what is a autonomic dysreflexia. But just remember if the lesions are above T six, there will only be sympathetic overdrive below that lesion. So that leads to hypertension. Headaches. Usually, more common reasons are that uh there's a constant stimulation of a patient's uh uh organs. It could be bladder because of a kink, the catheter or a uh rectal stimulation because of the impacted uh stool. Or it could be a simple bagged crease. All these can cause uh autonomic dysreflexia. So you need to be a little bit alert, just make sure keep the patient uh upright a little bit. Uh uh try to uh look for the offending cause and uh start treating hypertension and they should settle down. Main thing is to keep this in mind. I identify appropriately. These people also start developing spasticity at a later date. And this is a little tricky area because spasticity means the foot and leg, ankle goes into spasm. Ok. And that is quite routinely misinterpreted as a movement. Ok. And uh you get nurses and uh uh patients telling you that actually I'm moving uh yesterday, I couldn't move, but I'm moving the stool but it should be a little bit guarded. What, whether it's actually the movement or it is the spasticity which is kicking and protect their skins from ulcers. So they need a secondarily changing of positions and the appropriate mattress, don't forget bowel and bladder. Main goal after you catheterize these to maintain uh the structures. Otherwise they go into hydrodilation, that's a problem. And then again, they lead to urinary tract infections. There is no generalized way of management, bowel and bladder. But it, it all depends upon how the individual is motivated and what are the other uh factors he has particularly on background of uh uh his uh diabetes or if he is a, excuse me, if it is a thoracic injury, then he can use hands for self intermittent catheterization. But if it is a cervical injury, then we may have to consider a suprapubic cystostomy. So those are the certain things which may have to uh happen. And uh as the time progresses, you also need to start uh thinking of how you want to mobilize the patient, particularly passive to begin with. Ideally should start within the first week. Sometimes it might not happen if the patient is too medically unwell when with the uh polys injuries, which usually they are and appropriate physio therapy and ot assessment. And by the time spinal cord injury rehabilitation there, uh uh team will get in touch and they might uh go to a suitable rehabilitation. I did not get any uh recent evidence guidelines for the traumatic spinal cord injury. But there is something on the neck from American College of Surgeons, which is quite recent. If anybody are interested, they can go through spew of uh the best practice guidelines I I suspect except for the uh steroids, rest all everything uh or amen. Is that ok? So I'm going to that spinal uh special spinal precautions, which I was telling to you earlier in my talk, see the patient with spinal uh sorry ankylosing spondylitis who have this uh spinal alignment, tic spinal alignment. So if you can imagine you can just put the in line immobilization, isn't it? You can see that if you do an in line immobilization in them, it basically just worsens. So you might have to probably put a pillow, adapted pillow or have to consider traction in such a way that it it accommodates the deformity. You got that point. If there are no pillows, they have to get the pillows. There is no reason for that triangle pillow search in the theaters but get it and do that. Ok. There's an example of which I got on the internet, which is a kyphotic deformity in this patient. And you can see how the fused spine after the accident causing the traumatic uh spinal cord injury. And that's the CT scan. See if you put a regular collar, how that collar causes opening at the spinal cord. Did you see that spinal column opens and that's bad. So you might have to consider putting a pillow or use some uh a different type of orthosis. What normally here it is a Miami Jay collar they are using, but that's how they use it. And that's one of the common things you get. Probably if you have worked uh in a neurosurgical unit, they quite often use that in. Also, we sometimes use it. There's another elderly patient who has this kyphotic alignment and see how the spine is fused. Ignore all the markings. There just wanted to highlight how the spine is fused and when they fall, they snap like a stick. And that's the CT scan, you can see the alignment and that's the MRI showing the likely injury in the same patient. OK. Can anybody read this scan here? CT scan of this patient? Um There's uh so this is a sagittal cross section of the CT scan. There's um some localized coos uh T 11 12, which could be an old fracture. And, and then at seven, there's an extension type vertebral body fracture. Yup. Yup. Uh Good. This was one of my cases when I got a job at Derby and the Onco register said patient to be mobilized as tolerated by pain. I got AC T scan done which confirms that extension type of injury. OK. And also there is a thoracic injury here. Can you see the edema here? So basically, I wanted. The reason why I wanted to put is one, do not underestimate the injuries. Number two is also aware it can snap at the different junctions. OK? Until you are, you know that it can happen, you look for it. Otherwise you just say that's fine, just mobilize. This is a another uh another example, it's a bond or diagnosis. What is it? How does the spine look? Uh It's a, he's got an pod, any atony for it, bamboo spine. That's correct. Nothing, nothing wrong. No rocket sign. That's it. Yeah. And, but a and it naps. So this is how they come. And uh they will do if, if you, if, if main thing is uh you need to make sure clinically you look for cervical thoracic. OK. Yeah, this patient is on the bed. All right. Everything is fine. Don't send them home. Just make that effort that OK. Do you have pain elsewhere and document that? So that at least there is something for protect us. If in doubt we do lots of s uh scans for a cardiac one getting a CT and an MRI in this patient is not a challenge. They will agree. Problem is uh these patients cannot lie in the MRI scanner because of the deformity. That's where is the challenge. And in Children, if you remember the A TLS principles, the head circumference is bigger than the body. And when you start putting on the spine, stay like that it will close up the airway. So you might have to create a recess, if not at least put in a blanket and elevate the body in relation with the head. Of course, with precautions. Is that ok? So, uh I know uh Tom has again briefly mentioned about spinal stability. Can anybody de define spinal stability, anybody define? That's, this is one of the very common questions define, defined as um er under physiological loads, not deforming um or causing neurological um deterioration or er excessive mechanical pain, pain, neurological deformity and ne neurology in the pharmacy and the physiological load. Correct? Yeah, I think you nail it. That's what the white and Punjabi described. This is def they are going to definitely ask this question. OK. So uh what you need to tell under physiological load, progressive pain deformity or neurological ration is considered s spinal instability. That's what uh it is meant saying. All right. But before that, you need to identify the mechanism so that you build up a picture how the patient has because sometimes it is so difficult on the x-rays uh or the CT scan to say that. Uh actually, you know what uh this is a unstable spine. So build up a picture, then you will know that. OK. You know what, I'm not happy with this x-ray or a CT scan. I'll get an MRI. All right, then you will have a little bit more understanding. There are numerous classification systems I don't know. I, I don't think this was, uh, uh, uh, needed in my topic. I thought I'll just cover it so that you're aware that, uh, aot is quite popular. Ok. Uh, I have recently read, uh, an article in European, uh, uh, Trauma and orthopedic Journal, uh, for, uh, Thoraco Trauma, uh, how, uh, how the classification systems evolve, uh, for a fast preparation. If anybody interested, just Google that you will. It's a one or two page article just quickly have a look, but they are definitely going uh grill you on that and this is actual proper definition, but uh whatever that small one under the physiological load is the main thing is that ok. Thanks. Right. The take on points from the talk would be primary injury was a secondary injury. Our role is to reduce the secondary injury so that we have less impact on the spinal cord uh damage and improve the outcomes. Consider spinal precautions, especially adapted uh position of immobilization and be aware what is considered as a spinal stability. Thank you all. Thank you for giving me this.