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I'm gonna start off today on by talking to you, um, all about spinal column and spine and that's me know, physiology and then bone physiology. And then afterwards, Megan's gonna take her over, and she's gonna talk more about pathology on and what can go wrong with bones. Okay, so the last meal of the spine, I'm sure you'll know that despite divide into four separate regions, um, with cervical lordosis. So Lord ist doses being to capture in towards the anterior side, your body and then kyphosis is it's more like the hunchback, so of shape, which you see in your thoracic spine and also your sake room. Yeah, so and your c spine or your cervical spine? Um, you got, um, Lord Isis on D on the cervical spine and contained these to specialized vertebra, which I'll talk about later. Could the access and atlas, which allows your head to rotate, then in your lung the spine you have. So we're going through a six fine. That's expired on. We have faces on this allows us on the thoracic spine. Larger body Teo, very taped around on D on. It's also the most common area of the spine that you got compression fractures, which you might see an officer process. And that's specifically between t 10 and T 12, then onto the lumber spine. So the lumber spine has the largest that broken. Sorry, but body. And that's because it has the most weight on the spine from everything above it. So it has to have that large diameter so that it can support um, or the structures about it on. But because of all the force and wait on this area, the spine is the most common site for disc herniation. Okay than onto sacrum. When you're born, this is actually four or six bones. And then as you grow older, these fuse together on this axis and anchor for the spinal column. Now, I hope you guys would help me to label some, um, key parts of the vertebra. So to start off good, anyone type in the chat? What? A is give you a couple of seconds. Okay. To quiet your view. Direct message directly. Message me on is the Trans first process. Okay. Okay. Now on to the next one is anyone know what? Here's this one slightly harder. Yeah. Somali message may is the superior articular print process. Um, and then next door to that year, the superior articular facet on this allows the bird spread to drawing on to the vertebra above it on. Now, make sense in the next slide. More now, hopefully not. Have you know what deers someone quickly put in the chart? Yeah, it's the spinous process. So this is what you can feel in the back of your spine on, um, it provides the protection support and also allows your spine bend. And then is the lamina say connecting? Um, the spine is processed. The rest of birth book, book, body. And then last ones, anyone? There were efforts. Yeah, s is the pedicle on that again. Just allows the transfers process, Teo drawing on too, on the body of the spine Onda Then that forms thie circle in the middle to the battle Framan. Um, where with that no bruits on the spinal cord itself will travel. Okay, so the cervical spine and a little bit more detail here. You can see the superior facet on then how it joins on on to the That's for above on. You can tell us this up. Cool spine because the small hose next door to the bad before human could there transfers Framan on. These contain the best artery on the bathroom vein. Now it's important to note for exams you might get asked the what structures run three. The transverse Freeman on from C one to see six is the best fruit aspirin bein How they're in C seven. The best book artery actually doesn't go through the transverse framing, and it goes around that of the best that's through. Vein does go through it. Okay, Then again, the thoracic spine is a the steam that match up on these have a larger bad body in the sixty's Fine, not as large as the lumber spine. They have any facets, which you might notice on the left lateral view. And this is where the ribs articulate So the ribs actually articulate between two vertebra, as you can see here by my slightly dodgy animation. So here's one bread and that will attach to to demo facets and then art round. Now the London spine has more prominent articular process is that's the the drop down that here on the lateral view on this is to allow the best breath to reach the next that lower down people. You can see that on this diagram or so on this, um, a shit. And like I said earlier, it has the largest of that group, buddy. Yeah. Now, I said at the Star, I mentioned the atlas in the access. So the atlas, um, is see one. So that sits on top of the access, and then you have their structure here on. Then you'll know what this school. Yeah. So is the dance floor done? Um also, could the auditory process on that? That's why I mentioned earlier allows your head to rotate onto your c spine because it's, um yes, it's a lot like irritation might be on a finger night because it's circular fits into that circular group, and it allows for lab retention on. I like to remember Setu is the access because it has the dens and it kind of looks like an access. So I've drawn two arrows here. The dance for trees upwards. And then you have the other, um, longer she had no access to be. There's out through body. It works. It may help your back for you. No, no onto the ribs. You have a program. It's the first seven to describe as true ribs, because they attached directly onto this done in three. Cross the cartilage and then ribs 8 to 12 a code four strips because they don't tax on to the sun and directly. They either merge were other cost of crop cartilages to Dendreon to the standing. Or, in the case of ribs 11 and 12, they didn't actually attached to the stone. And two Okay, so time for an SBA and a T. T. Rowe, man with a history of prostate cancer. Presented back pain and X ray is the form which reveals a winking our sign which part of the birth bull vertebra is damaged, causing this fracture on the X ray? So for those of you that don't know what the winking our sign is, if you look at the x ray, um, at the fats for you can see small circles on the lateral side of each vertebra. Then it's on the third vertebrae down from the top. You can see that there's a missing circle on the left hand side. This is quite a tough question. Start off. I'll give you a few more moments, okay? Get stuff, guys, I stop you there. Say the correct answer is the pedicle Onda. As you can see on the, um, next X ray on this, um, damage the pedicle because it degenerate and then that causes the area or less density, causing the winking our sign because you don't have that area so well done, everyone. He put a, um as people d I can probably see why where you're coming from, because it does look like it's an articular process just because of the nature of the exact. But it is in fact, the pedicle say that's on the spinal and that's me. Now I'm gonna talk about the spinal cord. Okay, so I say a spinal cord, I'm going to spoke a some nerves in particular. So the most answer layer of the nerve is called the afternoon area. So So just a flashback again to that of the diagram. The acne very, um surrounds the outside of the whole nerves. Our self, the whole not it's out. Sorry. It has made a collision on on it forms when the nerve leave suspended cord and then, um, areas of Iraqi would matter and juror matter, leave with it and then back Hurts the nerves, um, to form the up in Erie. Um, then going in from that you have lots of bundles of nerves which is surrounded by perineurium on each thunder of nerve is called a fast you. And between the after Neary, um, and the perineum, there's a blood supply for the nerves. So here you can see blood supply that's in between the acne area and the parent area. Um and then from that you had the endometrium, and that's surrounds each cell itself, and it's surrounded each mile and see, and then within, um, within the engineer e, um, does version of cerebrospinal fluid crude, and then you're really fluid attacks in a similar way. But in the peripheral nervous system, then just to recap on action potentials, I'm not gonna go into it. And that that just a quick, fine knowledge is anyone know what the resting potential is for? Um, and I have in that peripheral nervous system. Okay, a few of your messaging me? Um, yeah, it is, in fact, minus 17 minute votes. So it's just it's no, no, very relevant clinical knowledge. But you might be are certain exams that until sunup transmission again. I'm sure you know this, but I would just with over it quickly you get action potential. And then that causes calcium. And to the Baltic age that calcium channels were saying cause, um, he's coast me to the south sex membrane and then release neurotransmitter. And then near a transmitter will bind to receptors on the postsynaptic membrane, which causes side, um, channels, a pen. Everything causes the influx of stadium. And then it's that influx of sodium which causes a new action potential. And then, um, assume there's neurotransmitter is released. Then that new transmitter would be broken down by the cholinesterase. Such a seat. Okay, Lunesta rays to reset the whole system. Now, I'm mentioning, um, this because it's important having understanding of how a son acting transmission works so you can understand how different anesthetics work. So I'm gonna mention depolarizing and non pet depolarizing neuromuscular blockers. Said it, um, both depolarizing and non depolarizing. You must feel it broke. Doctors work, Teo paralyzed muscles or areas of his body particularly useful if you want to intubate someone. So, um, Atracurium is a non depolarizing no muscle a blocker on it's non depolarizing because it was simply block any neurotransmitter. So actually, attentions can't be generated. That's why I got this cross and then onto depolarizing on these use less commonly because they have a wider range of side of backs. Been non depolarizing your muscular blockers. Um, but they do work faster on, and they work by acting like a neurotransmitter. So they're buying Teo Postsynaptic receptor on by binding to the postsynaptic. Seen that receptor, um, with an open it to allow influx of sodium on D action potential to be generators. How about that? Um, depolarizing, your master block block is are not broken down easily by CTL curly nest rays say as a is, though, you get a prolonged opening of these, um, receptors on the sodium channels so eventually on channel is broken so long that they become ineffective so that when national potential is generated that, um, that's already fake neurotransmitter bounds Teo the postsynaptic receptor. Now this is more important for your exams on, but it came up often in my my exams. In my experience on it's nothing injury say there's two ways to classify near nerve injury. I had, uh um it has neurapraxia accident missus on your missus, Um, or the sunlen scale on in your practice here, you got damage to myelin. So this only effects of mine And she it might be seen in a compressive, say, literally is compressing the nerve causing your practice here, Onda. It doesn't cause actual damage to that accident itself, but it does cause damage to myelin sheath, So conduction is slowed. Okay, that accident, missus, is a canary in damage, so that's well, actually, have the accent damaged. Um, and then, um also the canary. Um, And then, um, stage I sent me something. Scale. Stage three. Yes, Um, refers Teo Paraneal your damage and then for ended near damage. And then, um, five is complete nap division. So, um, here I've written I think I think the slides actually actually wrong. And the diagrams correct. So everything opinion damage for two. I'm sorry. Afternoon damage would tell you that that should all be moved down. One. So two is only acts on injury. Um, three. That's an injury on D up in urine damage. Four para noon damage, and then fires complete division. But our check this at the end, and then the slides to go out and make sure that correct. Okay, Bollenbach's degeneration, This is after nerve injury. So, um, you've got the accent being damaged, and then this because degeneration distal to the injury. So I guess it's like having injury. Distillate. You haven't have injury then distillate that now would die, and then it just creates it out. Degree. Onda. Well, let Well, willenberg degeneration just clears that DeVry to allow a fresh plate for the new nerve to grow. And then I write here because in 2345 verifiers to the types of nerve injury. Okay, So sorry. Made that rather confusing on. Hopefully we're making more sense than I did. This s t A. So, Tommy was unfortunately, of empty stage am during storm G. Yeah, a piece of debris felt in room and crushed his arm. A nerve is damaged. Um told me had no conduction in the nerve in a month's time, to me seems to be improving, but his doctor tapped his arm and on the side burner here, here's a tingling sensation. Three centimeters distantly. Um, then he did the time of his injury. Okay, so I didn't actually cover the whole of the last side. So, um, we'll get this SBA Go on down. Hopefully, some of you on wood. Haven't understand. Thing of the sentence scale. Ready? Okay. Give you a few more seconds. They tell you, um, we're on the pole. So, um, all my sort of you got that right. And it was B, which is Sunday. It's got type two, so I hope I can explain it better now. Um, when the doctor taps Tommy's arm, um, he feels a tingling sensation. Three centimeters distal Eat that you did at the time of the injury. It's a This is may hinting at, um, hinting at something. It's called advancing Tinners. So, um, advancing to assign shows the regrowth nerve on at the time for injury. He feels a tingling, say sensation. So cricket is out by I'm just an example. Um, but then as the regresar over time, then you end up getting, um, an advancing 10. Oh, sign. Because you got regrowth. The nerve destiny from the injury. Okay, that actually can see here. You only get advancing to sign in. Sunburned class two and three on since three is non option, then the FDA has to be some dumb part, too. Moving on Teo being composition. Most babies, it's made up of cows. Him crossed first four main hydroxide. Christos. However, a lot of it's also connective tissue Andi osteoblasts class sites on because the water so also clasts responsible for breaking down old bein and they do this by secreted enzymes has been attacked in irons because the break down the bone and then, um, the bone breakdown also releases calcium and phosphate into the blood. So when osteoclasts are working, um, too much, then you can end up having to much cancer in the blood on us. As far osteoblasts, these build new bone. So, um, that largely found in periosteum on the handed groups is well, so the groups of osteoblasts cooled and osteo on. They deposit proteins to for matrix um, on these or so release. Hey, how climb first stays during the process of mineralization. So by making bone, they release LP on that that could be a marker for how much bone is being produced, or what the turnover of bone is like on then Also cites closely linked osteoblasts because they were, in fact, old osteoblasts. Which number is surrounded by the extracellular matrix. So they excreted, and it was thought that they didn't do anything. And they're simply old osteoblasts that now it's believed that they helped communicate with the other cells in the bone and also help to maintain the bone so specifically to maintain that, actually, cellular matrix that they are surrounded by okay, down some conditions. So also crisis, um, refers to a low bone mineral density. So if you don't have um, dense enough bone thrown that brittle and then you're more likely to get fractures so specifically in osteo process, you're at risk to you. Frailty. Fractures on this has been start fragility fractures, and that's when you're full, say, from a standing high. It's new. Break a bone on in a healthy person, you wouldn't be expected to break a bone from a simple full other. If you have pasta process on, you might be likely to break about it. Hand that a few risk factors there for a set process in particular low estrogen. So in postmenopausal woman without taking any hate chart E, then you might get all ST process, and it's very common in females. Post menopausal. Um, as for treatment of patients will be given visiting D and calcium supplements, and they're know also be given bisphosphonate. It's, um so this phosphinates work by, uh, inhibiting osteoclasts say you stopped breaking down isn't too much pain. Um, because ultimately, if you have no bone mineral density, you don't lose any more by and this is an exam question you might get is, um, I look alendronate is a type of bisphosphonate on day when you take this medication and we must take your empty stomach and remain sat up for 30 minutes to prevent a soft generations on. There aren't many drugs that her specific instructions house take that alendronate, this one of them as a Paget's disease. So Paget's disease reverse it overactivity of osteoblasts and osteoclasts. On at least, Teo, the form bones with sclerotic lesion lesions on a little Asians. So when you have and this regulated overactivity of osteoblasts and clasts, then you might get an area where you have lots of osteoblasts. You make lots of bone, and you have one area very dense bone. And then on the flip side of my having area. Lots of lost plastic lasts cause they lots of low density bone on a second See here in the diagram can cause deformations bone absent to the spending of fema on you yet, but I'm paying on if bones in the air, uh, affected you could also get hearing loss. Um, complications as osteosarcoma on I know stenosis, I say sarcoma at serious and has a poor prognosis. And spinal stenosis is also serious. However, it's often responsible to this phosphinates. Um, as you can see in the management, um, just an actual fact in Paget's disease on do you get time? I shan't to sign on. That's the area of thickening in the front of the skull, which you can see um, on the image just to the top right there. And then on the left, you can see is sclerotic lesions. When is brighter bone showing high density both okay on parathyroid hormone. So, um, from your diet supplements and sunlight, um, it's fasting until about the road. If it's Monday. Sorry. Um, you get is Mindy from supplemental diet and sunlight, this congested too, can cause a dye. Oh, in the liver and then it's that's converted to calcitriol by the kidney on. But Calcitrial works to absorb calcium and phosphate from the giant track. An increased osteoclasts activity. So by absorbing calcium, forced the night, Have prostate. Sorry. Um, well, a Z increasing osteo class activity said breaking down more bone, you're gonna get a large increase in calcium in the blood and also phosphate. And this could be used to form new, healthy baby. So that's why but, um in D is good for healthy banks on gas, the parathyroid woman parathyroid hormone is released from chief cells in the parathyroid on Paris bones. You teo high calcium in the blood. So if you have if you have high calcium in the blood, you want to um, sorry. I said hi. Cast in the blood that should say low calcium in the blood. So load house in the blood causes parathyroid hormone release on, uh, that will increase also class activity and also increase calcium absorption from the Gilotrif in the kidney. So in a similar way too busy and d parathyroid home a will increase. Calcium in the blood, however, is different because it actually encourages phosphate excretion. So deaky crease phosphate in the blood. Whereas vitamin D would increase for, say, in the blood just to clarify, that should say low calcium in the butt. Okay, on. That's the calcitonin release and thyroid. Um, this is the opposite, You could say a parathyroid hormone. So this does respond, Teo high calcium in the blood. And that will cause an increase on excretion of calcium and phosphate and also inhibit osteoclasts activity. So if you don't get the osteoclasts breaking down the bone, then you don't get that release of calcium into the blood now onto another SBA. Hopefully, you're listening to that last slide there. What is the function off calcitonin? Yeah. Okay. Few more seconds. Okay. I learned the pole there. Um, I'm glad that most you were listening on. Uh, the answer is, it decreases prostate class activity. Um, so, um, it works by stopping or steak lasts. So it's good. Let's get back to us like, uh, a inhibit osteoclasts. So it prevents the ribs open and phone. Um, it causes cast. Turn him, um, so cast on it. Increase inhibits osteoclastic decreases casted in the blood. Okay on. So, if you if you said um, a increases full state secretion on D. Uh, it does, Um okay, escape. It increases prostate excretion of that, um, secreted. Refer. Teo being secreted from the kidney on. It's not secreted from the kidney into the blood excreted into the urine. So that's not correct on equally, um, increase it excretion. Um, And either way, the correct the single best answer is osteo decrease osteoclasts activity. Okay, Hyperparathyroid is in. So yeah, three main types of hypoparathyroidism. If you get tumor, which causes increased secretion of parathyroid hormone, then you're going to get high. Calcium. Do you see the increase? The absorption increase absorption from the gut and also the increased osteo class activity. And I lied. High calcium and high calcium in the blood, which is? And Simpson symptoms of, uh, bone pain. Um, start show pains, Thrones, psychiatric overtones on very symptoms. The second day. Hope that parathyroidism is due to low calcium. Um, Andi increases parathyroid or homaine secretion. So when you get low housing the blood, um, this causes your body to correctly increase your parathyroid hormone secretion. So this is ah, normal response to the low calcium, and you have high parathyroid hormone But the way to treat it is to increase that calcium because it's no actually issue with the, uh, parathyroid parathyroid itself. How about that? If you get a long term low calcium, you get ah, high demand for parathyroid hormone secretion. And as a result, you get hyper Pazeo the parathyroid gland on D. This means that when the calcium is eventually tracked, it then your parathyroid gland has helped Pleasure. So you and a facet you get excess parathyroid hormone secretion on high calcium as a result. So you have high calcium in both primary and tertiary. A parathyroid hyperparathyroid is, um um than his table Teo. Like half, Um, but in profile so you can see an Allstate process. It's just low density, so everything's normal in osteomalacia for rickets, you get that's low vitamin D. So you end up with the calcium, Um, and then, due to low calcium, you produce high parathyroid hormone, which will cause, um, captain to try and increase. However, you don't have the risk Mindy to allow it on. Do it was they get low phosphate because parathyroid hormone increase his phosphate excretion. And then we still got Paget's disease. That's dysregulated, um, osteoclasts on blast activity. So if you remember me saying osteoblasts, um secrete, um, we'll release our client phosphatase course mineralization of pain. So we have high lasted last activity. You're going to get high, outlined phosphatase. And then we just take about primary hub Paratore. It is in. And then in bone metastasis, you got, um, the breakdown of bone causing the high calcium height for state. And actually, in a lot of cancers, you end up getting high. Calcium. It's the last SBA say a six year old male present presents with bone pain. You decide to get X ray and a bone profile. Yeah, on you notice. And Boeing, um, office tibia, this fella, some sclerotic lesions. Well, pathology, it's most likely. And then you've got some results there. So appears high calcium, normal phosphates, normal and parathyroid hormone. It is normal as well. Okay, it's the last one guy's I'm going to Yeah, going to make section. So yeah, The correct answer is Paget's disease on. Do you might got confused and thoughts osteo malacia because of the burning in the tibia. Make you hoarse nationally. Think brick. It's because of that coming presentation However, because of their sclerotic lesions on this points more two packets and then that's backed up by having, um, the high, um, the high open. Um, say that's high our air p c. Shows that increased osteoblasts activity. Um, where's your PSA again? Patches. Which you wouldn't get. Um, I'm sorry. In osteomalacia, you got low calcium and low phosphate on high parathyroid hormone is, um how's thecal dances patch. It's water. Okay. And I'm even Teo make now. Thanks. You guys listening? Yeah, thanks to be that was really good. Um, she had a short break. Um, yeah. Do you want have a quick break until just before seven? Maybe. Yeah, about three minutes of That's a good idea just to give her a chance to want the loosely Well, problem. Great presentation, Toby. That was really, really helpful. Big up your animations, Toby. Um, thank you. Can you see that sound? Okay? Yeah. Brilliant. So, hi, everyone. I'm sure you know mean why now, Megan, today I'm going to give me be giving you a talk on the spine. And so these are a few things we're going to be covering today on for those of you that are from Cardiff. Here are your, um, learning. Objectives are mapped out for you as well, from your lectures and cases. Well, so let's continue on a little bit with neural physiology that's relevant to this lecture. So starting with the upper and lower motor neuron soap in or Motor Parkway, we have two neurons. We have our upper, and we have our lower. So are promoting yours. They start in the cortex in the outer grey matter of the brain. On that brain matter contains neuron cells. Body's. That's what grade matter is. So the cell bodies off the upper motor neurons have found there. Then the axon of those a promoting your on's comes down from the cortex down the spinal cord into the White Matter tracks. And we remember it's a gray matter is our cell bodies. White matter is our axons, so it comes down in those White Matter tracks and goes into the horns, the spinal cord that you can see here. Hopefully, consumer mouse. Can anyone type in the chapped for me just to get our brain's going for this session? What is the name of the main motor tract that you guys need to know. Yep. Those ones coming in smash it. Guys were down yet? Corticospinal Really good. So within the horns off the spinal cord, you have a small cyst type of cell called the anterior horn cell on these are basically the cell bodies of the lower motor neuron, and they're found in the as kind of central toe, anterior horn of the spinal cord. On that is where the lower motor neuron starts on. That's where the point of which you differentiate in, uh, promoting your, um, from a lower motor neuron. So then that lower motor neuron, as you can see from this diagram, comes out with the Ventura roots of the anterior route through through spinal nerves, into the nerves of the periphery. And then that innovates are muscle to carry out in action. So in certain pathologies, we could have lesions to our upper motor neurons or Lomotil. You rinse, and it brings about certain signs. So can anyone pop in the chapter me some of the signs you might get with an upper motor neuron lesion, anything you like doesn't have to be in a particular order. Anything you can think off that says this is not promoting urination, paralysis, hyper reflexia, brilliant. Any others that people can think off Hyperten. Yeah. Yep. Pretty. And that's a good That's a good start with, um and can you think of any for a low? A motive urine lesion. Now, any signs that would suggest to you that we've got a low motion your lesion fasciculation Zibri in the classic world? Um, active Opinsky hypotonia hyper reflexia. Yeah, pretty and guys. But, um so I've listed the main ones that you need to go here, So let's working through and make sure we understand them. So to start off with both upper and lower motor neuron legions contro muscle atrophy, which is basically just a loss of skeletal muscle tissue. But this occurs of different reasons. So in an upper motor neuron lesion, it's kind of a use it or lose it type principal where because they've got this, uh, promoting your religion. They're not able to use their muscles. And so they lose muscle mass quite simply to someone. Maybe that doesn't go to the gym or doesn't use their muscles quite often. They because you don't use them, you lose them basically. Whereas in a low motive. You're a lesion, you have muscle wasting. And that's because lower motor neurons release special factors called neuronotropic factors from the ends of those nerves, which basically help to support the muscle. They're basically like supportive proteins on If you have a lower motor neuron lesion, you don't have those supportive factors being released on. That is what causes the muscle to waste away. Basically, many of you guys also pointed out Sorry, pointed out particular a shins. Let me get out. Sorry about that. There were many of you guys, also pointed out particular a shins that's correct on. So for Circulation's occur when a sickly the distal end off a lower motor neuron so past the point of a lesion. If there's a lower motor Neural, Asian on fires, action potentials quite spontaneously. And what that does is that causes small, involuntary muscle twitches in the Marshall muscle like small contractions. But because you're only getting these like small little firings of electrical impulses, it doesn't generate enough electrical potential to cause the muscle to fully contract and generate a four movements. It just creates these little small movements in the muscle. Then agency both upper motor motor neuron and lower motor neuron lesions have a decreased power or weakness on, but it's because the muscles are receiving that signal to contract or they might not be receiving a signal. It'll when you're trying to do a voluntary movement. And so um, and that basically means that you become weak basically then in terms of tones. So in what is tone tone is basically produced by a baseline level of contraction muscle fiber when it stretched. And so for muscle fibers, relax. That's not not the case we talk about. When they're stretched too much muscle, it will contract just a baseline level. And that may need because from low motive you're on stimulation. So in upper motor neuron lesions, you can get either spasticity or rigidity on. This is quite some. This is something that's quite like confusing and easy to confuse. So I thought it's mention time talking through this. So spasticity spasticity is velocity dependent on. That basically means that the faster you move a muscle, the more the muscles suddenly becomes resistant to further stretch. So you would if you move it quickly. The muscle kind of stops quite quickly as Well, um, whereas if you move the muscle slowly and you slowly moved it, it it would be fine. It would move in it. You wouldn't see that increased tone, whereas with rigidity, that's velocity independent. So that basically means, no matter how old far start slow. You move the muscle, you're still gonna have that increased home. Basically. Then if we talk about your reflexes, so many of you guys had an upper motor neuron. We get, um, hyper reflexia on in low motion. Um, we get hypo reflects your reflex here, meaning you don't get reflex elicited. It'll everything about how a reflex comes about. It's basically when a signal is picked up from a sensory receptors in your pro free and it's passing all the sensory neurons to your CNS eso, usually the spinal cord. And then what happens is it loose back around into a lower motor neuron lesion to supply that muscle to elicit whatever reflex you need to do where they need to move your hand away from a flame or whatever you're doing. But what's key to remember is only lower motor neurons are involved in reflexes. Know promoting your legions know are promoting you're on. Sorry. So the role that upper motor neuron plays is to basically inhibit lower motor neurons by a process called descending inhibition, which is basically what it says on the tin. When are promoting you're on will basically inhibit any low motoneuron signals in those reflexes. So if you have a lower motor, your lesion, because they are low motors and mainly using your reflexes, you will get our hope, your Effexor and a reflex here, depending on how bad of the lesion. How about the lesion is, um, whereas if you have an upper margin urine lesion because you're know the lower motor, yours aren't receiving that inhibition from the upper motor neuron You, you're low. Much in your ears will create really big reflexes, so you will get a hyper affects you. So let's test how much you guys know as a Honda said, these videos aren't mine. They are on YouTube. They're being used for teaching purposes only. But I thought they were quite good at demonstrating the topic. So I'm going to show you a video, and I want you guys to tell me what it's showing on whether it's an upper motor neuron or Lomotil, You're on site. So here's the first one. He tell me what that is and whether it's a, uh, upper or lower motor neuron sign violation. Yeah. Brilliant. Particular Asians. Lower motor neuron. Yep. Brilliant. Guys were done yet so you can see these little small, tiny contractions on. That's your situations that you can say, ready in sight, Moving on to our next video. So this is a gentlemen where his media reflexes being, um, tested. So that was his left left limb. And I want you to focus on what happens with his right him when he goes to test this one. So what's that showing you that? And is it alone? Might in your honor and upper motor neuron sign Upper motor neuron yet? Yeah. Hyper flex. A yet. Well done, guys. Yep. So you can see in this one is quite normal is a tiny little reflex you can say, um but when he doesn't some, it's quite a big need. Your reflex good on our final video. Any ideas? What? That one. Is that what that showing? And is it up motor? You're on a low might in your upper. Okay, do they won't know what it is having rigidity where you mix of rigidity and spasticity. Yeah, one of those is right. So let me explain. So this is an example of spasticity. So remember, spaciticity is the lost two depending dependent meaning the faster you move the muscle, the more on the muscle suddenly becomes really resistant to movement. So we watch this video from the start. You can see he moves his lymph quite quickly and it suddenly kind of stopped moving. It becomes very resistant before the stretch. If he doesn't quite slowly, you can see that the them doesn't have as much issue moving. And that's why it's spasticity. It's well done. But it's another thing that comes up on exams. Really commonly is your dermatomes your mind turns and reflexes. So let's go through these. So a dermatitis is basically an area of the skin supplied by a nerve from a single spinal route. So the nerves are coming off the spinal cord. Um, in our skis are skis and also in our exams. We need to know how you test the different dermatomes. So can you guys tell me in any order you like for the upper limb. Dermatomes. Where would you test them? What site would you press on? A patient to test certain dermatomes and starting with the upper limb. So maybe see five. Where would you test the five? The actual up around? Yep. Any other suggestions behind the elbow? Shoulder. Okay. I think you guys have got the right idea. So Yep. The main place that we would take test it is the lateral elbow. Any ideas? The C six next one where we tend to test here. Any ideas for C six where we test some thumb black hole for, um hum. Yeah. You guys got it. So it's the dorsum of the thumb where this little stars here. So on on the backside on. But way I remember. This is if you make a six shape with your left hands like this, you're touching the tip of your film and your index finger together. So that's how I remember the test C six C test on the thumb, so I'll go through these quick, quickly. Um, so you have C seven, which is tested on the dorsum, uh, surface of the middle finger or third digit. You then have see a on the dorsum of the pinky finger with 50 gypped and t one, which is on the media elbow now for our level, um, we tend to test L2 in the upper thigh on the medial side. Then we tend to test out three on the medial knee. Um, l fall in the medial malleolus L5 in the web space of the big toe and Onda. I like to remember this as L5 is being test on the big toe because it's the largest off the five toast, So largest of the five L5 is on the big toe and then s one is on the lateral malleolus and then for all my tones, sadly, these are things you just got it. You guys just have to learn. I would recommend doing the movements to learn it. And so the couple in flexi elbow extend the rest, extend the elbow finger flexion, and then finger abduction for the local. Um, the way I like to remember is it's a bit like kicking a football eso. If you were going to keep a football, you reflect your hip, then you would extend your knee. You would kick up words. Extend with your big toe to point it towards the ceiling. And then after you've done it, you would put your foot on the floor so you would plant plantar flex at the ankle. And then your reflexes are important. To know is, well, there's the 1 to 8 rule. So if you look at the the vegetable that was that used the of 1234567 and eight, you're different. Reflexes on 1 to 4 are involving the leg on 5 to 8 or involving the home. Okay, so related to that is the Asia chop. So the Asia chart is basically it's the American Spinal Injury Association. That's what ages stands for on They basically created this scale, um, or castigation system that is used to classify a spinal cord in injury. And it's basically an internationally standardize neurological examination used by healthcare professionals to basically assess the sensory motor levels, which affected by a say, a spinal cord lesion, and that really helps to localize where the lesion could be. So what you guys need to know if you ever see these is, it has a dermatitis. That's, um a little one I showed on the previous slide. And it has the points where you should check sensation for both life like touch and pinprick sensation. When you're doing one of these examinations, um, it also has the Meyer terms on there for you for the upper and lower limbs, in case you forget as to what's each of the actions are for each of those spinal levels. I'm another thing I want to point out that, um, wasn't included on the previous dermatitis side is some other dermatomes that might come up in exams. So t four is that the level of the nipples see six is that the level of the different process on the umbilicus is the level of T 10. And the way I like to remember the last one is your umbilicus is your belly button to remember that as belly, But 10. So belly, about 10 being t 10. That's the way I remember. So that was the front of the Asian shot. This is the back of the aging shop, and you don't really need to know this in too much detail. But I just want to point out the grading for both motor and sensory function. The main one you need to know is the motor functions that ranges from 0 to 5, where zero is total paralysis of limp or the muscle. Your testing one is a small, visible contraction, so I called for circulation's that we showed earlier. Two is a full range of movement, active movement. The patient can do it on their own is basically when gravity is eliminated, too. If you were moving your limit kind of transversely in a horizontal line because you're not fighting against gravity, you're doing it in a straight line. Um, number 33. Grading is probably the one that your best need to know, which is when someone has active movements that could do it by themselves. They have a full range of movement on. They can do it against gravity is they can do it in and up and down. Motion four is next, and that's when they can do it against some moderate resistance in a specific direction. So they're doing a movement. It's almost put a little bit resistance on. They're able to do that, but they can't do it against a lot of resistance on then five is your CA normal range of motion. You can do it by yourself on, but you can dose of full, normal resistance. And then your said, three grading is just not to so not being absent to being normal on one, basically meaning that you have altered sensations either your hypersensitive or you have decreased sensitivity. So our first S p. A. You have been else to perform a lower limb neurological examination on a 54 year old man who has sustained a spinal cord injury on testing his motor function. He is unable to point his toast with seeding on tapping his patella tendon, his knee kick forward very briskly. Which of the following hours on his lower limb would you most expect an abnormality based on your neurological findings so far? So I've given you a clue about what my home is impaired. What reflexes impairs. Can you work out what damaging that corresponds to? If it helps to write out well, feel free to go pen and paper and quickly right and dropping down. I'll give you another 15 or so seconds, and if you're not sure, give it a guess. You might be right and you learn more if you get it wrong. So don't worry too much. But, Papa, guess in right. I'll get five more seconds, right? Okay. Going to end the pole there. So the majority of you did get the right answer, but there was a bit of a split, so I will explain it. So the answer was See? So in this question, it says the patient is unable to point his toes to the ceiling. So that suggests Dorsiflexion. So he's unable to point is kind of all of his toes up, not just his big toe, but all of his toes. So that suggests a problem endorsee function. Then it says that his knee kick forward very briskly, so that suggests some things impaired with the knee reflex. Which, as I said before, is L3 out full from a 1 to 8. So because we've had a lesion in l three L4 on out for for the my time were probably thinking the most likely dermatitis to be affected is helpful. And you remember from the map, I should Julia the best place to test that is the medium, and I notice So I hope that makes sense. Well, don't all of those you that got that right, Andi, if you didn't don't worry. I have a look back at the slides on Gets should hopefully make some sense. So our next topic lumbar puncture. So landmarks of the spinal cord so we will know the spinal cord. It's basically a cylindrical bundle of nerve fibers within the CNS that extends from the medulla. The bottom of the brain stem to are lumbar vertebrae and in lumbar punctures, I think has three main landmarks off the spinal cord on disassociated tissues that you that relevant to lumber Bunches that you need to know. So does anyone know what the Conus Medullaris says? Can anyone pop it in the trap for me? I've also had some questions through I'll Do the same is Toby and aunts them at the end defense. Okay, I will get them. I will, Yeah, tape, tape it. Spinal cord Jeopardy! And so it's basically the most inferior point of the spinal cord, where it's really tapering to an end. Yeah, really Well done. So does anyone know what vertebral level the spinal cord terminates in an adult? So what kind of vertebral level didn't stop. Oh, yeah, you guys about it? Well done. Well, one L2 brilliant. Does anyone know for a child? What vegetable level does it terminator up? Well, three or four. Brilliant. Yet really good. And does anyone know why it terminates lower in a child? Out of curiosity, does anyone know that because of the shorter spine? Yeah, that's the right idea. So and as a child grows, basically, the vertebral columns of the actual bones grow a faster rate than the spinal cord doesn't. So the bones are growing faster than the cord. So if you imagine as you grow, the cord will move up. Um, more quickly in comparison to the bones on when you're a child before that growth takes place, your spinal cord is closer in height, if you like to the vertebral column itself. And so that's why it terminates a little bit lower. Yeah, really Well done. Then we have the quarter a quarter. So this is basically a collection of spinal nerves that are suspended in the CIA cff for the cerebrospinal food below the level of the Conus Medullaris on this is known as a horse sale, just because of how it looks, which I will show you in a second. And then we have the the phylum terminal A. So this is basically an extension of the P, a matter which will go into in a second, which extends from the spinal cord, the end of the spinal cord to the sacred and the coccyx on. The function of that is to anchor the spot spinal cord in place. So here's a little picture so we can see our Curtis. Medicare is here. We can see our quarter acquired all these small, thin and herbs here coming off looks a bit like a horse's tail, and you can see just about the film Terminal A, which comes right down to the coccyx. So now we've looked at the court itself. Let's look at the meninges that cover it. So you'll remember this slide from the last previous the session that we did. So we remember that the meninges, other three membranous coverings of the brain and the spinal cord Um, I showed you the side last time. Does anyone know which of these layers? So of the four that I've shown the two of the jury, Marta the Iraq robot in the PM Marta, Which one of those is no found in the spinal cord? Three of them are but one of those 41 of these four isn't. Does anyone know which one had a huge suggestions of PM Alta Your, um, art of peri A steal period. Steel. Yeah, Well, don't hold of you guys that put barriers. Deal. That's pretty really good. So, yeah, the periosteal ear is not found in the spinal cord. Um, the periosteal day. If you remember from last time, it's very adherent to the skull. So we just don't have that in our spinal cord. So if I change your labels So we got rid of peril stool A, uh, let's change the label so they now show what it looks like in the spinal column. So we have all three layers against. We have our jury. Marta are out. Mostly er, it's quite adherent to the spinal column this time. Um, and the, um it's a tough five restructure, and that's really important on the outside. Then we have our record martyr, which is the middle, thin, delicate membrane on. We have the PML, which is the innermost in there, and it's very adherent to the spinal cord itself. On, um, another thing to know about the PML toe, which was really important and you might see in SPS, is between the nerve roots. So between where the nerves come off of the spinal cord, the PMR is actually thickens on it forms something called think then to kill it Ligaments, which you can kind of see on this diagram here by this purple bit, um, on the den dentist cure it ligaments attached to the jury, Marta, and suspend the spinal cord in the versatile canal. Um, so basically, make sure that the although the fill in terminal is keeping the spinal cord and kids kind of centrally and in the canal if you like. This is making sure that the spinal cord is I'm kid on either side and Canadian. Remember from last time? I'm sure you guys do in which space is the CSF round? Keep up in the trap Pretty quick. Subspace. Which subspace? Several records base yet Ready? Well, dumb. So another thing that's really important to know is the ligaments of the spinal column. So this is a little diagram of drawn So just to orientate you a little bit here is the vegetable body. Then we have the pedicle, which is this kind of white section here. Then we have the lamina, which Toby spoke about earlier. And then this pink structure is the spinal cord on. We have these little small spinal nerves coming coming off of it. Then we have the interval Vertical Framan. Which of these kind of circles here, Whether spinal nerves except and then we have the spinous processes at the back here. So could anyone tell me? I shown you buy the different colors, but can anyone tell me the five main ligaments that you find in the spinal column? Any order? Whatever ones you remember, test yourself and see which ones you you know, ligamentum flavum goods into spine issue yet and here and posterior long. Did you know? Brilliant. One more someone know which one it is. Super spinous. Yeah, pretty. It wasn't guys. So we have our until you're due to, you know, ligament down the front and this runs in front or anterior to the vertebral body along the entire length off the vertebral column because it's a longer treating or ligament and are longitudinal ligaments run the whole way down. This is quite thick, and it prevents hyper extension of the vertebral column. So if you imagine if this wasn't here, you would be able to extend your vertebral column and mean back quite a bit, so basically prevents that. Then you have the posterior longitudinal ligament, which is basically the same. But it runs on the back of the vertical body's this time and it prevents hyperflexion. Then we have the ligamentum flavum, and this extends between the lamina of adjacent vertebrae. Um, them. As you said, we have the interstim unit, which, as the names just is between but intermediate between spiral meaning spine ISP processes. So it's between the spinous processes of adjacent that spray. And then we have a super spinous ligament, which once again, as the names just runs between, um or above, if you like, the spinous processes on the tips of them of adjacent vertebrae, and that's the most superficial or ligament that you have. Another one that isn't on. This diagram that you may be tested on but is less common is the into transversally gum int, which once again the name tells you it's function extends between the transverse processes over Jason vertebrae. So finally, too long Book on for what is a lumbar puncture. So it's basically a procedure involving inserting a needle into the separate fluid space to obtain a sample of CSF that's usually to get a diagnosis. For example, meningitis or a separate code hemorrhage. Um, so when in 30 lumbar puncture your you need to insert it below the level of the spinal cord so below the level of the components. Mental arrest because below that level, you have the quarter quieter, and those nerve fibers that form on the quarter minor can move out the way quite easily the needle so they're not gonna be damaged. Whereas if you put the needle up too high and you hit the spinal cord, that's a fixed rupture and can't move out the way. So I've asked this before, but let's test your knowledge. What level does the Conus, Medullaris and, uh, in another L1 L2 brilliant? And in a child we said was out three or four. So to make sure that we don't hit the Conus medullaris so any of the spinal cord above it. What we want to do is insert are needle slightly below that. So in an adult, we insert a l Street, L4 L5 sorry. And their child, we insert. It s five l l five s one. So put that on the sides of in an adult. You answer helpful special five. Their child L5 s one. You know, in another, um, who you probably most commonly do a lumbar puncture on. If you're going to do one, you need to identify the level L4 L5. Very well. So what they use is something called, um, toughies line, which you can see on this diagram. Here. It's basically ah, horizontal line between the top of the eye like I'll be at crests. So if you were doing it on a patient, you would feel for their pelvic bones. You feel for the eye like crest on. That's the vegetable level where you want to go for, and then also, you guys really need to know the course of the lumbar puncture needle as it goes through as it goes through the the various different ways. And so I'll let you go through it in your own time, but it's skin, subcutaneous tissue or fats. Then through that super spinous ligament into spinous ligament through the ligament and plevent. And then we get to a woman in juice or epidural space, your Amartya subdural space, or actually Walter into the subject. Or it's based. Remember, it doesn't pay us the P Amata. So next six s p A. So you've been asked to perform a lumbar puncture on a female with suspected meningitis? You hear the final pop as you pass through the last ligament in the nose, cause which part of the lumbar puncture needle course have you know, reached? You've passed through that last ligament where you know, when you've gone through the ligament? Okay, I'm going to end the pole there. So the majority of you went with a I'm afraid that's the incorrect answer. Apologies, guys. So the correct answer is actually he so in this question, it says you've gone through the final pop and you've passed through the last ligament. So we look at are ligaments again. You would have passed through the skin through the subcutaneous fat through the Super Spinous ligament, which is in red through the into Spinous ligament, which is in yellow. And you just passed through the last ligament, which is the ligament and flavor. So we've gone through are ligaments Now, Now we're getting to the meninges, so we're gonna get into our Your amata are actually master of pee a lot. And sorry, the periosteal one should be on there. So you're going as to say, from the ligaments to the meninges on before you get to the jury. Mata, you get to the extra dural of the epidural space so you haven't quite reached the subarachnoid space yet. Eso Just remember, as you're part of the ligaments, you get these three pops on because you've passed through the last one. You must be through the ligament and flavor, and therefore you must be heading towards meninges on. You'll be in the extra or actual space. So I heard that makes sense. So now, on to some very quick spinal radiology, that's quite a complicated topic. So I haven't gone into it. Loads. Um, can you tell me super quick? What type of image is this? What imaging specialty. Is this in the trap? Well, image of I taken the CT MRI Brady A graph? Yeah, on X ray. Pretty it. Yes, it's an X ray. What's good about X rays? Well, that quick that quite easy to do that cheap. If you're trying to look at bone, they're really good at bone. But however, they give you a two D image on deviously because you're using X rays, you have a lot of iron eyes. Ingrid E. A shin that you're exposing to the patient on as you can kind of see from these images here. It's not very good at showing you different soft tissues. You can't really tell the skin from the fat and all the other things that going on anything. It's really good. It's showing you is bone. So let's test your last May. So can anyone tell me in the chat? What is this Pointing up vertebrae? Well, what part of the vest breakers since I told you the vertebrae? What is the name of that specific one? Yeah, brilliance is the spinous process in your bottom. Someone's got the right answer in the chapter. So is the vertebra. Prominence s so this is a really important one to know when you're looking at radiology because you wanna be able to orientate yourself when you haven't got lovely labels and diagrams like this, so your vertebra prominent is basically, if you feel the back of your neck, you can feel a spinous process that's quite prominent as length. Guess on that is your C seven vertebrae. So yep, that's fine. This process there, which is a bit longer than the rest is you can see that's the vertebra prominence. What's that on the image that that would put you at? Now it's it's see one. But what part of see one posterior arch? Brilliant. Yeah, really well done is the prostate or arch of the apus. So just remember, see one doesn't have a spine is protest. So even though this looks like a spinous process, it isn't. It's the posterior arch next hour. This is a general term, nothing specific about this vertebrae. But what part of the vertebrae that Toby talked about earlier is the arrow pointing up to the spinous process? Pedicle that kind of thing. What is it pointing up? Yeah, I've had some correct ancestry. It's quite hard to tell. To be honest on Be a is pointing at the Transversus process specifically of C four. Okay. And then this hour here, this space here. Can anyone tell me which nerve exits in that space? Use this diagram to help you? Because it's got the labels of vertebrae. Did anyone tell me what nerve is going to exit there? See 77? Okay, I may be getting C seven, which was done. That's correct. Answer is C seven. So that's another high your point. You guys will want to know. As you know, we have, um, seven cervical vertebrae, but eight cervical nerves. So where a nerve is labeled based on the vertebrae? It's named after changes at the bottom of the Vicodin spine. So if it's above sea seven. The nerve roots it's above the vertebrae that it's named after. So in this case, this is the kind of exit Um, that's above the C seven vertebrae. Citizen. See somebody for here is You can see here and it's extinct. Buff. So we said above sea seven, which this is the nerve root sits above the vertebrae. It's named after. So this C seven nerve roots. It's above Sea seven, which is named after the see a nerve roots. It's under the C seven vertebrae and then below t one. The nerve roots. It's below the vertebrae that it's named on after, um, so the T one nerve root sits under the vertebrae. T one. I had them a sense. Another thing that comes up in exams with the cervical spine is it's alignment have drawn on here four lines that you can use to assess It's alignment. You have the antirougeurs. It's borderline, which is until it to the vegetable body posterior vegetable line, which is posterior to the vertebral body. The spinal lamina line, which is basically the interior edge of the spinous process. On the posterior wrist spice line, which is the tips of the spine, person sees so to see if there's a fracture or any misalignment malalignment. These four lines should be smooth if there's any steps in them, so it jumps out as a vertebrae. It's not sitting right when you draw these lines. That suggests that there's a pathology going on. So, for example, fracture um subluxation, which is also known as a partial desiccation or a dislocation completely due to trauma. So great job. So then you often get exam CT's and MRI's can anyone putting the chapter? Which of those two is the CT? Which one is the MRI? So left. All right, Right. His CT. Anyone? Other thoughts? MRI left CT, right? Yep. You guys got it yet? The CT scan is on the right here, and they're MRI's on the left. So in terms of MRI, MRI is really good, As you can see at delineating between different types of soft tissue so we can see our ligaments that different our skin off at eight cetera. So I've drawn in our here another anatomy question. Can anyone tell me what vertebrae that is if you have to give it number, Okay. Have have an answer in? Yeah, cup of answers. Yet I think you guys have got it yet. Or five. Yeah, really? Well done. That's L5 Onda. You can tell this is our five, and I like to tell it because it's the first one with an individual disc in between. And it's also the one that's kind of that's slow pee angle. That's how I tend to tell. It's all five. And so I've labeled all the others. Therefore, you hopefully that's helpful on these cysts. and things that you should really know about MRI's before your exam. So it's some of the consequence indications I won't go through them all now. But what I will say is metallic objects is quite a common one to be asked. But do be aware that some new pacemakers are not contraindicated in them or any more on in practice. What they do is they have a questionnaire that they go through with patients to basically check that they haven't got any other country indication to an MRI before they actually go into the scan on then. The types of memory sequence is also a common exam in so t two are fat is bright and our water is break or is the 91 or fat is bright, but water is dark, So the way I like to do two different is if I was to get a lumbar spine looked for the CSF because that's mainly composed of water. Um, so in this case you can see the white here, which is you can see the white of the CSF kind of hair on the on the back, so this suggests that is a teaching sequence and This is what the CT MRI Sorry, useful for? And then finally a CT. These are the properties of it. Here they are, say a bit fast for the memories they take about 10 to 20 minutes, which is a bit quicker than animal rights on there's some other properties that for you to read on your own time side next. SBA. You've been also look at a 66 year old males Emory Lumber spine. You've been told that the nerve extinct, the level marked by the error has been damaged, which now has been damaged. Brilliant. Lots of right answers coming and keep it coming. Guys, you don't really well. And if you don't know, think about what we said before thinking about logically give it a guess. I'll give you five more seconds cause a lot of you getting the Royals, which is really, really good and really promising. Okay, I'm gonna in the poll there, so yeah, the majority of you put see is the correct answer, which is the correct answer. So, as I said before, if you're above sea seven, the nerve roots, it's above the vertebrae. It's named after Onda in below T one the nerve. So that should say no Ovary sits below the vertebrae. It's named after so in this case. So if we work through So we've got hellfire, which is I want a bit of a stand Yanga, which is this one on? We've got this therefore being L4 and this one being l free. So we'll look at the nerve. A. It is between L3 and L4. So, in this case, because we're below the level t one the nerve roots it's below the vertebrae that it's named after. So, uh, between L3 and L4. This nerve roots, it's below the vertebrae it seemed after to the vertebrae above it. In which case is L3 so well done, everybody so understand spinal pathologies. So that's talk for the red flags about things. This is quite a common example is well, so what is a red flag? So red flag is basically when you take a history probation, it helps you to identify the something serious of sinister is going on. In the case of back pain, something sinister is causing that back pain like a malignancy or compression of the spinal cord. something like that that's causing the back pain. That's a bit more serious than just, ah, muscles, brain or something like that. So it's these cruise that we get in our history. So I'm gonna flash ups. Um, potential Replax. I want you guys to let me know. Is it a red flag or is it no So pain overlying the t nine vertebrae? Is that red flag or is it? No, just pop in the chat red flag, not red flag. It's like no and no, you're okay. Okay, You make some. This one? Yes. We'll get a mix of yesterday's. Okay. So pain overlying the T nine vertebrae is a red flag. I like the use of the actual red flag in the chat. That's very cool. Um, so yeah, because it's a explains more in a second, because it's a thoracic vertebrae. That would be a red flag. Know, Going to explain that more in a second pull coping strategies, so patient doesn't coat very well with stress. Is that a red flag or is it? No, no, no, no, no, no, no, no. Yeah. Okay. Lots of notes. Pretty and yeah, this is not a red flag is something called a yellow flag, which is basically something I'll explain more about shortly. But it's more of the psychological factors that play into a patient's back pain and how well their coat with treatment and things. But it's not a red flag. It's a yellow flag. Pretty and yet, And someone put you on a Friday and tackled, um, fever red flag. Well, no red flag. Yes, Yes, yes, yes, yes, yeah. Brilliant. Both guys pain when sitting still. So when you're, um, breast Yes, yes, yes, yes, yes. Pretty. And yep. So that's a good flag as well. An absence of history of trauma or injury. So there's no history of trauma, No injury. No, no, no, no, no. Yeah. Brilliant. Yeah, well done. So yep. That's not a red flag. Because if there is a history of trauma or injury, that is a red flag of them. Closest. So we talked about the different directions. That's fine. Moves. No, no. Yes. No, we've had a bit of a mix again. Any last few? Guess is yes or no. No. Okay. This one is a red flag. Um, and always say more about that in a second, An 18 year old with new onset back pain, red flag or not reflect? No. Yes. No, no bread fly, you know? So a bit of a mix. But I think leaning towards No. Yeah. No, that's not replied. Our been a bit cheeky. The technical technical criteria that you see in a second is a 16 year old less than 16 year old with new onset back pain is a red flag. So we're just out of the range is this is not a red flag. And finally, a past medical history of cancer. Red flag on all. Yes. Yes, yes. Yep. Those messes. Well done. Christ yet So yep. That is a major red flag. So these the list of red flags of back pain that you need to know. I'm not gonna go through. All of these are You can read them in your in time. But as a general rule, young and older patients with new onset back pain is generally a red flag. Any non mechanical pain? So mechanical pain is basically any type of pain cause by when you put in excess stress and strain on um, and the muscles of the vertebral column Basically, but non mechanical pain occurs when you're sitting still. So you're getting a non mechanical pain when you're sitting still. But you've got back pain that's more of a red flag, as we suggested before bar first one. Thoracic pain is a red flag because the thoracic spine doesn't tend to move, You know, from your, um, spine of examinations that it has less kind of movements that you can do compared to your lumbar and cervical spine. And so, if there's pain there that suggests a more serious pathology turned any spinal deformities is also the kyphosis Lord does is scoliosis of the natural deformity in the spinal cord. There were red flags, a swell Let's quickly start working through some pathologies, so musculoskeletal, non specific back pain. So this is basically when I person has pain in the lumber, say cool area of their back, so overlying there'll, um, lumber and sacrum off this fine on gets mainly accepting anywhere between the lower margin of the ribs to your pelvic bones. Basically, and this is something called a diagnosis of exclusion, where basically need of all that all other courses of back pain rule out any serious pathology is using our red flags that we just went through to diagnose someone with this and it's it's diagnosed when you can't find an underlying nociceptive stimulus that's causing the back pain so you can't find any reasons why. You know, see sectors that are picking up those stimuli are being set off. You don't know what is happening. It's a really common presentation as well. In medical practice effects the majority of adults during the lifetime, and I know my GP present. I see a lot of people with Ms K type back pain, so risk factors you have if someone's obese. If someone has a sedentary lifestyle, is they're not moving around very much. If they have an occupation that's physically demanding or the during heavy lifting, that's a risk factor. If someone has mental health problems. There's a lot of research and interesting ideas about how our own mental health effects how experienced pain. Um, so if someone has a mental health problem, that can be a risk factor. Other co morbidities smoking lower says you economic status. They can all manifest and be risk factors for um, SK. A non specific back pain are signs and symptoms are here. So it's Germany and the number sacred region. It's a gold comes on gradually. It's an ache. It's made worse by moving and it varies. Posture and most importantly, haven't got any of those red fax symptoms we talked about on. This is how we manage it. So we even though you think pain, I don't want to move it. We recommend you move it, do lots of exercise, do some physical therapy if you need it on because they use instead a swell. And this can last 4 to 6 weeks. But often patients will have this, either chronically or quite recurrently is less. It's a major problem. Okay, so then we have three pathologies here. I'm gonna try and summarizes in the best I can, because I think that, um, pathophysiology can be a bit confusing at times. So let's start with neurogenic shocks and you're a change. Shock is basically a state of inadequate tissue profusion and oxygenation off the tissues do to reduce sympathetic outflow with unopposed vagal time. So that's break that down. So you have a sympathetic nervous system, and that's the division of your autonomic nervous system, which controls your automatic function, so your fight or flight response specifically the nerves that are part of the sympathetic nervous system originate in the thoracic and the lumbar sections of the spine and spinal cord, Specifically between levels. T one toe L2 what you can see here on if someone has Nugenix short it usually because, um at the level of t six or above. So a Z I said the sympathetic nervous system nerves are between these levels on what they do is they cluster there cell bodies in the peripheral nervous system in structures called sympathetic ganglia. Um, some of these ganglia come together, and they formed this chain that you can see. I've tried to draw out here, which is basically loads of interconnected ganglia together. And we call this has the name is just the sympathetic chain on. That's how quite posted spinal court. So from here on, the sympathetic nerves from the ganglia then travel out to the organs that they're talking about is the heart. But best is acceptable. So we know that the sympathetic nervous system fight or flight among many other functions, it stimulate your heart to beat really fast early stimulates vasoconstriction in your blood vessels to get them to vasoconstrictor. No, a neurogenic shock. You have a spinal cord injury which basically reduces the amount of sympathetic outflow that you have from the spinal cord. So these organs that we've just shown here that normal getting a sympathetic stimulation don't get anymore. However, your vagus nerve is doing just fine. Your vagus nerve, your parasympathetic nervous system nerve remains active. So think about this. Now, if you pop in the chat if are sympathetic, nervous system is gone on our Vegas system, it vagus nerve is still working. Can you tell me what effects you're gonna have? Unopposed, Vagus nerve stimulation on the heart and blood vessels. What's gonna happen to the heart rate and what's gonna happen to the degree of dilation of the blood vessels? Bradycardia? Yep. Onglyza dilation. Yeah, brilliant guy's brother. And it's mushed up. So yeah, Frederick, you get a bradycardia because your vagus nerve is being stimulated on your blood vessels are gonna be's. I donate as well on. That's what causes the shock because your vasodilator your BP is going to drop eso you're not gonna get that perfusion to your end organs. And how do we manage this? What we use drugs that called vasopressin and vasopressin, basically drugs that work to perfectly vasal constrictor. So that helps to basically oppose the vagus nerves vasodilation and constrict the blood vessels again. That's Nugenix shock. Then we have spinal shock, and this is basically an altered physiological state immediately after a spinal cord injury on it basically presents as a loss of spinal cord function below the level of the injury sentence of your sensation, your motor function reflexes. Um, this tends to occur. You can have a spinal cord injury anywhere in the spine. With this one doesn't have to be a certain level on what that does if you think you've injured do spinal cord. That's kind, of course, and bleeding. And it's gonna cause some information at that site on when you get that bleeding. In that information, you can get damaged to those tissues because we know you anywhere in the body. If you get damaged tissues, you're gonna release chemicals on. In this case, you release up surveys of constrictors. Eso. What that's going to do is you release these chemicals that be's a constrict your arteries that supply your spinal cord on what happens is when those azo constrictors do their job and vasoconstrictor your arteries constrict and you get skinnier off the spinal cord. Um, that little leads to hypoc Sierra ischemia. As I say, you basically get a shot down on the spinal cord because you're not getting that blood flow to it anymore. And that's what causes your ordered sensation. Motive. Function your reflexes. Only the spinal cord is affected here. Know the whole nervous system like we had in Neurogenic shot where all of the sympathetic nervous system went down. It's just at the spinal cord itself. So, um, you can tell basically how shocked the spinal cord is, if you like. Based on how well patient regains their function, which I've written here on, do need to assess them, using their dormitories on my terms of the reflexes on a chart to see where the level of injury is. Does anyone know incomplete in the trap? What is the lowest reflex that can be tested clinically, um, that we would use for, say, a spinal shot to work out where the level of the lesion ist? Yeah, brilliant. Yeah, I've had a few guns come through to me. But we'll have a nisus. Yeah, really Well done. Yet this is basically a reflex, which is the lowest one you could test. Clinically, it's basically a contraction of the anal sphincter when you squeeze the clitoris or the brands Penis. Basically. So that's final shock. Finally, autonomic dysreflexia. So this is a syndrome where you get a sudden onset of Vicks excessively high BP. Um, once again, this is an injury from T six or above. So in this case, what happens is you have a very unhappy bladder or bowel a Z concede here, so that could be due to fecal impaction. Um, your attention. A UTI the catheter that's really annoying Your bladder. Know the different things on your bladder, basically, or your bow. Send signals that enter the spinal cord to travel up to the brain to initiate response to get rid of any feces that's impacted or pass urine. Anything like that. To get rid of that stimulus basically know in these in these patients is to say, there's a lesion around about T six or above. It stops, stops the signal going up to the brain to tell them what's going on. Eso it stops at the level off the spinal cord injury on. When it does this, you're having this signal that's coming up on. Obviously, it's got electrical activity. So what that does is it it stimulates local sympathetic urines on? As we said before, your sympathetic euros will cause basic instructions. As you can see here, so increases your systemic vascular resistance on because your BP to rise, which is why you get the success with the high BP. No, your BP is you guys will know is detected in many ways, but one of those is the barrel receptors that we haven't talked about it at arteries in your neck. Um, and those Aricept is we'll go hang on. The BP is really, really high. We need to jump on down this BP right now, so they are stimulated on what that causes the vagus nerve to be stimulated on. It causes a bradycardia of the heart. The heart starts to slow down in its heart, be in the aim to try and lower your BP. So that's what you'll see in a sign and symptom of those patients. You would see that they have high BP because that raises constriction. They will have the bradycardia, but they also get some of these other features as well. And that's basically because you have sympathetic, um, nervous system stimulation below the level with the lesion. Because this signal is coming up, your parasympathetic signal is coming up. It can't go past the lesion on it's setting off. All these sympathetic urine's in your the record number region on your brain and other areas of your body is detecting that sympathetic nervous system stimulation. And they're going to kind of we want more parasympathetic so from the brain, it sends signals down to say, Hang on, that's dumping this down. Send the Paris and sympathetic signal so everything above the lesion is gonna be a parasympathetic response. Everything about a below your lesion is gonna be a sympathetic response. So that's why you get the flushing the headache in the sweating because you get a flushing because of the days of dilation, of the professors in the face to try and calm down so that you don't because that sympathetic stimulation, um, you can get headache and you can get sweating as well, which can be stimulated by your parasympathetic, uh, nervous system. And the way to treat this is basically just to remove the stimulus Onda treat them for the hypertension, the body cardia. So next few people. Geez, so you have spinal stenosis and sciatica, so spinal stenosis is basically a narrowing of the vegetable. Freeman. I've listed some of the causes here that you can read for in your in time, but I think the main thing you guys into over your questions is your signs and symptoms. So this presents as a union actual or bilateral leg pain about on the back. Pain is, well, sometimes as well, and this is a gradual onset. It's sometimes described as a a quick like crawling and numbness pain. It's it's quite horrible. But what you need to know, for example, is it's worse on its worse or it's brought on by walking on. It's usually relief when the patient sits down with leans forward or crouch is down. Um, so in an SBA, you might get a patient that is finding it hard to walk, so they begin cycling everywhere because they're leaning forward when they cycle. Well, it might say they find it easier to walk uphill when you kind of lean forward to keep the body weight correct rather than downhill when they're having telling backwards to keep their center of us in the right place. And this is all happening because when you lean forward, you open up your vertebral frame and it gets wider rose. When you're leaning back your vegetable frame and become smaller. So it's already narrowed and you lean back. Then you're gonna get some of those this leg and this back pain, whereas if you're leaning forward, your opening up a bit and you don't get the symptoms. So to manage it, we use an emery whole spine, which consist narrowing where it is, what's causing it, that kind of thing, and we treat it using a laminectomy. So Toby went through where the laboratories So laminectomy is basically when you remove the lamina, so you just get rid of it on. That helps to kind of decompresses find a little bit. Another important thing that you guys need to know for exams is how to differentiate spinal stenosis from vascular claudications. Vascular cortication is basically a cramping pain that you get because of the throat. Scratchy lesions in the leg where your arteries aren't providing enough blood to your limbs. Basically, so the way to differentiate it is in spinal stenosis. The patient will have a normal peripheral vascular examination, so you'll be able to feel the pulses. Um, and the claudications doesn't tend to have this position or pattern where it's worse walking and better leaving for you. Don't see that in quadication as much, and then sciatica. So sciatica is the compression of the lumber. Take nerve roots, forming the sciatic nerve. So between L4 and I think has been saying yes. Three apologies about So, as you can see, hear these sciatic nerve exits. The pelvis posteriorly an imperative to this red band here, which is called Piriformis muscle through the greatest sciatic foramen, and it travels down the back of the leg. Then, um, at the knee. It divides into the tibial on the common paraneal nerves on that for the variety of functions. So it has a sensory function on your electricity's of your leg on both your dorsum plant off surfaces of your feet, and it also has a little motor functions in your posterior thighs, your leg, and if it does well, it in terms of causes very similar to spinal stenosis on for signs and symptoms, it characteristically produces this electric shooting pain in the back, the buttocks and basically down the level down the root off the sciatic nerve, and you might see some numbness of passed easier or tingling. Motor weakness and low reflexes as well was really important for you. Guys know someone has bilateral sciatica that's a red flag, because it could be. It's if it's on one side. It's more problem with that one. Sciatic nerve is if you're getting it on both sides, that suggest is a proper, more further up before the two nerves have separated into left and right, so that could be a sign of quarter a quarter that will go through in a second. Another really high, your point know, is a straight leg raise, so that's when you lay a patient on the back. You raise their legs, defects the hip, so you're stretching that sciatic nerve. And at the very end of that movement, you dose affects the foot to basically for the stretch the nerve. And if they get that same electric shooting type pain when you do those movements that's suggestive of sciatica the next quarter crying already quickly. So this is compression of the number second nerve roots extending blow the spinal cord. So the quarter a quarter that I showed you before in the past me. This is a medical emergency is something you really need to keep your eyes out for. So causes. Most common is a central disc prolapse, because if it's central, it's gonna push from both left and right sides in terms of nose. Um, so could anyone tell me what level it's most likely to a Cairo? Any ideas? What vertebral level? What? We have a central disc products causing corner corner. Any ideas out? Five s one. Yet that's one of them. There's another one that's quite common as well. Four or five, yet brilliant. Yes, they're the most two common places and your other causes. Unless did their signs and symptoms. You get that characteristic lower back pain, bilateral sciatica. As I said before, I characteristically a quarter quarter, you get a reduced anal tone, so if you did a PR or a rectal examinations a month. They won't be able to squeeze your finger because they don't have that tone there, and they don't have one trick in trouble over it. You might get some urinary dysfunction so they might be incompetent. Incontinent? They might, eh? So they might just kind of release urine without realizing it. They might have a reduced awareness of when they're bladders form when they need empty it on, They might not feel the urge to go to the toilet. Um, and those are all quite late signs for urinary dysfunction. And you also get kind of pins and needles sensation in the perianal area, which is notice adult parse teacher. So in terms of investigations, management program assists, urgent MRI, whole spine. You want to see where it is, what's going on on. You need to decompress this pollen quite urgently, so make sure that that compression has gone away on diffuse diagnosed late. It can cause permanent nerve damage. So it's really important we pick this up early and screen for it when we ask our history questions. So next these two pathologies, they're very easy to fix up spondylolisthesis on spondylocladium lithiasis even contact quite hard to say. So. Spondylitis is that is a defect in the parts into articular ist. So this is basically the area of bone between the superior and inferior facet joints, which I've tried to show here in pink. The best way to do is to find the transversus process, find the pedicle find the superior and inferior articular facet. It's basically the parts into articular. Is is the area in between those four lummox to find the transverse process here, find the pedicle, which is kind of here, and then you've got the superior articular facet so you can see here and imagine the in for your underneath. It's basically the area in between. This is quite common. Um, it's often asymptomatic, so isn't picked up, But a lot of people do have it that usually effects out for No. Five. It can be something you're born with, or it can be something that's acquired, usually by a repetitive hyper extension of the spine is commonly seen in gymnastic young Children that are playing around doing crazy things and extending. That's fine. Um, if if they're asymptomatic, they don't require any treatment. But if they are symptomatic, then you could go for surgery, then we have spondyloarthropathy Asus. So this is basically a forward shifting of one vertebrae over another visit is basically one month slips across the other. Basically, the most common side is L5 s one. So where we said that kind of kink in the spinal cord was before these are some of the causes of it. You need to know so spondylitis can cause it. Because where you've got the defect in the pas intraarticularis, that means that the front and the back of the vertebrae aren't connected. Um, so that because stepping forward to occur and the signs and symptoms that listed here as well, so low back pain, neuropathic pain, extra low doses and sensory loss and much weakness as well, um, in terms of treatment, if it's quite a mile slipping, then you can actively monitor. But if it's quite severe, then you can, as you can see here, you could decompress the spine and stabilize it, using things like screws. So cold syndromes. This is another thing that could be quite confusing. So I'm gonna wish through this and hopefully make some sense for you guys. So you have three spinal tract. So I want you to remember this. You have your spinal thalamic, which is a sensory track. It decorates at the level of enters the spinal cord because pain temperature in light touch your dose. A column zero So sensory. But Dex, it's higher up in the medulla, and it carries discriminative touch. So picking out to different places when you touch with something touches you vibration and proprioception zone, where your joints are in space without having to look for them. And then you have your court for spinal tract. That's a motor. It dec states in the middle, and it carries motor signals. So our first three quarts in dreams So, anterior, does anyone know common cause of anterior called syndrome off top of head? Why would you have an anterior coat syndrome? Yeah, Brilliant of help. One answering any other other ideas. Anyone has got any ideas? Yeah, I've had a couple. Okay, Brilliant. Yes, Until his final artery occlusion. So your anterior spinal artery supplies the anterior two thirds of your spinal column. So this is occluded or it's damaged. Then you will get an interior called syndrome. So if I put this on our little diagram here. So we had our daughter column at the back are called to prescribe it spinal and blue and I spinothalamic in yellow. So if we have a lesion here showing by the bread, we're going to damage our corticospinal on our spinal spinal thalamic bilaterally on our daughter, Columbine, naturally is gonna be intact. Visits in the posterior part off, or the daughter part off the spinal column cross section. So what's gonna happen is you're gonna lose. The function of your corticospinal spinothalamic tracks is we showed up here so you can lose that motor power lose pain. Tempter in like touch bilaterally below the legion posterior is basically the opposite is usually caused by a tumor compressing on the spinal cord on. But basically you get the opposite this time, so this part is affected. So this time you're gonna lose the function of your daughter column, which we said before and then central is usually due to a narrowing off the spinal canal, and what happens is when it narrows, you basically squeeze spinal cord, Um, and that can cause the center of it to include, um to become damaged. So what happens here is you get the central portions of each of the three tracks. Bilateral has been effective and the peripheral portions are okay. The result Hey, is that you will lose your motor power from your corticospinal tract. You'll lose your pain in temperature and light touch from the spine at lamic. Um, but you have this what they call a cape like distribution. So the nerve fibers associated with the arms tend to be in the center of the spinal cord, whereas the nerves associated with the limbs are, or the lower limb story on the periphery. So you find that your upper limb is more affected than your lower them in this case. And finally, our last pathology of the light is brands cards. Injury is this is commonly caused by penetrating trauma. Such a knife into the spinal cord on this basically causes a heavy section or half cup of the spinal cord s. So it's actually three of the tracks are going to be okay on. The side isn't affected on the side that is affected all three tracks on that side of going to be affected. So I want to talk through the results because I think this is really important. So loss that you're gonna get a loss of motor or most power paralysis. It's a lateral to the injury, so almost powers are quarter for spinal tract. We know it's exciting, the medulla. So say your brain. Your right cortex say, for example, wants to tell the left side of your body to do something. So you're right cortex. The motor signals going to travel down in the middle. It's going to switch sides sides to the left in this case, and it's gonna move down the left side of your spinal cord in this example lotion on this side. It's been going to hit the left side, which is where there is a lesion, and therefore it's not gonna be able to supply the left side of your body. Therefore, you're getting a loss of motor power on the same side, in this case, the left side off, which is the It's the lateral to the injury, where you cut spinal cord. Then you have a loss of discriminative, discriminative, touch, vibration and proprioception. Also, it's the lateral to the injury. So this is Carol. We carried by a dorsal column What's again? Index states in the medulla. So say we have a left sided vibration that we're picking up in our left leg that travels up the left side of the spinal cord. And, oh, it's gonna hit the lesion here, so you're not going to get any left sided? Discriminative touch, vibration appropriate option. It's a natural once again to the injury. Then finally, are spinothalamic functions are lots of pain, temperature and right touch. It's gonna be contradictory to the injury. So say we had some pain on the right side this time, so the pain that you detect on your right side, it travels up to your spinal cord, Say, from your leg to your spinal cord and Dex aids. It's what side straightaway, and it then begins to travel up the left side of your spinal cord. Here is gonna hit a lesion, and therefore you're not gonna be able to feel pain, temperature or light touch from the right side, which is contralateral the opposite side to the leisure, right? Thank you for listening to you guys do really Well. It's been a long one. Apologies of run over our last s t a. Just to check your knowledge. What? We've covered a little bit. Um, be very careful to read the question very carefully. That's a low Can give you 10 more seconds. Get those owns is in. If you don't know, I guess you might be right. Okay. Pretty. And I'm going to stop the pole there. So this is what I expected. We're gonna have a bit of a split, so I've got a step between a so well done. All of those of you. That part is the correct answer. So read the question carefully. He's had shooting pain in his legs, pleural, both legs. He is having symptoms of sciatica because he's got his pins and needles shooting pain down his legs. Positive struggling, straight leg raise. I see why a lot of you put a because it is signs of sciatica. It's on both sides. So remember, that is a red flag. We need to rule out quarter a quarter. Which the path of the pathology. Is he in? Its answer. So thank you so much for staying on everybody. Sorry, we've gone over again. Um, we hope it was really useful. Please fill out with you. Bet for and please give us constructive You back both positive and negative. It really helps to know what we're doing. Right on what? We're what we can improve on, I will say