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I'm just checking. Um, if people can hear me, um is anyone able to maybe like type something if they can hear me talking? Just so I know anyone hear me, I think they should be able to, they should be able to. Okay. Fine. I'll just assume that they can hear me. Um Okay, I'll give it another minute just to give a bit more time um for people to arrive. Okay. Okay. I'll think I'll probably just start now and then people can join as they want to. Great. So welcome everyone to the last session of our spinal week today. We have Keeley who's going to go through spinal neurosurgery and some TNO as well. You're in the brilliant hands. She's a penultimate year student at the University of Oxford and she's really interested in neurosurgery as well as A and E and anesthetics. Um So without further a do handover Teeley also just as a note, if anyone has any questions, feel free to pop them in the chat and feedback will be sent at the end of the session. Thank you. Thank you, Hannah. Um Okay. So I'm just gonna start. Um hopefully a few more people will join um as time goes on. Um But yeah, I'm Kiwi, so I'm essentially covering if any of you were at Will's presentation yesterday, he covered kind of all the cranial neurosurgery stuff. And so I'm doing um tino spine and also a bit of like spinal neuro. Um So that's what the focus of this talk is. So, um in terms of how it's structured and what will cover, I'm gonna start with 10 oh spine and I'm just gonna go over kind of basic anatomy. I'm kind of assuming that there will be a kind of basic level of knowledge. Um But I've kind of got things on slides for reference as well as like a refresher. Um And then, um I will go over kind of different fractures and degenerative changes to the spine, um and disc herniation because those tend to be with most high yield topics. Um And then I'll move onto spinal cord pathology, which um is a bit more dense because I've got some anatomy sections prior to that just to sort of remind um as a reminder of the different pathways and things. Um and then some other more clinical stuff like called Requena and called syndromes and that sort of thing. Um So that's the structure. So to start with 10 oh spine. So this is just a kind of reminder of the layout of the spine and the different sections of the spine. And so you probably already all know this, but you've got um c one to C seven cervical vertebrae. You've got the um T one to t 12 thoracic vertebrae, L1 L5 lumbar vertebrae and then the fused sacral vertebrae which is S one to s five. Um and the coccyx right at the end. Um And I also just wanted to quickly point out um different kind of mild positions of the spine or the vertebral column. So you can get this kyphotic spine in particularly older patient usually. Um And it's because it's associated with age. Um and this is something to kind of always have in mind or consider because it can cause cardio respiratory compromise. Um And normally this sort of thing is just managed with painkillers, um, exercise usually. And then, um in the middle, I've got an example of scoliosis. So this is like lateral deviation of the spine from the midline. And again, um the first line sort of thing would be um, things like nsaids, pink colors, steroid injections, bracing, and then possibly surgery. Um if the symptoms are really severe and it's kind of quite limiting for the person. Um And then finally, law doses which is kind of excessive inward curvature of the spine or swayback. Um And this position of the spine is actually completely normal and pregnancy. Um But again, painkillers or physio, if, if it becomes troublesome. So there's a different position of the spine and then focusing more on the different vertebrae. So, um the kind of main point I wanted to make here was that obviously at different levels of the spine, the vertebrae look quite different. Um And so I've kind of got examples here of how to tell apart um different parts. But essentially the most important things to remember is that in the c spine, you've got seven vertebrae, you've got Atlas and access, which are um they make up part of the cranial survival junction, which is a really important area and I'll expand all that in a minute. Um And then you've got thoracic which is, they tend to have heart shaped vertical bodies. Um So you can kind of see in the middle of this actually looks less heart shaped than um the lumber spine. But the classic description is often that it's a heart shaped vertical body um with a long spine is process. Um And um you've also got costal facets, which of these kind of bits on the edges of the transverse processes. Um And that's for the river attachment because obviously in the thorax, you've got ribs. Um and then lumber spine is this classic kidney being shaped um vertical body. And um you also have slightly longer transverse processes and then obviously the sacred um uh the sacred vertebrae are all fused. So that's kind of a general way of telling apart how the different vertebrae look at different levels. Okay. So I'm going to ask a question but I don't know, like how willing people will be to answer. Um, I would just suggest that you put an answer in the chat and I'll wait for like a few seconds and then if no one answers, I'll be gone. Um But does anyone know, um, what the unique features of the C one vertebra are? So something that makes it different from the other cervical vertebra, anyone know? Okay. No one's saying anything in the chat. So I will just carry on. So to see one vertebra is unique because it has no vertebral body. Um and it also has no kind of prominent spinous process like the other cervical better produced. Um And there is a kind of embry logical reason for this and it's because of it's partly to do with the MBA logical origin of the C one vertebra, um which I won't go into because it'll probably take too long. But yeah, so there is an umbilical reason why it's like this. Um And actually what the kind of anatomical substrate of what would have been the virtual body of see, one actually forms the dens of see too, which I'll show you in a minute. Um Which explains why, see one doesn't actually have a vegetable body, but it is this sort of ring shaped structure. I was going to ask another question, but because I'm not sure whether people will answer, I will just skip past it and I'll tell you that the unique features of see two or access um is that it has a bifid spinous process. So that's this kind of triangular looking. Um I'm not sure whether you can see my cursor, but it's like a triangular looking bit on this spinous process here. And then here is the dens. Um And you can see the dens pointing upwards. Hopefully, you can see what I'm pointing out. I'm not sure whether you can. But essentially, all you need to remember is that the c too has a bifid spinous process. And um also the dens. Um Yeah, so this is kind of them next to each other. So you can compare them. So the Alison access are two really vital parts of the cranial cervical junction, which is the transition. It kind of houses the transition between the um Kordell brain stem and the rostral spinal cord. So it's a really important um area. And it's also um so it, it's composed of these two vertebrae, C one C two. But there's also um ligamentous structures that also help to stabilize um this junction and it's very vital for head movement um as well as protection of the spinal cord and arteries and things like that. And you've got these important joints um that make up part of this area. So you've got the Atlanto occipital joint, which is where the occipital condyles of the uh skull bones or the um occipital bones articulate with the Atlas or the C one vertebra and that particular joint allows faction and extension of the head. And then you've got um several joints making up the Atlanta x your joints. So you've got actual articulations between lateral masses of C one and um see the articular facets story um of C one and C two. But you've also like bilaterally, but you've also got an articulation between um the dens of see too and the um anterior art of the atlas as well. So there are kind of two um sorry, three points of articulation there. And you've also got this really special ligament called the transverse ligament. And this is actually the most important ligament in the spine. And um it pushes up against the back of the dens and kind of pushes it onto its articulation with see one. Um and it's a really important ligament for stability of the C spine. So if you ever hear the term Atlanta makes your instability. Um that's um often what can be a something contributing to that is injury to the transverse ligament because that can happen quite commonly in trauma. Um And Atlanto axial instability is a bad thing because like I was saying before, this part of the spine is very important for mobility, but also for protection of those vital structures like the upper um spinal cord and the lower brain stem and also protection of um vascular structures. So things like the vertebral artery which is important for supply to the brain, which I'm sure will covered yesterday. And atlantal axial instability is associated with conditions such as Down syndrome, um lysosomal storage disorders and also achondroplasia. So, it's just one of those things that can sometimes come up and pass med questions that I've noticed anyway. Um Yeah. So um the first kind of major pathology I thought I'd mentioned is the Jefferson fracture. So this is a A C one fracture and it's caused by um classically um diving injuries. So what happens is it's like a burst fracture that happens because the occipital condors of the skull are driven into the lateral masses of the seat of see one um into the superior articular facets of see one. And um the fracture lines normally involved both the anterior and posterior arches. I'm going to show you what this looks like um on a scan in a minute. Um But it usually involves both anterior and posterior arches. The stability of the fracture depends on the integrity of the transverse ligament, which is kind of what I was saying before. So the transverse ligament can actually become a evolved um or disconnected as a result of um a Jefferson fracture which would, which would make surgeons extra worried about possible Atlanta excellent stability. And um there's this other thing called the Atlanto dens interval, which is the distance between the Atlas and the and the dens and the transverse ligament is what like I was saying that pushes the dens up against the arch of Atlas. And if you've got a distance between those two things that suggests that the transverse ligament has ruptured because it's not performing its job of pushing those two things together. Um And so stability of this fracture dictates what you actually then have to do about it in terms of management. So just to kind of demonstrate this is kind of just what imaging looks like. I don't know whether you really need to know this um for the purposes of finals or anything. Um But I just thought it's quite nice to look at the pictures and actually see what's going on. Um So this is a classical kind of Jefferson fracture injury where you've got um the C one, this would be really useful if I knew if you could see my cursor, but I'm going to just assume that you can. Um But these red lines have actually drawn on to help. So the two, the kind of pair of upper red lines that I've drawn, those are on the edges, the C one um or Atlas vertebra and you can see that they're kind of overhanging with the lateral masses of C too. And that is because you've got separation of the C one lateral masses, you can't see my cursor. Okay. Thank you if you ever said, oh Hannah. Um Yeah. So hopefully I can just try and explain this as well as possible because I'm not sure how to make my cursor visible. Well, if I can, can I, who do you think I can? Um So anyway, what I was saying is that you've got, see one C one natural mass is kind of over hanging over the top of the C too. And that's because you have separation of the C one natural masses on both sides. Um And that's because of those fracture lines that you've got um on the anterior and posterior arches. And sometimes conditions use this um to infer whether there's transverse ligament injury. Ideally, I guess an MRI would tell you that. Um But if there's a distance of greater than six millimeters between the lateral masses of C one, it suggests that there is a transverse ligament injury. Um And this one on the right is I've drawn a little arrow as well. So the red arrow is essentially showing you the Atlanto dens interval. Um And so, in this patient, that's too big that interval. And that essentially suggests again that there is rupture of the transverse ligament associated with the Jefferson fracture. And then this was just quite a good diagram cause it's kind of like a transverse section of what's actually going on. So um you can't see my cursor, but if you look at the anterior arch, which um is the kind of top part and then you got the posterior arch on the bottom, um You can see that there are fracture lines through both the anterior arch and the posterior arch. And um that, that's shown by these red rings that I've drawn. And then this yellow ring is actually a bit of a Valls bone fragment. Um and that's just behind the den. So this like kind of very kind of intense white um oval in the middle is the dens. And then you've got this little fragment next to it. And that's because the transverse ligament has ruptured. So that might be something that they look for. If they do kind of aches, you'll ct. Um But I think an MRI is probably the imaging of choice to show, would like to confirm a transverse injury, uh ligament injury. Yes. In terms of management, most patient's can be managed conservatively and they'll just be given these immobilization collars, which probably lots of you've seen if you've been on trauma wards and things, a lot of the patient's with c spine injury, we'll be wearing collars like this. Um And the idea is just to kind of stop the patient from moving that joint and to kind of promote um union and healing, natural healing. But if transverse ligament rupture has occurred, then the injury is considered unstable and these patient's may require, you know, surgery and more aggressive management. Um I have shown just some other kind of options. So you've got these halo vest immobilization. Um These just to me look quite awful like, I think I would absolutely hate wearing these as a patient. Um But patient's might be given these um to kind of restrain the cranium from the top down to the torso. Um And it just kind of means that you have more effective immobilization of the joint and maybe other joints if there's kind of multiple trauma going on. Um But then, um in terms of surgical options, you've got posterior C one or C two. So it's C one to C two lateral mass, internal fixation. And that's kind of exactly what it sounds like. It's sort of just um stabilizing those two by fixing them together and you use these screws to stabilize the lateral mass is in place. Um And then there's also trans oral internal fixation. And so, um the surgical approaches that at the um different levels of the spine can be a little bit complicated, particularly ones of the cranial cervical junction, but trans oral is essentially going through the mouth. It's exactly what it sounds like really, you go through the mouth. Um And you use that to act the oral cavity to access the C one C two joint and then you can stabilize the fracture that way. Um So it's just like a different point of access. Basically. Um The next injury I'm going to talk about is the fracture of dens. So these are also known as Adan Toyed fractures or peg fractures. Um So if you ever hear those terms, they're kind of all, you know, referring to the same thing, but they are quite varied. And so I've got some classification systems that I'm showing you, but these are all a bit outdated and I'll talk about that a bit more in a minute. Um But essentially fracture of dens is a fracture of the anti process of the c too. So the pointy up it that I was showing you um in previous slides um that can become fractured itself. Um And in terms of why that happens or how it happens, it's usually high energy trauma in younger patient's in like road traffic collisions, for example, um or in adults, in older adults, like the elderly and things it can occur in them actually do too much lower energy trauma. So like falling down a couple of stairs or something like that. Um But it is usually associated with trauma um from my understanding and it's the most common fracture of access and it accounts for about 10 to 15% of all cervical fractures. Um So it's reasonably common. Um And like I was saying there are these different classification systems. So these are some older ones. Um the Andersen do Alonzo classification and then Roy Kamil classification. So these just classify the fractures based on slightly different things. So the Anderson Kalonzo one um characterizes it based on like the base of the fracture and how high up it is. Um or the level of the fracture. And the Roy Camels classification system classified dense fractures based on the plane of the fracture. So whether it was kind of diagonal or just kind of straight across um and completely horizontal. So those are kind of older classification systems that have been used and probably still are used quite a bit. Um but this is all sort of being superseded by a new classification system which is called the A oh Cervical spine classification, which some of you might have heard of. And it's a much simpler way of classifying these fractures because they're actually really heterogeneous and a lot of them, you could kind of argue fit into multiple categories. So the A O Cervical spine classification aims to kind of remedy that so that you can um better standardized treatment and diagnosis across different centers. Although at least that's the hope of it, but essentially um what you need to know about this fracture. So displacement can be anterior or posterior. So it can happen due to hyperflexion or hyper extension, traumatic injuries. Um anterior displacement um is associated with transverse ligament failure and Atlanto axial instability for the reasons that I've already mentioned because the transverse ligaments so important for stability um and a fracture at the base of the odontoid process um combine it comprises the stability of the upper c spine. So those are kind of the key points to remember about those. Um Don't worry too much about the classification systems. I just included them because they can be really, really confusing when you first come across them the first time. Um And in terms of symptoms, I mean, this is kind of obvious and it's the same with the Jefferson fractures really, like the patient's going to be in pain, especially with rotation. They're probably not going to going to be moving their neck very much or their head. Um There may be dysphasia um and it's not usually associated with further neurological symptoms unless there are, there is a kind of direct neurological insult as well, which there can be. Um but I think it's less common. So diagnosis is usually made with standard lateral and open mouth x rays. You can see that this patient on the right in the X ray, um they've got their mouth open because you can see their teeth and um you can just sort of, I wish I'd put a circle around this now. Um But if you look really closely between the teeth, you can kind of just about make out the edges, the edge of the dens pointing upwards. And that, that you can see the fracture is kind of pretty much transverse fracture across that tip. Hopefully, you can see that um if not going also bullets and um look up fracture of the dense and you be able to find this exact image. Um and they've got lots of good photos on that. Um and like I said, classification of the fracture and risk of nonunion did takes management. So essentially, if it's unstable, if there's any involvement of the transverse ligament, um for example, then you're almost always going to be taking this patient to theater. Um But if not, you might be able to just give them a collar like I was showing you some of the other ones before and you might just be trying to completely immobilize. Um And a lot of older patient's, that is what is usually done um to avoid the trauma of surgery if, if they think that the risk of non union is quite low. Um But in terms of operations or operative approaches, um you would do posterior C one or C two fusion, um which is a preferred method if you are going to do this in older patient's um or for those at risk of non union. So younger patient's, but there's a risk that you won't have natural bone healing. Um You can also do anterior odontoid screw, which is essentially screwing it back together. Um or a trans oral odontoid ectomy, which I was saying about the trans oral approach, you going through the mouth and you just remove the offending bit of the odontoid process. Um but not the whole thing, you just kind of take out the fractured bit um and let the rest of it, he'll um yeah, that's kind of what I really had to say about that one. Um, and then Hang manufactures. So these, I've read lots of different things about this and I think it's quite controversial why they're called hang manufacturer because I was trying to figure this out. Um, the other day and I saw, I read one thing which said that they're called Hang Manufactures because they were, they are associated with Hanging. And I read something else that said that that was nonsense. So I don't actually really know what it's called a hang manufacture. Um but they just are um but essentially a hangman fracture is a C to fracture. So affecting the axis and it's a particular fracture or it could involve the parts into articular Harris, which is the little bit of bone connecting the superior and inferior articular facets of each vertebra. So those are the potential bits that could be fractured um in a, in a hangman fracture. It's usually due to forceful hyper extension of the upper c spine. So, again, very much related to trauma, this kind of fracture. And um what else do I want to say? So, I've got some more of these classification systems um which you might come across. Um I've included living in Edwards, but I'd say just concentrate on a oh spine because it's much simpler classification system. Um But that's purely for interest. I don't think you need to know anything about it. Um For the purposes of finals, I think it's probably a bit too specialist. Um if you're interested to have a look at it, um and you can get kind of typical or atypical fractures. So, in a typical hangman fracture, both sides break symmetrically. Um and an atypical fracture. Um the fracture is usually located in the posterior part of the vertebral body or one or both sides. So you can get kind of variations on what the fracture looks like. Um But essentially the worry with this kind of fracture is that you get um a broken ring. Um And obviously, these vertebra, they're forming a ring at the spinal, the spinal canal for the cord to go through. And so if you break that ring, there's a worry that that will then result in nerve damage. Um and it presents, usually presents with things like neck pain um and a history of high velocity trauma and neurological impairments actually quite common um in these. So it's in 25% of patient's, you might get neurological um symptoms and compromise as a result. Um And um there also maybe vertebral artery injury and that's because the vertebral artery has a really close relationship um with the spinal nerves and um in these levels. So that's why and I've included some images just to kind of show which ones are the best. Yes, you can kind of see that in the kind of bottom in the middle. Um I've tried to just isn't a very big image, but you can kind of pointed. I've got arrows showing where the fractures are. So you can see how they can be on both sides affecting, I think these are sort of affecting the pedicles more than anything else. Um And the way that you might pick this up on an X ray, um you would probably do like more imaging, you probably do an MRI, especially if neurological impairment could be, you know, a potential um factor. But if you were looking at a plane kind of X ray, you can sort of track that this might be happening. Because if you try and draw a line between the spinous processes um of the C spine, they should all kind of roughly line up. But you can see um in the image on the right. Um The C two is kind of weigh the spinous processes way past the yellow dots um which I've drawn on and that kind of indicates that there is a fracture there. And um that is something that's quite classically associated with the Hangman fracture. Um So, in terms of management, um again, it depends on the classification. It depends on whether there's neurological compromise or vertebral artery image damage, sorry. And um to look for that, you might do a CT angio uh to help you to decide if there's vertebral artery compromise or not. And um if you have an atypical fracture, then neurological impairment might be kind of, you might be more suspicious about that. Um In terms of non operative options, again, you'd use a collar or halo mobilization and fixation. Um Or you would do surgical fixation. And I haven't included all the different types because it depends on the specific kind of category of fracture. And I think it was just, it would be a bit too complicated. Um Certainly for me anyway. Um So I haven't gone into that in much detail, so I have another question, but I'll skip over it just in the interest of time. Um And I'm going to talk about osteo fights now and degenerative spine injury. So osteo fights are bone spurs. And if you look at the top right image, you can see there are kind of little knob li bits um on the vertebra, on the bone and they're these bony lumps that grow on the vertebra of the spine or, and they can actually grow in the joints themselves. Um And they're associated with aging. So it's a degenerative process that occurs within the bones and the joints and it happens in most people as they as they age. Um, but it is associated with osteoarthritis. Um, so if you do suffer with osteoarthritis, arthritic joints, um, these can become more troublesome for you. You might have more than like the average person and that's because your joints are kind of subjected damage and you get kind of increased servicer of the joint, you get your bone trying to kind of form your bone, sort of responds to this by forming more bone, but it's not really very useful bone. And you end up forming these osteo fights instead which these little novelty bits. Um and they can actually be quite painful because they can, especially when they affect the joints because they affect the way the joint can, the joints articulate. So, um you might have a patient with painful joints and limitation of movement in affected joints. And I've kind of just included this because even though this is something that applies to, you know, knees, for example, um you can get them in the spine and as a person ages and they develop more and more kind of bone spurs or osteophytes, it can actually result in nerve impingement if they form in the wrong places. And so you may get patient's presenting with pain in the upper or lower limbs. Um and also kind of sensory changes um in a dermatome or distribution. So, there might be a kind of spinal level associated with it. Um So it's just worth bearing that in mind, particularly older patient's. Um I try to find some good X ray images of what they look like. Um the osteophytes. And if you look at these yellow arrows, they're pointing to little kind of bony fragments that look separate from the rest of the spine and those are actually osteophytes. Um and lots of people have these, they actually can cause completely no problems. They can be completely asymptomatic. Um, but the problem comes when they start in pinching nerves or you can see how, maybe if you've got nerves coming out and exiting from the vert, from the vertebra, you can see how they might get a bit impinged by these bony bony spurs. And that's when they become troublesome. And for management it's pretty much always conservative. Um, you just give painkillers like nsaids to treat that kind of thing. So other bony vertebral pathology that I wanted to mention was just because they seem to be quite um topic, topically relevant um and come up and pass med a lot. Um was spondylolisthesis. Um And this is essentially when you've got separation of the vertebral body from the vertebral arch. So if you imagine someone trying to cut um a gap between the vertebral body and the arch bit, which is where the spinal cord sits, um That's essentially what spondylolisthesis is and that can happen on its own um with or without anterior sliding. So it spondylolisthesis um is when as a result of that separation um of the vertebral body and the arch, you actually have anterior sliding of the body. So the body slides forward. Um And that happens in around 65% of people. Um and that can be quite painful. It usually happens at around L 45 or L5 S one because that's the kind of heavy kind of load bearing uh part of the spine and the way that it looks is. So you might have heard of this Scotty dogs sign. I don't really, I would struggle to see this if there wasn't a red diagram around it, to be honest. Um But apparently because of the, when the anterior sliding happens and the separation between the body and the arch, it makes this kind of Scottie dog looking appearance. So it looks a bit like a dog. So I've kind of um if you look at the image on the right at the top, there's this red, the red dots are supposed to show you what the Scotty dogs sign looks like. But again, I don't think I could confidently um, identify that, to be honest, it's just something to be aware of. Um, and management for that sort of thing is usually conservative surgery for that is pretty rare. So you would just be kind of advising pain relief and that, that sort of thing. Um The other problem that I've seen come up a bit is sacred ization of L5. So you can get um, the L5 vertebra fusing to S one. So essentially, it, it becomes and behaves a bit a bit like a sacred vertebra and then it becomes fused and that's actually not uncommon. It happens in about 17% of people. Um It's normally congenital actually. So it's not something that's associated with age usually. Um But it can result in lower back pain. And then this thing called lumbers is it lumbar ization of S one. This is much rarer, but it's essentially where the S one loosens from the. So, you know, the sacred vertebrae all fused together. S one to S five S one can become dislodged from the other fused vertebra. And it behaves a bit more like an l like a, like a lumbar vertebra. And that's why it's called lumbar ization of S one. And um that can happen unilaterally or bilaterally. So on one side or both sides. Um And um again, that causes back pain and that's something that you would really just, in fact, pretty much all these problems, you would use an X ray to diagnose them. Um and civilization and number ization are similarly then managed conservatively with physio and analgesia and that sort of thing. And I've got a picture on the bottom, right? Just to show you what synchronization of L5 looks like. Um So you can see that the bottom, the L5 vertebra has become fused to the sake to the two S one. And that's what that is. Uh Yeah, I just wanted to mention those. Um and before moving on to all the neurology stuff, um I thought I would cover some other things that are quite important. I don't really know else to put this in. So it's probably important that we talk about ligaments. Um I'm sure probably you already know this. Yes. So vertebral ligaments, um they're not too bad to remember. Actually, I find because they're all sort of named appropriately. So you've got um the anterior longitudinal ligament which runs along the anterior aspect of the spine longitudinally. So that makes sense. Then you've got the posterior longitudinal ligament which does the same thing. But posteriorly, um the ones that I always got mixed up a bit more were these three at the back. And the reason why it's important to know these three is because they are relevant for performing lumber punctures because you have to go through these ligaments to get into the spinal canal to reach this spinal cord and then puncture the juror and get your sample. So the again, they are very actually named. So starting on the outside, this yellow one is the super spinous ligament because it sits on top of the spinous processes or kind of, you know, not on top of that behind if that makes sense. And then in between the spinous process, you have the inter spinal ligament. So in between the spinal, the spines processes and then um the ligamentum flavor, which isn't very actually named, but it's the innermost ligament. Um and it's kind of the last ligament that you have to go through to reach the spinal canal. Um Yeah. So just know that I think because they like to ask those sorts of questions and the posterior ligament is interesting. Uh the posterior longitudinal ligament. This purple one um is interesting because it's kind of deficient posteriorly and this has relevance in um disc herniation, which I think I'm talking about. Next. Yes. So, um vertebral discs and disc herniation. So the disc sit between each vertebra again, I'm sure you already know that um and disks themselves are formed up of two kind of key um parts. So you've got the outer layer, which is the annual is fibrosis, which is quite tough and fibrous. Then you've got the inner nucleus pulposus, which is gelatinous. Um And as a person ages or with kind of general wear and tear and strain in a younger person, um the Manulis fibrosis can become, it can break down and degenerate and the nucleus pulposus can then actually migrate through that fibrous area, which is what the the pink and yellow images at the bottom is showing is kind of the process of generation and then kind of migration of this jennifer this part to moving through that layer. And it can eventually actually um go past herniation and be sequestered into the spinal canal, which is obviously no ideal. Uh you'd want to pick it up before then. Um Yeah. So that's the process of disc our nation and it usually happens in the posterolateral direction. And that's because you've got an anterior ligament anteriorly, you've got a posterior ligament posteriorly, but um it's kind of slightly deficient. So the um the vertebral discs are able to kind of just herniate backwards but like an angle in a posterolateral direction. So that's why that happens in that direction. Um And of course, with something like disc herniation, you always have to worry about um called compression and things like called required syndrome. Uh If, if it gets that bad. Yes. So more on disc herniation. So disc herniation is pretty common. It usually happens in middle aged adults. Um but it can happen in patient's of all Asia's. So it's important to bear that in mind. Um Don't rule out even if it's a younger patient. Um it can be a symptomatic and lots of people, but it can be symptomatic and that's usually because it will start to compress nerves and um it will give people paid and that's usually what they'll present with. Um the most common kind of sites of disc herniation R L5 S one and L 45. And that's again because those are quite heavy kind of look, they bear a lot of the bodies load. So that's why um that happens most commonly there and it's a common cause of lower back pain. And the classical kind of history that you might get is a sudden onset back pain that happened after lifting a heavy object that could be occupational related. Um And these symptoms improved when like uh improving lying supine, um or with the knees and hips flex because it takes all the pressure off of that area and um, they may report ridiculous symptoms. So you might kind of be able to pass out that there's a particular spinal level that this might be associated with because of radicular symptoms. Um, and this sort of injury or pathology is always kind of worse on sitting down. So if someone is sitting down for long periods of time, um, then they might find that, that flares up their symptoms. So that's something to kind of watch out for. And you also want to in a patient that you think might have this. Um then you need to be thinking about cord compression, quarter equina, and we'll return to that later on in the talk in terms of imaging. Um an X ray spine can be quite useful to localize where the problem is. Um an MRI is more helpful for actually being able to see the herniated disc. Um And if you're thinking that someone might have called compression and called a recliner, you'd probably want to do an MRI um to look for that. Um And I just put this note in about if a patient has a pacemaker, um you often you might opt for a CT myelogram, but this is usually the older pacemakers. Apparently the newer ones, you don't have to be as cautious with MRI, but the older ones or specific models of pacemaker, um you do because they can interfere with the pacemaker function, putting them through an MRI. Um, so that's just something to kind of be aware of, always check the type of pacemaker and if it's compatible with an MRI, um, and in terms of management, conservative is the first line as with most things. Um, and things like physio painkillers, corticosteroid injection if, if the pain is, you know, considerably bad, um, and then you might progress the surgery if it becomes debilitating and that would be doing, um, something called a laminectomy and micro dissect A me, I think I have pictures of this later as well, but I've just included a diagram to show what that means. So a laminectomy is essentially you make the incision, you go in and you remove um the bit of vertebra that's in the way trying to say. So they've done it. If you look at the bottom left image where it shows L1 L2 L3, they've removed a bit of bone there and that so that they have access to the area where the cord is. And then once you're in there, you can then remove the offending material. So you can remove the bit of honey to disc that's causing the problem and compressing the nerve. Um And that's what a microdiscectomy is okay. So that's all the TNO spine stuff. I've only really covered this stuff that I think is actually um kind of in most people's curriculums and kind of important to know for exams. Um So there's lots of stuff that I've not covered. Um But I'm now going to move on to talk about the spinal cord. Okay. So, in terms of gross anatomy, I'm not going to go through this that much because I feel like probably most of you already know a lot of this. Um But essentially you've got 31 pairs of spinal nerves in total, you've got eight cervical ones. So one more than the number of vertebra there are in the cervical region. You've got 12 pairs of thoracic nerves, five pairs of lumba nerves and five pairs of sacral nerves. So the rest of them kind of match up. It's just the cervical one. You have to remember there's an extra pair of nerves there. Um And the other kind of key thing that I always used to get forget is that the spinal nerve roots C one to C seven always emerge above the corresponding vertebral bodies. So see one will go uh nerve will um emerge above, see one vertical body, for example, and all the way down to C seven. But then see eight nerve roots and onwards emerge below the corresponding vertical body. So that's just important to know that C eight is when that rule changes. Um because that's definitely tripped me up before in exams. Um the spinal cord ends at around L 12 and that's called the Conus medullaris, the bottom of the spine. And then um just kind of beneath the Conus medullaris you have the call to kinda, which is like, I think it's named after a horse's tail because it looks exactly like that. And it's all the kind of nerves coming out of the Conus medullaris and that's some, just kind of, it's just sort of bathed in CSF at the, um, and then covered by the meninges and it's kind of at the bottom of the spinal cord. Um, yes, there was, there anything else I was going to say about that? I don't think so, let's just move on. Yes, this again. Um Most of you will probably know this. Um I just wanted to kind of include it for completeness where you've got sensory information coming in from the periphery or peripheral nerves. They enter the spinal cord via the dorsal horn or the in the dorsal root ganglia in the dorsal horn. And then they travel through the spinal cord to the brain and then motor inputs are descending inputs that come from the brain and they're sent to the periphery via the ventral nerve root. So that's kind of the flow of information. So you probably remember like if you, you probably learned about reflex arcs and things and the sensory information coming in via dorsal horn and then the most information going out via the ventral, um the sensory and motor inputs are integrated within spinal roots and nerves. So you often get kind of mixed um sensory and motor nerves. Um in the kind of spinal nerve root. And then spinal nerve then splits into dorsal and ventral Remy. And that innovates the dorsal and ventral aspects of the body or the dorsal and ventral services of the body. That's probably the basics there. And then this is just to kind of mention because I'm going to talk a bit about bladder dysfunction and spinal cord injury later. Um This is the very basic overview of the autonomic nervous system. So you've got the, you've got the parasympathetic nervous system and you've got the sympathetic nervous system. And the main thing to know is that your sympathetic nervous system is thoraco lumbar output. So T 12 L2 is where you've got um synthetic nerves coming out of the spinal cord and they only happened between those two kind of levels. So, T 12 L2 and that's shown on the left and then parasympathetic nerves are craniosacral output. So you only get parasympathetic nerves coming out of the cranial um parts of the spinal cord and the sacred. So it's just important to kind of know that. Um And of course, you've got with, with both of them, you've got a pre preganglionic neuron, um which then goes to innovate a postganglionic neuron which will then innovate a target organ. And in the, in the, I've forgotten what it's called sympathetic um the sympathetic nervous system. Um that is usually a long pre preganglionic and a short postganglionic neuron and parasympathetic nervous system. It's usually a um short preganglionic and long postganglionic neuron. I think I've got that the right way around. Um and the transmitters are also slightly different. So, parasympathetic nervous system is always acetycholine and sympathetic nervous system is the first of the preganglionic neuron is acetylcholine, but the second, the postganglionic neuron is uh your adrenaline. So it's kind of the key things to remember about the about the makeup of the autonomic nervous system. And of course, they perform all these important functions. So I'm sure you already know about sympathetic and parasympathetic um symptoms and functions. Um And I've included a bit more detail on the anatomy of the systems which I'm not going to cover now just because of time and I don't want to massively overrun, but I've put it here on the slide. So feel free to take a screenshot of this slide um for your own reference because I used to find it quite complicated knowing um what the sympathetic neurons did because they can actually do lots of different things before synapses on to the next you're on. Um So feel free to take screenshots of the slide, okay. Um And I'm not going to go over this because this is just again, parasympathetic synthetic functions. Um So you're sympathetic, one's a fight or flight, parasympathetic ones are the calming functions. So I was going to ask a question again. Um But again, I won't um just because I don't want to force people to answer questions if they don't want to. Um But essentially, um these are just different sections of the spinal cord and um it's kind of just good to have an understanding of which level these might represent. So, um these are the answers. So A is lumber. Um D is sacral and cervical is C and B is thoracic. And so I'm just going to kind of go through each of those in the correct order just to explain why they look the way they look. So the cervical um level, which is C you can kind of, if you contrast this with thoracic level, which is B you can see that there's kind of the areas of grey matter and much um a much wider, there's a lot more gray matter um in and that's the, represents the cell bodies. And that's because you've got more output um coming out of the cervical region. And that's because you've got things like the brachial plexus, which you need um those cervical spinal nerves coming out of that level to innovate the upper limb. Um The thoracic, you don't have as much because you don't have um because the upper limb receives all of its, most of its input from the cervical um region of the cord. So you can always tell those two apart, even though they're more kind of oval shaped, you can tell them apart by looking at how much grey matter there is actually. And that's a good way of telling it apart. And the lumbar and sacral a bit harder to tell apart because they're both quite, you know, they're both circular, they're both quite round. And if, if you didn't know that they were to scale, then there wouldn't necessarily be a way of knowing, um, just off that. So it's kind of good to know that in the sacred region you've just got, if you notice that all the different horns like the, the, all the different horns of the spinal cord are much wider and they take that they occupy much more area of the spinal cord compared to the lumber. And so it's just kind of good to have an idea of which ones which and why they look the way they do. So moving on to the next. Yes. So like I was saying, the shape of the cord segment corresponds to the function or I should say really the appearance of the cord segment corresponds to the function. So the cervical cord is oval shaped, it's got thin dorsal horns and small eventual horns compared to the lumber or sacred segments. Um And that's because you've got um the lower limb has a lot more kind of um spinal cord inputs or, you know, cell bodies from the spinal cord contribute like innovating it. Um And so that's why um the eventual horns are much denser in the lower spinal record compared to the upper and then the thoracic cord has a smaller diameter, it's more circular and it has dinner, dorsal and ventral horns. And that's because of less um innovation um during, you know, for those levels, it's kind of, you don't have an upper limit to innovate in the thoracic region where as you do in the cervical region, um and then the lumber, lumber cord, larger dorsal and ventral horns, steak record looks similar to the lumber, lumber cord, but it's smaller in diameter. And as I said, the horns often look much wider in terms of, they look as though they're occupying much more of the spinal cord than in the lumbar spinal cord. Cause that's kind of a good way of timing part the tracks. Um There are lots of them, the three ones that you kind of need to know or like the ones to kind of commit to in terms of ascending pathways or sensory pathways are the dorsal columns. Um The spinal thalamic tract and spinocerebellar tract, spinocerebellar, I guess is less important, but definitely the top two um dorsal column and spinothalamic just know those and roughly where they are in the spinal cord because it could be quite useful, especially when it comes to um different spinal cord lesion's and spinal strokes and things. It can, it can really help to know where the tracks are. Um And so the dorsal columns are always at the back in the dorsal part from the spinal cord and spine, spinothalamic ones are always kind of towards the front. Um And so that's kind of how I sort of remember. Um And of course they have different functions. So dorsal column is discriminative touch or fine touch. Um and conscious pro preception and span Islamic, the lateral spinothalamic tract, which is the kind of majorly important one um is pain and temperature and then anterior spinal tract is pressure and crew touch and then spinocerebellar is unconscious, pro perception and also kind of input from muscle spindles. Um I think probably don't need to know much more about each track than that. Um This is just to show you the anatomy of the tract. So again, I'm sure we've covered this a lot. Um But essentially the major thing to know is that the first order on it comes in from the periphery via the dorsal horn and it sends immediately. So it doesn't cross over straight away. It sends via the um it, it sends via the fasciculus brazil is or cuneatus. And that just depends on whether it's coming from the lower upper limb by the way, just, just to point out. Um and then it synapses in the medulla and then when it, when it synapse onto the second order neuron, that's when it crosses over um to the other side or the contradiction side, and then it sends to the thalamus and it synapses in the thalamus before um a third order neuron projects to the cortex and that's the basic pathway. Um spine, Islamic tract is very different to that because it um comes into the spinal cord from the periphery and it immediately synapses. So um it will sign ups in substantial ethno psa and then second ordinary on will immediately Decca state, but it, it starts to decorate, but it does. So in a kind of graded manner and that you have um it ends up ascending a few levels before properly devastating. Um And that's so that's so it kind of doesn't immediately go over at the same level. It will, it will kind of crossover gradually. Um And you do have another connection between um those layers and that's called the attractiveness hour. But I won't go into that that much, I don't think because it's probably unnecessary. Um But anyway, so once it's crossed over, it sends to the thalamus and synapses in the thalamus gives order to the third order neuron and then that goes to the cortex um similarly to the last one. So it's kind of just important to know the difference between when they crossover because that can be useful when a patient presents with um you know, certain sided symptoms, like pain on one loss of pain, sensation on one side, it helps to know like what the tracks are doing. Um spinocerebellar tract. Um There are three different tracks which is why like, I don't think you need to know this really, I think maybe just knowing the function in general is probably enough. Um So I'm not going to go through this because it's not really clinically relevant um for the things that I'm going to be discussing. Um But just to know that you've got three different spinal cerebella tracks and they're the dorsal rostral and ventral. Um And like I was saying, they're important for unconscious pro preception. Um And yeah, I think we probably leave that there. Um These are the dermatome. Um I still forget these. I think the main ones that I try to commit to memory is like C five is kind of shoulder tip or like kind of C four, C five is shoulder tip. Um The nipple is T four, T 10 is around the umbilicus. Um And then the groin is sort of L1 L2 sort of region. Those are the main ones I've bothered remembering. And then also the fact that on the upper limb you've got um C six on the outside. Um T one on the kind of inside. And that's pretty much all I really bother remembering, but it's just good again to have an idea of the dermatome. Um because when a patient presents with loss of sensation in a certain area, um you can immediately try and pinpoint where the problem might be. Um And just as a reminder of water dermatome is, um it's an area of the skin that's supplied by specific spinal nerve. And so it's really helpful because if there is loss of sensation in the fingertip, then you might be able to localize the problem to a C seven cord injury, for example, or affecting the C seven nerve root or something like that. Um So it's really useful to, to know and then descending pathways. So these are the motor pathways and the most important one really is the corticospinal tract. It's kind of the only clinically relevant one um for most of what you end up needing to know. Anyway. Um so the corticospinal tract is split into a lateral and anterior tract and the lateral tract accounts for about I think 90 something percent of the fibers. So the most predominant one and the most important one is the lateral corticospinal. Um and that enables voluntary movements of the limbs. And then the anterior um is thought to be involved in voluntary control of the trunk and also postural control. Um and these are just other motor tracks that you probably have heard of already. Um So, rubrospinal, vestibulospinal, tectospinal and reticulospinal, the only thing to really say about it is um tectospinal is quite important for head movement and also moving the head towards a visual stimulus. Um Rubrospinal um is important for upper limb flex, atone on the contralateral side. And reticulospinal is important for voluntary movement of proxy, a war axial extensive and flex is this is kind of like a just memorize this from flashcards, I would say um it's, there's not really a lot of clinically relevant pathology for these tracks. The most important one is the corticospinal tract. Um I'm going to talk about that a bit more. So as I said, most of this tract is lateral fibers, it's 1990% is lateral fibers. Um The first ordinary on arises in the cortex. So the primary motor cortex specifically, um but also kind of rise from the supplementary motor area or the premotor cortex, which areas proximal to the motor cortex and kind of often feed into the corticospinal tracks. Um that then descends um and forms the internal capsule um which is this kind of thick red where these kind of these death of these like separate lines join. Um that's the internal capsule and that travels down towards the medulla and um they actually cross in the medulla. So you may have heard medullary pyramids and that's because um that's where all the fibers are crossing over there. And then the the second order neurons then um the second order neurons actually are lower down in the cord. So you don't actually have a synapse onto a second order neuron until you're actually at the anterior horn cell and then you sign ups there. And then that's the, that's the um peripheral motor nerve that will then be sent out um to innovate to limb. So you only have two neurons that make up distract rather than three like in the sensory tracks. And the important things to know clinically are um any lesions that happen above where the decoration happens. So above the level of medulla, essentially, you'll have contractual symptoms, which is why when you have a right sided stroke, you get left sided symptoms. Um and similarly lesions below the declaration point. So below the level of the medulla, you get it's actual symptoms. Um And so that's just something to um have in mind. It's important again for localizing pathology. And the other thing I wanted to quickly cover was this idea of upper motor neuron versus lower motor neuron symptoms. So up moving on symptoms are um I've just seen someone asking for the slides. I'm happy to give you the slides. I don't really know what the like policy is. So I have to check that. Um But yeah, I'm happy to give you these slides. I'll find out how I can do that. Okay. So um up motor neuron symptoms are spastic paralysis. So hypertonia increased muscle tone, hyperreflexia and clonus and also upgoing plantar's so positive Babinski sign, if you've ever seen one, um lower motor neuron signs are weakness and hypotonia, hyperreflexia or areflexia, so inability to elicit the reflex at all. Um and not just from being crap at it. Um Like genuinely you can't list it. Um And also for circulation's which are quite interesting to see if you've seen them um they really are just like kind of twitching of the muscles and it's quite cool, not cool, but, you know, interesting to see. Um and then muscle wasting as well is a sign of low motor symptoms. So it's useful to know this because it can help you to figure out whether there's an upper motor neuron apology or lower motor neuron pathology. Um But then of course, in some conditions like MND, for example, you can actually get a mixture of both upper motor neuron and lower motor neuron signs. So just something to be aware of. These are my tomes. I'm not going to talk about these. Other than to say, a myotome is a group of muscles innovated by a single spinal nerve root. Um So different from dermatomes, which is an area of skin innovated by a single route. Um and they're tested clinically by asking the patient to do certain things. So, um when you're kind of testing for power um doing a neuro exam and you're getting the patient to sort of resist you like pushing them or pulling them or whatever it might be. Um You're kind of testing myotomes in that way to see whether they're able to do these movements and with what level of power uh reflexes. Yeah. Again, just memorize these, the most important ones are the ones that I've put in bold. So the biceps reflex, um the spinal roots of those c 56 triceps, see 6 to 8. I've seen some sources saying C 67. So I think that's one of those, these things that just tend to vary based on what you're reading, but just roughly see, 6 to 8 is around about the right answer. Um, the knee jerk, L2 to 4 and ankle jerk as 1 to 2. Those are kind of the most important ones um, to remember. And the other kind of concept I wanted to um kind of go over again is this idea that that are just as their body maps in the brain. And there's kind of the sensory and motor homunculus. I um that our body maps within the spinal cord as well. And so essentially fibers within these tracks running through the cord are arranged in a way in a kind of spatial manner. So you've got um so for example, if we're looking at the, let's look at the corticospinal tract, so the red triangles towards the back of the cord, you can see that um in this diagram, it's split into say call lumber, thoracic cervical and cervical is kind of more medial and sacred is more lateral. And that means that all the fibers within the corticospinal tract are arranged in such a way that the sacred fibers are more lateral and the spike or fibers are more medial. And that's important to know because again, it can help with localizing pathology. So in like a we'll talk about this more in a bit. But for example, in a central cord syndrome or something like that, um you might only find that there are cervical or thoracic symptoms or the symptoms that could be localized to those areas. And that's because in a central cord lesion, only the center of the cord is affected. And that's because those are the two most medial um kind of fibers um within the parameters tract. Um So it's just useful to kind of know it helps you to localize what's going on and also to work out. Um if someone's got a specific cord syndrome, so we'll go over this more in a minute. Um But the main thing to remember, I've put in red, which is for the corticospinal tract and the spine Islamic tracks, the cervical tracks, a medial sacral is lateral and for the dorsal column it's reversed. So sacral is medial, cervical is lateral. Just remember that and you'll never get it wrong. Um Sorry, this is a lot of anatomy. I just felt like I needed to cover it before going through all the different pathologies because it just helps to have a thorough understanding of the anatomy. And I feel like this is the same with cranial neuro. It's like if you know the anatomy and you roughly kind of understand um the tracks and the relationships of things and the the the blood supply, everything makes so much more sense in terms of like when the patient presents to you and the symptoms they have um so vascular fighters, one called, there are three longitudinal arteries. Um There is one anterior spinal artery, which is the one at the front and surprisingly, um and to posterior spinal arteries, which have kind of connections between them. Um And the most important thing to really know about that is that because there's only one anterior spinal artery. Um It's kind of an issue because if you, if you get occlusion of that artery, you really do cut off a lot of supply and you'll show like it. And actually, there's a picture here that shows you. So if you look at the yellow picture, the with the yellow background, um if you look to see how much of the spinal cord is actually supplied by the anterior artery or branches of the anterior artery is quite big. Um compared to that supplied by the posterior artery, and there is definitely some collateral supply. But you can see how if you lose um supply to this anterior spell artery, you're losing function of a lot of the spinal cord. Um So that's kind of the main kind of clinically relevant point to be aware of. Um And yeah, so as I was saying, spinal spinal strokes most often occurred you to a schema of the A S A. So the anterior spinal artery and that's because you have a lack of collateral supply and it supplies so much of cord, it supplies two thirds compared to one third supplied by the posterior spinal artery. Okay. So getting onto the actual clinical stuff, I always found um spinal shock versus neuro cardiogenic shock and all these different things quite difficult to understand. So I've just included this slide sort of um provide a bit of a guide for that. So spinal shock is a transient loss of function below the level of cord injury. So when someone gets a spinal cord injury, um below that level, they will lose um reflexes and they will suffer with motor paralysis and possibly also autonomic dysfunction. In fact, definitely autonomic dysfunction. Um and that's the kind of transient thing that happens to all people. Um And then what might happen is after a few days um after the injury, the spinal reflexes become restored and then you end up with hyperreflexia. So when you see a patient and it's like, well, they have an app remote in your own leisure. And I don't understand why that you know, so why you might get hyperreflexia later on is because you get this initial period of spinal shock, which completely gets rid of all the reflexes. And then you get this hyperreflexia developing later on. I always found that concept really poorly explained when I was in medical school. So hopefully, that makes sense. Um And that will explain why sometimes you see that some patient's have hyperreflexia. Um some don't, it kind of depends how soon after the injury is, um it will most commonly occur after something like complete transactions, but it can occur in other cord syndrome. So, complete transactions when it's a complete sort of, if you imagine a knife wound, a knife going straight through the cord and cutting it completely, you would definitely get spinal shock after that, you can get it um with other cord syndromes as well. And in terms of the difference between spinal shock and neurogenic shock, spinal shock refers to the transient loss of sensory and reflex function below the level of injury, what I just described. Um but neurogenic shock is the inability to regulate important autonomic functions like heart rate, BP, temperature, etcetera. And that's because it's final called damage. Um So it's a type of distributive shock. If you've looked at kind of classification of shock, it's a distributive type of shock and that's because of loss of ability to regulate these important things. Um And that's what neurogenic shock is. So that's the difference. Um just to kind of highlight that. And I've just included this diagram to show you kind of how long the different phases of spinal shock and how the symptoms change over time. I found this a really useful diagram. Um So I've just included it. Okay. So moving onto cold syndromes, um I've kind of, I'm only going to talk about the most common ones um because some of these, I haven't really touched on a few of these, but I can't remember which ones I've covered in detail in which I haven't. So we'll just go through and I'll try and cover the ones that I haven't really gone over in much detail just for completeness. Um, the anterior called syndrome. I've already touched on this before when I showed you the anterior spinal artery and it's, it's um territory. Um an example of an anti record syndrome. it's essentially anything affecting the anterior part of the cord. But an example of that would be anterior spinal artery syndrome, which is due to a scheming of the anterior spinal artery um for many possible causes and I'll go through a few of those in a minute. Um But essentially you lose supply to the anterior two thirds of the cord, which is obviously a significant portion of the cord. Um The most common cause is actually I intragenic. Um So it's actually quite often due to cross clamping of the aorta during thoracic and triple A surgery. And I'm gonna show you a slide on that in a minute actually to explain that in a bit more detail. Um but other causes include direct injury. So, trauma, for example, if somebody like a knife wound or gunshot wound, um occlusion of the essay or hyperperfusion um for whatever reason. So, a throw probiotic disease or vasculitis, uh those sorts of things. Um And the most important thing with this is that the anatomy explains the presentation. So if you think about the things that are in the anterior part of the cord, so I've drawn these like not very well drawn green lines um to kind of portion the front two thirds which the anterior teeth included in that, that it makes sense why these symptoms are what they are. So, because you affect the corticospinal tract, um you get complete bilateral motor paralysis because of course, you've got loss of function on both sides. So you're gonna get bilateral motor paralysis below the level of the lesion, followed by um lower motor neuron signs at the level of the lesion and upper motor neuron signs below the lesion. Um And this is something else that I really struggle to understand until recently. The reason why you get um lower motor neuron signs at the level of the lesion is because at the level of the lesion, you cut off some of the um nerve roots coming out. And if you remember the nerve roots are the lower motor neurons, um which is why you get those signs at the level of the lesion because of damaged locally. And then everything below is upper motor neuron because those are the bits that are received, they're still kind of receiving the descending tract portion. They haven't actually synapse yet. So that's why you get lower motor neuron signs at the level of lesion of motor neuron signs below. Again, I didn't understand that concept for a long time. So I thought I would just highlight it. Um Spinothalamic tract is the other major pathway affected. So you're gonna get loss of pain and temperature sensation at um or below the level of the lesion. Um and you may also get the lateral horns being affected. And one thing I didn't mention is that the sympathetic um system neurons, they actually arise from the lateral horns of the thoraco lumber segment that I mentioned. So if you have um an anti record syndrome injury happening between T 12 L2, then you might also get um sympathetic dysfunction. Um because obviously, that's where all the outflow comes from. The important thing to note is that the dorsal columns are spared in an anti report syndrome. That makes sense because this posterior third pretty much wholly contains the dorsal columns and so those are spared. So you won't have any issues with pro preception um or fine touch. And I was, I don't really know, I was going forward this diagram. I think I was trying to kind of visualize the symptoms, potentially not that useful. So just kind of read what I've written rather than bothering much with this image. Okay. So I was saying about how the most common cause of Ontario called syndrome or one of the most common cause is, is um heterogenic. And so um linking to that because I was mentioning how part of that is due to Tripoli repair. So I'm just kind of linking onto this from that. So, an anterior segmental medullary vessel arises most commonly from the posterior intercostal artery which originates from the thoracic aorta. So I'm just kind of trying to navigate myself. Yep. So if you look at the diagram on the right, um the thoracic aorta is giving off to the posterior interhostel artery which I've um circled in orange, that kind of bends around and eventually gives off this artery called the artery of I actually can't pronounce this word. Um but it gives off the artery of Adam Kia, which hopefully, I said that right. Um And this artery is important because it's the only major arterial supply to the anterior spinal artery. Um And as I was saying, the anterior spinal artery, it provides, it has a big vascular territory, but it gets its major supply from that um artery of Adam Q, which artery and this particular artery is vulnerable to injury during triple A repair. And that's because when you do a triple A repair, if anyone's ever seen one, um you clamp the aorta either sides of the aneurysm. Um And normally sometimes there might be a kind of bypass, but often you'll just clamp it because the patient will be fine for however many hours or sort of fine. Um And because you're clamping the artery or kind of blocking the major blood flow through it. And so you can imagine how if you clamp this thoracic aorta or lower, you're going to lose some supply to the posterior intercostal artery. And then as a result of that, the artery of Adam Kia, which um that's going to cause um interest bile artery insufficiency. Um and it leaves you vulnerable to an anterior um spinal artery syndrome or an anti record syndrome. And that's bad because it can result in um paraplegia, bladder or bowel dysfunction and also sensory loss. Um And so that's just an important thing to be aware of. Okay. So plus posterior cord syndrome um is pretty much the reverse of the antiwrinkle syndrome. It's just that now the dorsal columns are affected. So, in terms of causes, I'll start with the causes, the causes are a bit different. So, um common, more common causes of posterior call syndromes are things like demyelination, uh which you can get an M S but also B 12 deficiency. Um So you may have heard of subacute um subacute, is it combined subacute degeneration of the cord or something like that? Um But that's associated with the B 12 deficiency. Um and you that then affects your posterior columns and also tertiary syphilis. So, back on one of the previous slides and I was showing all the cord syndromes, I think I had um neuro syphilis or tubs do solace. I think it was labeled as uh um So tabs dorsalis affects the other posterior part of the cord as well. And so you end up with damage the dorsal column and this how does present um it's actually typically unilateral. So you can imagine a demyelinating lesion is less likely to be bilateral. It's more likely to be unilateral if it's a single lesion. Um it um effects that also column. So you have loss of fine touch and pressure and pro perception, sensation below the lesion and that's also called sensory ataxia. Um and you also have, you can have some issues with the corticospinal tract as well. That depends on the extent of the lesion. So you may or may not have motor deficits. But the most, the thing that you most definitely will have is appropriate reception deficits and loss of fine touch and pressure as well. Um I did miss out some of these other causes which I probably should mention. So, um you could also have external compression from a tumor like a spinal tumor, um or mechanical degeneration of the spine. And you can also have posterior spinal artery occlusion. Um I think this is less common because of the fact that you have quite good collateral supply between the posterior spinal artery. So you'd be quite unlucky to have bilateral posterior spinal artery occlusions. But I suppose you could in theory get it. Um Yeah, that's posterior cord syndrome. I just alluded to. This is subacute combined generation of the cord. This is um B 12 deficiency that is so bad that it eventually causes demyelination and it affects the posterior and the lateral columns of the spinal cord and results in a posterior cord syndrome. Um and this is also associated with pernicious anemia. So, in a patient with pernicious anemia, um they're going to be um you might need to consider this as a potential issue in them because they're going to be resistant to B 12 supplementation or they can be um in terms of presentation. Um it's a gradual onset, starts in the upper or lower limb distantly. So it will kind of start distantly and move proximately. Um It will involve legs, arms and trunk bilaterally usually. And um there is weakness and stiffness and that's due to involvement of the corticospinal tract as well. You have tingling and numbness sensations. You may also have a positive romberg's um because of the sensory ataxia. Um If there's motor neuron involvement, then you also have a positive babinski sign, absent or reduced achilles and knee jerk reflex is um that's the interesting thing actually about this condition is that um you have positive Divinsky sign but absent or reduced achilles and knee jerk reflex is so the more proximal reflexes you lose, but you have a positive Divinsky signs, that's kind of a good way of differentiating this from other things. Um And you may also have possible bladder or bowel dysfunction. Um I've included some causes of B 12 deficiency, which I won't go into because it's not, I mean, you can just look this up um in your own time. Um But what you need to do with patient's like this is get them and me like very quick b 12 replacement because this sort of damage once it happens is irreversible. Um And then central called syndrome, I mentioned this briefly before. Um But this is a pathology affecting the central spinal cord. Um And I've just realized that the circle has moved from where I put it ignored the orange circle. Um It's not in the right place. Um But it usually involves the cervical cord, a central called syndrome. So it's usually in the upper part of the spinal cord. Um And in terms of how it looks or the affected tracks because it covers, if you look at the bottom image as opposed to the top image, um because it covers the sort of middle region of the cord, all the kind of medial parts of the of the tracks are affected and this results in a cape like deficit. And that's because I was telling you before how um the cervical regions are more medial. Um And that means that in the spine Islamic tract. And so they're, they are going to get pain in temperature loss from a central called syndrome, whereas the kind of distal like longer sacred regions won't. Um And that's because of um the arrangement of the tracks and the overlap with the lesion. So you get arm weakness but the legs are often spared. And that's because like I'm saying here, the the leg fibers are more natural, they should say not on um loss of pain, temperature, light touch and pressure below the level of the injury. Because of course, you're affecting the um spinothalamic tracked. Um is kind of a key component that's that's affected here and you also get loss of motor function. Um Yeah, that was the main thing I wanted to say about that in terms of how it's caused. Um it can be neck hyperextension in older people with spinal stenosis. Um So if you have spinal stenosis, which is narrowing of the canal, um you can be more prone to developing this sort of thing. Um One thing that you might see quite a lot is um Syrinx or Syringomyelia, which I think I'm going to talk about. Next. Yes. So Syringomyelia is a fluid filled cyst that forms within the cord and it's usually cervical. Um it grows over time and it compresses the cord from within. Um and it predominantly affects the spinothalamic tract initially. Um And then later, you may get corticospinal tract involvement. So you might get flaccid paralysis or an atrophy of the upper limb muscles due to destruction of the ventral horn cells later down the line. If the cyst grows, that was um so on the bottom left, you can see a picture of a fluid filled cyst and that's what a Syrinx looks like. Um and then I've also got a diagram of a person with the distribution of symptoms that I was talking about. So the cape like distribution. So you can see the arms are affected. Um And I kind of across the chest is affected, but the lower limbs and the trunk are completely spared and also the face. And again, that's because of the arrangement of the tracks. Um and causes of Syringomyelia, they can just be idiopathic and nobody really knows why. Um But patient's who have chiari malformations um are at high risk for Syringomyelia. And also, um there are other required causes. So if a patient has, it could be associated with an intra intra medullary tumor, um or it could be post traumatic um cyst formation as well. So it's just good to be aware of the different causes of that. Um So I was going to ask the question but it's very long. So I think I'm gonna skip it. Um But essentially this question was going to get at if I can get it to load Brown's Card syndrome. So this is one of those things that I think is actually quite like exceedingly rare in real life. But um it's always in exams. Um This has definitely been a couple of mine. Um But Brown's Card syndrome is a hemi cord syndrome which means half of the cord is affected or roughly half. It often is never as neat as uh only half, there's usually a bit of overlap or a bit less if that makes sense. But it's for simplicity, it's often termed as a hemi cord syndrome where one half of the cord is affected more than the other um complete hemi section of the cord is rare as I was kind of just saying it's never usually complete. Um but causes of a hemi called syndrome are things like M S lesion's. Um So I think actually the question I was going to ask you was 26 year old female with numbness in the left leg in blah, blah, was going to be M S um causing a branch of car syndrome. Um But you can also get this from penetrating injuries like knife or gun shot wounds, um as well as tumor's or vertebral fractures. And obviously, based on what those causes are, the natural history of the symptoms are going to differ. Um As I've mentioned in terms of what you get at the lesion, you get ipsilateral loss of all sensory modalities because those pathways haven't crossed yet. Um You get ipsilateral except for the pain and temperature, which I'll talk about in a minute. Um ipsilateral flaccid paralysis because um the upper motor neuron hasn't um has already crossed um at that point. So you get ipsilateral flaccid paralysis. Um and then below the lesion, you get ipsilateral upper motor neuron signs because of course, you're affecting the lesion before it sign ups on to a lower motor neuron. So it's up emotional signs. Um it's lateral pro perception um or find touch sensory loss. Um because if you remember the dorsal column doesn't cross until it's up in the medulla and then contralateral pain and temperature sensory loss. And that's because um the S T T kind of immediately synapses and immediately dictates um low down, lower down in the cord. And so you get contralateral pain and temperature, uh sensory loss and normally, so I don't know whether this is actually true because I've read different things, but something that I keep seeing is um you kind of get sparing of a few spinal levels and that's supposed to be due to this tract of LaSala, which is like a kind of um it's like a parallel tracked which can connect um some of the tracks when they cross over. Um It's like a, it's almost like a kind of alternative path um that can kind of spare sensory some of the sensation at those levels. Um So which is apparently why you get, you can get a bit of a buffer zone if that makes sense. Um But I don't actually know whether that happens in clinical practice or not. I've just sort of read that in different textbooks. Um But the main thing to be aware of is that you get ipsilateral everything except for pain and temperature, which is contralateral. And that's because of where the path where the pathway crosses over. So that's Bronze card. Um a complete transection of the cord, I'd already mentioned this before. Um So it's complete interruption of the white matter tracks, the gray matter and everything um of the cord and complete transactions usually going to be something that you only really see in trauma situations. I can't really imagine U M S and M S lesion getting this bad um to cause complete transactions before being, you know, recognized. Um at least in higher income countries, I would say. Um Yeah, I'm not sure how commonly M S can cause complete transactions, but anyway, it's listed as a potential cause. Um It's nearly always traumatic and like I said, there may be a period of spinal shock initially. Um and then there will be lower motor neuron signs at the level of the injury and then up emerging, you're on signs below the level of the injury. Um MRI is the investigation of choice because MRI is really good for looking at neural structures and you want to actually look at the cord of what's going on with it. So, on the right hand side, I've got a transactions at L1. Um and you can kind of just see if you, if you look at the CSF is bright white, the cord is this kind of area, this kind of grayish area, I believe. Um And you can kind of see how this white CSF is kind of cut almost cutting the cord in half, which is showing um the transactions. Um And this is MRI, so MRI is best for, for viewing this sort of thing. Um And then management depends on the cause. Um treatable causes are things like an epidural hematoma, um a cord compression because you can just decompress it. Um Obviously, if it's an irreversible cause you can't really do anything about it, which is quite sad. Um And also the other thing with this is that significant transactions can actually contraindicate surgery. So there's probably quite sad cases where you can't really do much. Um, other than a mobilize the c spine. And um the other thing I've noted as well is that if someone has a complete transection um above the sea three or five segments, then you have to think about because these are the phrenic nerve roots where the phrenic nerves come out and innovate the diaphragm. Um You would need to ventilate this patient pretty rapidly if you thought that that was going on because they won't be able to um innovate their own diaphragm because they have lost that innovation. Um I've included this, I don't know how much we need to know about this. It's just something that I think it may be useful to know. Um it's to do with cord injuries and I guess severity of function of functional loss as a result of that injury. So, um for example, e is completely, is kind of normal where motor and sensory function are completely normal. And then a is um no motor, no sensory know sequel sparing. And it's just a kind of way of grading the severity of the cord injury and the kind of functional deficit. Um, yeah, I think it's just good to be aware of that. And then the other thing I wanted to talk about was um cord injury and bladder function because this is another kind of, I found quite difficult concept to get your head around. So cord injuries can result in um bladder dysfunction in a variety of different ways. And the best way to think about this is um if you have to remember that the Conus medullaris is around L1. So that's the bottom of this. That's where the spinal cord itself ends. But then obviously, you've got the quarter equina um coming off from there and giving rise to all the other sort of nerves coming off. And those are essentially, um in fact, I'll get to that in a minute, I'll finish what I'm going to save us. So, patient's, if they have a cord injury, they are often catheterized in the early stages. And that's because of the fact that um they are at risk of bladder dysfunction as a result of their cord injury. And the two different, I guess bladder syndromes that you come across, um our reflex bladder or flaccid bladder. And these are essentially um different syndromes with a sort of different kind of mechanism depending on where the transactions is. So if you get a transactions above T 12, um I E before the spinal cord ends, um that's often called reflex bladder. And that's because you get Afrin signals from the bladder, um not being able to reach um the brain. So the patient has no awareness of bladder filling or kind of conscious control if that makes sense. Um And you lose descending control of the one of the external urethra sphincter. So that remains constantly relaxed. And so you lose this kind of conscious control is one side of it. But because you've got the transactions above T 12 spinal reflex, um which is kind of craniosacral outflow. Um because it's parasympathetic um because you've got that intact, you still have the spinal reflex occurring. So you still have parasympathetic innovation of the detrusor muscle of the bladder. So, in response to the bladder filling, so you might remember that what usually happens is the detrusor is a very kind of um not contract contract. I'll, well, it is contract, I'll, but essentially it will sense when the bladder fills. And then you'll get this automatic spinal reflex where the detrusor muscle contracts to be like, right, we need to empty the bladder and that will give you the urge to go and use the toilet. You've always got this, um You've always got this uh descending control over when you actually pass urine but obviously, in this case, you lose that because because those signals are interrupted, so you still have, that's why it's called reflex bladder because you still have the spinal reflex occurring, but you just lose constance control over it. So the bladder constantly empties as it feels essentially flaccid bladder. On the other hand, is, um usually what happens when you have transactions below T 12 and this is due to damaged um parasympathetic nervous system, out flow to the bladder. So, unlike with the previous case, where you have this intact spinal reflex, you lose that. Um And so you have complete paralysis of the detrusor muscle and loss of the spinal reflex. The bladder fills uncontrollably until it becomes reef full. It just ends and then it starts to, you get something called overflow incontinence, um which is when it just empties because it's too full rather than emptying as it feels that makes sense. And um I recently came across a different way of thinking about this, which made a bit more sense in that. Um If you consider reflex bladder, bladder as an upper motor neuron lesion, because remember I was saying how when you kind of give rise to the quarter equina and all the nerves that come off of that, you've got lower motor or I was explaining how at the level of a lesion um when there's damage, um you get lower motor neuron signs and then upper motor neuron below it's kind of similar in that. But if you consider the anything that's part of the spinal cord above the chord require as being an upper motor neuron lesion and anything below being a lower motor neuron lesion, it kind of makes sense because upper motor neuron, you think um specificity hypertonic and in this case, the bladder, the reef in reflex bladder, it is hypertonic, it's kind of contracting too much and contracting as it fills. And so you get like passing like these small amounts of urine when they shouldn't be passing at that point. And then on the other hand, um in atonic bladder or um flaccid bladder, you've, it's kind of like a lower motor neuron lesion because it's hypotonic. Um So I came across that quite recently and I just thought it was quite, it was an easy way for me to actually remember which one was, which um so feel free to use that if it's helpful to you. Um So called compression, I'm nearly done. I think I have. Um Yeah, I think I only have like um five slides left. So nearly there um called compression. I kind of came on to this a bit in the first section, but I wanted to go through all of the spinal neuro stuff before coming back to it. Um Called compression can occur as a result of um spinal trauma, vertical compression, fracture, intervertebral disc, herniation, primary or metastatic, lots of things basically. Um And that can result in spinal cord injury. Um It can be acute subacute or chronic. So, time timescales can vary um and it occurs because of direct cord damage by compression or infiltration, for example, due to metastases um or by comprised compromised vascular supply. So, are kind of different mechanisms for how this happens. But essentially um it's an emergency is the main thing to remember. So, acute cord compression is an emergency. Um called compression can be distinguished from called rick wina cord Aquinnah is sort of um critical cord compression if you like. Um and I'll talk more about called require a in a minute. Um but the cord compression um risk important risk factors to be aware of. If someone has any history of trauma, then this is something that you want to rule out particularly high energy traumas like road traffic accident, um high risk occupations, the older someone gets as well. Um Well, not necessarily actually certain age ranges um can make certain causes more likely. So it's kind of can be quite useful to consider um the age. So if someone's younger trauma is going to be a more likely cause and the level of cord compression is more like to be cervical because those are often affected in trauma because of hyper mobility of the c spine. Um And then if you're middle aged disk disease is more common to cause. So we're talking about herniated discs earlier. So they can be a cause of cord compression. Um So in middle aged people, you might be more kind of thinking about that. And as I was saying before L 45 L5 S one tend to be the most commonly affected areas. Um And then anyone kind of older than that or even middle aged and beyond, you won't be thinking about, you know, could this be malignancy? Um And the timeframe would probably help you to sort of consider whether that might be um an important consideration. Um There are other risk factors like male sex, osteoporosis, history of malignancy, etcetera. And in terms of and presentation can be extremely variable because obviously, it depends where the cord compression is happening. Um It depends on the symptom onset and the cause of this, of, of the, of the compression in the first place. But obviously, the sudden you'd want to do like a full neuro systems. So you want to do things like, do you have any back pain? Do you have any numbness, parasthesia, sensory changes, bladder or bowel issues, weakness? Um And then you want to look for things like hyperreflexia, um signs of shock, spinal shock. Um And you may also want to check check sphincter tone because if they lose that, that indicates severe cold compression. Um And in terms of diagnosis and management, um so I think I did kind of allude to this before. Um ultimately, management depends on the cause. So to find out the cause you're gonna want to do a series of investigations. But MRI MRI spine is the test of choice because obviously you're looking at a neural structure and MRI S are good for that. So I've got a good image in the middle here which shows um just a classic disc, Ernie Ation. Um and it's compressing the spine, you can see whether three hours of pointing at that compression. So you can see how well MRI shows that sort of thing. So it's the, it is usually the test of choice. Um And you also want to look for signs of chord edema because if there's chord edema and swelling of the cord, um that can suggest quite severe compression and that might make surgery more of a kind of, it might make it even more indicated. A CT can be used, but just MRI is a better, essentially other tests that can be useful. Um These are more just for kind of thinking about other possible causes. Um So I won't, I won't go through them in detail, but like I was saying, management depends on the cause. Um if someone's got spinal mats, you're probably not going to operate on them. Um, you know, because especially if it's kind of advanced disease, but if it's a herniated disk, you can quite easily operate on that and the prognosis would be quite good. Um So let's move on. Oh, yeah. Okay. So I wanted to quickly just mention spinal cord tumor's. Um Again, I'm not really that sure how clinic, how relevant these are. I've only ever seen these in like neurosurgery theaters um in Oxford, which are quite specialist. So I don't know how, how it applies to kind of general um and how kind of common they are, but um spinal mets are obviously quite common. Um And the main thing I wanted to point out um if I get my notes was that um Mets tend to be extra medullary. So just to describe the dichotomy between them, so intra medullary tumor's arise from the spinal cord tissue itself. Um not the meninges or the surrounding structures. Extradural tumor's arise from layers in case in the spinal cord. So that could arise from the juror. It could arise from um the nerve sheath encasing the nerve, but it doesn't arise from the cord itself. So that's important nomenclature to be aware of if someone's talking about an intra medullary tumor versus an extra medullary tumor, um extradural tumor's are outside the juror and they arise from external structures and press on the cord externally. So anything outside the juror would be called an extra dural tumor. Um This make this actually sounds very straightforward. Now, I'm now I'm saying it, but it's just um one of those things that when I first saw, I wasn't quite sure how to differentiate what, what's an entry medullary tumor versus extra medullary. But anyway, um Mets So spinal mats are usually um epidural or extradural. They don't usually managed to infiltrate into the juror. So that's just worth being aware of. Um And upend a moma's are the most common type of spinal cord tumor and they are intra medullary. This was the kind of only thing I wanted to say about that. So, um if you do see an uh spinal tumor is being operated on or an intra medullary tumor, it's probably an append a moma. Um So yeah, that's all I really want to say about that. Um This was the final question I was going to ask, but I think everyone will probably know the answer anyway because I haven't talked about it that much yet. Um So quarter Equina syndrome, this is compression of the nerve roots, L1 to S five um in the thecal sac of the lumber spine and most commonly kind of L4, L5 level. It's most commonly caused by disc herniation, which is what the little asterisk means. Um But there are obviously other important causes to be aware of like tumor's infections, um fractures, etcetera, spinal stenosis, especially in older people. Um The most important thing about this is that patient's, if you, if you have any sort of suspicion of cord required to the patient needs rapid um MRI and um diagnosis because they may require decompressive surgery. And that's usually, I mean, ideally within 24 hours, but absolutely within 48 hours of presentation. Um So what are the red flag symptoms for called require? Um That's things like bilateral sciatica. So, shooting leg pains down both sides is a classic picture. Um severe or progressive bilateral neurological deficit of both legs. So weakness in both legs, um saddle anesthesia or parasthesia. So, parasthesia is kind of like altered sensation. Um And anesthesia is like complete loss of sensation. And so, um good questions to ask people about, um, two pro but that is when you go, you know, when you go to the toilet, can you feel, um, the tissue when you're wiping? Um, that's quite a good question because if they say, oh no, actually I have something, then that's quite worrying because that's a sure sign of saddle anesthesia. Um, any difficulty starting to urinate or any impaired sensation of urinary flow, um, urinary retention plus or minus overflow incontinence, um, and lots of sensation of rectal fullness. A good way of asking about that. Is, are you making it to the toilet in time to open your bowels? Have you been incontinent um, by your bowels? That sort of thing? Um Not very nice questions to ask, but that will give you the answer that you need to know. Um, and also things like erectile dysfunction in men and there are some other important differentials to have in your mind. So, um, this other differential I came across was Conus Medullaris syndrome, uh, which I wasn't sure what the difference was until I looked this up. So, um Conus medullaris is um usually a result of tumor's or vascular abnormalities. Um and it affects the Conus medullaris nerve roots. Um And they're usually mixed up motor neuron and lower motor neuron signs. Whereas in quarter equina, they're pretty much all lower motor neuron signs. Um So that's kind of the key way that you distinguish them because obviously in Corsicana, you've got the weakness in the legs and that's, that's a lower motor neuron sign. Um Yes. So in terms of other differentials, there might be a chord in parked, there could be just monopoly of, of a part of the cord, but um called require red flags are really important to have in your mind and try and rule out. And like I was saying, diagnosis needs to be rapid, um prefer them based on clinical suspicion. Um Make sure you get an urgent MRI to confirm the cause as well because you need to know that it's operable essentially. Um And then the management is like I said, ideally, surgical decompression within 24 hours, but absolutely within 48 hours. Um and in um called required a syndrome bowel and bladder dysfunction is usually a late sign. So if somebody presents you and they've already got signs of incontinence, um then you're going to be quite worried because that's already quite progressed um presentation, okay. So, in terms of what you do to fix it um that you, you need to decompress them and decompress the spine. So there are three main techniques, there's something called a microdiscectomy. And actually what often happens is you get pairing of microdiscectomy with laminectomy and I did allude to this earlier. So, a laminectomy is when you remove all or part of the lamina and essentially the bone that's in the way when you're going in posteriorly um to be able to visualize the nerve roots. And then once you can see what is compressing the nerve, um whether it be a disc, for example, you can then remove whatever is compressing the nerve. Um And that's the microdiscectomy, for example. Um if there's a disc herniation, um and that's why you use the two things together because the microdiscectomy removes the disc. Um Laminectomy with fusion. Um This was something I read about it. Did I did read, I think I can't afford it was on, but it did say that it's rarely indicated. Um And essentially you put screws on each, you kind of screw. So you have the pedicles are on either side of the vertebra of wherever the kind of pathology is and you have rods on each side and connect them across. Um And then you put bone grafts to like enable fusion. Um I don't really know like what that, what that's talking about. Um I think just look it up, it's rarely used. Um I think the main thing to be aware of is laminectomy. Um and microdiscectomy because those are kind of the most important ones and disc our nation is one of the most, pretty much the most common cause of quarter equina. Um Yes, and this is actually my last slide. So I didn't really know where to put this because it's a congenital problem and it didn't really fit neatly into anywhere else. But I just wanted to mention it because I don't think will mentioned it um in his, so chiari malformations, these are quite rare. Um I've never personally seen one. Um but I do have colleagues who have seen them. Um And a chiari malformation is essentially where you've got downward placement or protrusion of the cerebella tonsils or content of the posterior fossa through the Foramen magnum. And I've got a picture on the right to show you what that looks like on an MRI. Um So you can see that the brain stem is hanging quite low through the Foramen Magnum and the cerebella tonsils are sticking down. Um And you can get different sort of types of chiari malformation based on severity. Type one is the most common and type one is shown in the middle um kind of schematic diagram where it's essentially you've got downward placement of the tonsils. They're definitely poking through the Foramen magnum, but type two is slightly more severe where you've got downward placement of the cerebellum brain stem and the fourth bench course, you've got a few more kind of those posterior fossa contents, herniating down type three. Um is the worst um form, I think the most severe form, um which is when you've essentially again, got everything going down and being compressed. Um because the foramen magnum is obviously a unmovable um or if it's really for these things to be protruding into, um in terms of what, how do you know that someone has this? It's usually actually quite vague. So things like headaches, um movement problems, swallowing problems and that will depend on how severe um they're chiari malformation is. So someone with a type one chiari malformation, you might not ever know that they have one, it might be fine found incidentally or they might have mild headaches, but equally, they might still not get picked up because you don't MRI everyone with a headache. Um So often these malformations, if they're not causing any real problems and they're not causing um you know, like severe compression of the brain stem and the upper cord, then you don't really do much. You just kind of manage the headaches um and monitor. But if you do have um compression of those vital structures, then you would need to surgically decompress them. And also if the, if the symptoms are super severe, so if they've got really bad headaches and swallowing issues, you'd probably um decompress them. Um So it kind of depends on the symptoms. Um That's what kind of did it takes the management otherwise you treat with pain killers for the headaches. And the only other thing I wanted to mention about this is that is to be important, is to be aware of important associations. So I did mention before how people with Syringomyelia. Um sorry, people with chiari malformations are at higher risk to develop a syrinx or assist in the spinal cord. So it's kind of important to be aware of that. And also people with Atlanto axial um instability issues can also have chiari malformations. Um So that's just another thing um to be aware of, I think that might be the end. Yes. Um I was trying to be quicker than well was yesterday. Um But I was only actually 10 minutes quicker. So, um if you've made it to this point. Um Thank you. Um But yeah, that's everything. So um if anyone has any questions, I'll just hang around for a bit. Um But thank you for coming. I think there is some feedback form somewhere perhaps. Yeah, if you go on the chat, there's a feedback form. Um and I'd be really grateful if you fill that out. Um Yeah, thank you very much for attending. I'll just wait for a few minutes and I'll also find out about the slides. So, thank you so much for doing that lovely presentation is extremely comprehensive and hopefully everyone found it as useful as I did. Um in terms of the slides, these videos are recorded in there available to view on the medal platform. But if it's all right with you Kelly, I can check if we can upload your slides onto the platform as well. Yeah. Yeah, I've been more than happy for them to be uploaded. Yeah. Um So I'll get that sorted out and they should be on there in the next few days then. Cool. Brilliant.