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Cervical Spine Fractures for Orthopaedic Exams
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Cervical Spine Fractures for Orthopaedic Exams
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Language: EN.
Segment:0 .
Ruth and Hannah from OR UK and one of our mentors, Joe budda, who recently passed his FRCS exam, so the program for this evening will be the lecture on cervical spine trauma, which will be followed by invited questions.
And we ask that you place these questions in the chat box and we will ask them at the end. The questions will be followed by an NICU poll to check your understanding. It's completely anonymous and Mr. kiefel will talk through the answers after you've all completed it. Following this, Mr. Kiefer will then talk through some case discussions and give his top tips for the physics.
Exam will then move on to our ever popular vyver session. If you would like to have a vibe of this evening, then please raise your hand and send a message to Hannah, Ruth or myself. But ideally Hannah, including your name. And when you plan to set the part two exam, we will give priority to those candidates in the order in which they volunteer and those who are sitting in February.
We understand that having a vyver in this environment can be a stressful experience, but understand that we're here to guide you and this is the best way to prepare. As always, we recommend our textbooks the concise, orthopedic notes by the Fox mentors and the books by the UK. And of course, so I believe the 9th of January course has only observer spaces.
But there is another course coming up on the 6th of March, which you can find through the UK website. So I would like to introduce to Mr. kiffer, who is a consultant, orthopedic surgeon in Surrey and Sussex health trust. He completed two spinal fellowships one at frimley park and the other one in Auckland. He's actively involved in training at local and regional levels and teachers regularly on Fox courses, so I'm sure he has a lot to teach us this evening, and his experience as a clinician and a trainer will be invaluable to us all.
So I'll hand over to you. Will thank you. Thanks very much. It's always alarming as a consultant when you see people who you have had as shouse or registrars over the years, and some of them, I believe, even from the other side of the world, which is quite interesting to see. Anyway, I will start with.
My presentation, so this is Fox style. It's about cervical spine trauma now, it's not going to be. Exhaustive by any stretch of the imagination, but it will include two of the high yield topics which come up in the fox, and they include CT fractures and subaxial fracture dislocations. This is not the textbook of cervical spine injury. It does, however, give you the opportunity to hear in some detail the kind of conversations that come up and also the sort of questions that get asked and specifically the things that you'll be expected to discuss.
And then we'll, as we said, we will go through some different points of how to answer questions with regards to the FRCS as well and some top tips. Hopefully, the other areas notable by their absence that you do need to cover C1 fractures can still come up or they rarely sub actual vertical body fractures are also part and parcel of the trauma setting. However, less likely, it seems through past questions.
Spinal cord injury is something that you can be asked specifically in basic science or indeed in the trauma setting and 80s management. Mean, obviously you never forget that that's an important part of everything that you do. Sorry, getting used to the controls. So we started with CT fractures and it's a bimodal distribution. It tends to see that the young, the very high energy, these are the people that tend to do something silly, throwing themselves off things that are too high or into things that are too shallow.
And then they tend to get C1 fractures more than C2. So the team stoning phase that went through about four or five years ago was rife with C1 fractures. And then we have a different pattern for the CT fractures in the elderly well or upper cervical spine, where you tend to see more C2 than see one. Now, if you think about why that is, it was taught to me by one of my fellowship supervisors.
If you ever look around on planes, if they're ever allowed to fly again at people when they fall asleep, most of us, if we fall asleep on a plane, when we're sitting up, our heads fall forward, don't they? And if you think of that movement and where it occurs, it tends to occur in your upper cervical spine around the C1 C2 joints. Now, if you think about. We'll see naughty ones here and see 1 to two, if you think about an elderly person, they tend to sleep completely upright because their neck is so spondylitis and where it's under attack, it tends to fail at the areas where there is the most amount of movement, for example, around the level where there's the most mobility, which is the C 1 to articulation, which will be lateral rotation.
And it takes the C one, takes it on to a peg with it. And always remember that the areas of the body that have the most mobility because of their anatomy are also the most prone to injury because they're the most unstable. So less bony constraint tends to lead to it being more liable to injury. The young versus the elderly are two very different beasts, and you have to equally bear that in mind when you are treating the patient, you've got a fragility fracture on one side as opposed to a very high energy injury, which is often associated with trauma in the other.
They tend to be hyperextension or hyperflexion injuries, and in the cervical spine, you see that about 30% of all spinal injuries are incurred there. And that's because the great big pendulum of the head wobbling around relatively unsupported on a small stick of spine to amongst those is the most common. And then 50% of those are redundancy process fractures and 50% are of and remember, sorry, with your rotation and your movements intense, the mobility 50% of your cervical spine flexion extension occurs at C Nazi one, and then 50% of the rotation of your neck occurs at C1 to the other levels make up the remaining 7% per level of the spine.
The anatomy is quite common, and it's relatively common to be passed one of these. And it helps you to also understand the relative instability that can occur as a result of my hand up. So is that my hand was that someone else's and the relative instability that occurs where you've got the C naught and C1 articulation up here with a very strong ligaments that attach it to there?
And then you have your C one vertebral body in your seat with your adultery process that actually is and is embryologically probably a remnant of the vertebral body that gets of C1 that gets left behind and then gets stuck on to C to. Across the back, this is a PR view of the bony anatomy. You can see the same ligaments, but then you've got this very important transverse ligament and therefore you can understand why when there's a fracture across the base of the head onto a process across here, why the odometry process goes with the C one as it's a Biloxi's.
Because these joints here, the facet joints are lateral mass joints here. As it rolls forward, that can serve blacks, and there's no longer any constraint in these capsules are really very fragile and flimsy, so they don't really control it. You also have got a little bit of it, this is a useful diagram to tell you the different nomenclature of the fractures that can occur.
And it's all color coded you. The commonest one being the Jefferson fracture, which is the burst with an actual load of the head essentially being squashed on top of the C one, which blows out the lateral masses either side. It's a ring. It tends to fail in two points and therefore can injure then. Also worth bearing in mind that when you do have that separation, that this ligament, the transverse ligament can stay intact or it can tear or move apart, and therefore you have a very unstable situation.
If you've lost your transverse ligament integrity because you've got no ability or the Allen ligament, you've got no ability to control the dens against the anterior arch. You've got your two classification processes, the classifications here, and it essentially boils down to your advantage process versus your parsing traject class, the classification system for your to process being the and Alonso.
And then you've got the Levine Edwards classification across. On this side, the entry process is relatively straightforward, and it explains usefully the relative stability and also the relative likelihood of union of these. And we can go on a little bit later to the reasons why that's important. The important thing with your Levine Edwards is essentially boils down to the disk and the subluxation.
So your disk is intact here and we're talking about the C two three disk here. So the C2 three disk is here in two. By definition, the disk looks partly injured and angulation is your modifier, so you can have a 2a here where it's tipped very far forward. You can see that angulation has increased. And then a type three, you have an associated bi facet dislocation as these have blocked off.
So the facet joint sitting here and it's across the areas, it's moved forward. So that's your type three, your hangman's, which is bilateral paths into articulation fractures. It tends to be a hyperextension injury, which fractures through the pars. And then you have a flexion moment which causes your PLL to injure and the disk injury after that. So you get the extension followed by the flexion of the hangman's.
And it doesn't take much imagination or many Hollywood films to make you realize that's probably a fairly accurate mechanism for that to occur. So a general rule for your initial management and going through tips for this with how you would approach anyone with a spinal injury, you always approach it with an effortless approach. Significant distracting injuries can occur and associated injuries, and you have to remember that specifically a hangman's fracture for 30% of them have an associated other C spine injury, and therefore you should always make sure that you approach everyone in the 80s walk will use to.
The immobilization can prevent spinal cord injury in a neurologically intact person, and it can also prevent it from a secondary injury. And someone who already has a spinal cord injury and the age chart. For those of you that aren't aware of it, which is the American Spinal Injury association, Charles is now considered the norm for assessing people's spinal cord function and also for any level of spinal cord injury.
It's a really useful documentation, and I implore anyone that has seen anyone with spinal injury to use that time, stamp it, put it in the notes because it's incredibly useful. And it's actually what makes the spinal cord injury units in the UK certainly will use as well. Imaging is always an important. Aspects of cervical spine injury and CTs very important.
And also an MRI scan ct, obviously revealing the bony injury extent in the MRI scan, looking at the cord itself, whether there's any cord contusion, and also looking at whether or not any disks or engine location of the disc, the bony anatomy and the vascular anatomy of the cervical spine is relatively consistent to the level of C2. After C to the vertebral artery, all bets are off. It can do all sorts of weird and wonderful things.
And also, as you know, the brain stem supply runs off the vertebral arteries or they contribute to it, and therefore you have to be fairly sure that those are intact before you start considering doing anything to them. So it's always worthwhile, including CT angiography. And so it runs through the intervertebral frame and it's from C6 up to see three.
It can go through to it can wrap around two, and then there's a rather tortuous course around see one that lies over the back of the lateral mass before they coalesce higher up within the skull. The Levine Edwards, and this is shamelessly stolen from auto bullets, because it's probably the most reliable and most UK centric way of treating these fractures essentially boils down to the classification.
So it's one of the classifications where it is incredibly useful as it guides treatment. Now with one, you can use a semi rigid cervical or faces for 6 to 12 weeks. And by that, I mean your Aspen's or your Miami js, you obviously want to perform radiographic follow up to make sure there's been no subluxation. Your tos. Reduce with traction and then you can use a halo vest for 6 to 12 weeks, or you can perform an open reduction fixation, or you can do a C two, 3 and two.
I could just get some infusion or you can do a C1 to three posterior fusion. Essentially, it probably needs to be stabilized in some way in the halo vest and traction you're relying on bony union itself, secondary union. However, with the other methods, you're relying on fusion of itself or fixation and primary bone healing to cause that. Be very wary and the importance of just between differentiating between two and 2a because traction with Tua can cause a lot of problems and you can cause cord injury because of the dislocation, so you should avoid using traction in a two way.
Hence, it's important to identify whether or not that disk is injured and gaps open. And also what's happened to the angulation there, because reducing it can pinch off the cord. And then three. Is egawa reduction in posterior fixation tends to be the method because you have to reduce those facets to fuse across the back.
So just some examples here of the various types that you can have affecting it, so you can see here where there's. Subluxation across the T three joints you can see here are paths fracture and you can see very nicely where the vertebral artery runs. And across there as well, you've got the pars, intra articular fractures. But even here, you can see the difference in sizes of the vertebral artery Freeman.
And therefore, you can also realize that the anatomy is incredibly variable, hence the need for a yangzhou in a lot of these cases. So moving on to your azonto process fractures. Broadly speaking, it relates to the classification again. Now this is young and old included, and I've tried to subdivide it slightly here. The important point here is that your risk factors for nonunion occur mostly with your type 2 fractures.
There are several reasons for that. There is the relative paucity of cancer of Kinsella's bone within the center of the process. There's a high cortical tennis ratio. Which doesn't lend itself well to being a union. There is also retrograde blood supply and the same as the sky for it, the same as the tolerance. There is often a problem with union across these bones, and also it's in a synovial joint itself to the C1 two joints around the level of the dental processes synovial and that has entrainment of synovial fluid as well, for example.
And that also explains why in severe rheumatoid arthritis, you've got such severe C1 two instability because that synovial joint would develop a huge amount of Panis and erode those ligaments, leading to a C 1 to instability from that perspective. Now, a type, I can be confused with the nausea, Don told him, and therefore it is often treated non operatively. A semi rigid cervical orthotics and aspirin Miami J is treated the treatment, I think personally, mostly for the benefit of the surgeon that's looking after the patient.
And in reality, you could potentially leave them free. However, let's just remind them that they've hurt their neck and that they're going to need to be a mobile and be careful for six weeks. But in reality, they're a very stable injury and are unlikely in the majority of cases to move. I type two, the management differs significantly between the young and the elderly, a young person, a halo vest or closed reduction internal fixation, and that's the anterior screw or screws that can be placed across borders direct assistance.
This obviously open reduction is very difficult. It's not impossible, but very difficult with regards to this. It's onto a process against the body of C2, but it is done, but it's usually a closed reduction. And then failing that, there are the various modalities of see 1 to two fusion. In the elderly, a cervical arthritis is occasionally an appropriate option. And this is where part of your exam technique comes in because you equally have to have an appreciation that the cervical process is not a benign treatment for someone in the elderly, and they are associated with significant pressure areas.
They also tend to collect cornflakes quite well, rather than actually providing any stability for the patient's neck. But again, it's a marker of a disease process. The fact that they fall, the fact that are osteoporosis can have a spondylitis neck. But certainly, you should stay well away from the German perspective of putting these people into halo vest or closed, reducing them because there's not a huge amount of evidence that that's beneficial.
And actually, there is decent evidence now that the mortality of patients with two fractures in the elderly is probably worse than the hip fracture. If you look at them on a similar Nottingham hip fracture scoring system or on a frailty index. Type three are good. You've gone through the cancellous bone at the base of the Add onto a process you're through into the body proper of C2, and therefore you've got a lot of bleeding cancer, this bone and a semi rigid cervical, although this often does quite nicely.
In your type 2s, you have additional risk factors for nonunion, so the patient factors we discussed the age, for example, smoker diabetics, and if they have any other immune suppression, then you have other fracture characteristics, which include their angulation being more than 10 degrees, either in any direction, displacement of more than 5 combination. And a fracture gap of more than a millimeter.
The important discussion point for that is, is that all non unions are not symptomatic. And by that, I mean to say that if a patient doesn't have radiographic evidence of union across their CT fracture and they are an 80 year old, you actually, if you perform flexion extension, views may find that they are stable because they've gone on to fibrous union and therefore chasing bony union for the sake of operative morbidity is not necessarily particularly helpful.
So it's a discussion with the patient and with the patient's next of kin about the fact, yes, it might not heal. However, there's a good chance that it will be stable enough to live the rest of their life without any complications. And spinal cord injury in the elderly is remarkably rare for this type of injury because they tend to be canal expanding rather than canal narrowing injuries.
Hey, we've got some decent rate, he got a CT scan of the different fractures, so you've got to see type 2 across there and a borderline two three, probably more or 3 because it does extend across the body on this side there. And then you've got the retrograde blood supply. There is an apical arcade across there, but the majority of the blood supply runs in through the base and therefore separating those same as the slap capsule, a hip fracture and displacing it tends to lead to death of that, and it does arise from the vertebral artery that's been asked before.
These are various types of fusion methods, so you have transatlantic particular screws, which is the maghull technique usually supplemented with a bone block and subliminal wiring at the back across here. And then you have the gold Harms technique here, which is essentially pedicle screws and lateral screws. So pedicle screws of C1 natural massive C to. And roads across there, these are from a-o and the vertebral arteries, you can see that's what the textbooks would tell you they do, but I've seen them on this side of the transverse process.
I've seen them coming in side, wrapping around. They do all sorts of weird and wonderful things. So angiography is certainly vital if you're considering doing posterior surgery at the C1 two level. This is mostly just to show that halo this kill elderly people. They cause huge amounts of morbidity, they cause pressure sores, they cause enormous issues. They cause pressure areas even underneath the sheepskin lining.
And they are incredibly disabling for people and lots of statements from various national bodies with regards to spinal surgery and spinal trauma show that halo vests are in fact use less and less, not just in the elderly, but also in younger cervical spine trauma. With the majority of people now replacing it with a semi rigid cervical or thesis, it is, however, still a skill that is expected of someone sitting the fix.
And therefore it's one of the things you need to be able to reel off is how you would put on a halo halo ring and halo vest. So we'll move on to some axilo fractured discussions. And talk a little bit about that, and what we have here is the most common ones, which stands to reasons around the C6 or five six six seven or C 71. And that stands to reason because that is the area where you have transition of stiffness from the relatively mobile cervical spine coming down to the relatively immobile thoracic spine.
And that levels of transition of stiffness is where you tend to have injury again because the pendulum effect of the head. And the fact that it's stuck on top of the spine and eventually the thing that will fail is where the stiffness suddenly increases dramatically. They tend to occur from blunt trauma. You can equally have road traffic accidents, road traffic collisions and falls, and a nice way of thinking them is the energy required is roughly inversely proportional to the patient's age, so therefore fall from a standing height, not unreasonably cause some actual fractiousness occasion and someone in their 80s.
However, someone in their twenties, you usually have to do something slightly silly at speed with the assistance of a car. The forces dictate the type of injury and will come onto that slightly later. But remember that all of these also are associated with other types of fractures, including teardrops. And there are two different types as the flexion and extension type, the extension type tends to be a small abortion that comes just off the inferior corner of anterior inferior corner of the vertebral body on the sagittal slice.
And then you get your flexion type of teardrop, which is actually a large fragment which comes across because it shears off as the flexion moment occurs. You can still have burst fractures, and you can also have compression fractures occurring in the actual spine as well. So mostly because it's the hot topic and the high yield topic, we'll talk about facets, fractious occasions, and you have to bear in mind that there are two very different types of mechanism now.
Nothing's obviously perfect in real life, however, it tends to be associated with a flexion and vertical loading moment that causes a facet fracture dislocation. So when the neck is flexed, then there's a vertical load which hitches the facets and therefore ruptures the disk more often than not, causing that by facet dislocation. A lateral flexion with a rotation, a lateral flexion opens one facet and then rotate reloading can either punch off and fracture across a facet, or it can hitch a facet over onto the other side, and that tends to cause a uni facet fracture dislocation.
Now, it won't surprise you to see that this is the same approach as I had before, and these are the things that you need to be able to tick off in your vyver answer. That's it that I like to teach on bCourses that I tend to teach on is. If you are approaching a Viva station and you don't know whether or not it is a Viva about AIDS or its survivor, about spinal cord injury or a facet or unique facet fracture dislocation, a really nice way of starting it is to say I would approach this patient in accordance with the artlols approach.
And then I'd say, however, can I assume this is an isolated injury? What you've done there is you've tick the box, you are safe and then you've also turned around and asked the examiners essentially face to face, saying, am I talking about the spine or am I talking about this? And the answer that they give you next, we'll tell you which direction the vyver usually needs to go.
So if you say I'll approach this patient with, according to acls, can I assume that this is an isolated injury and they say no, then you've missed something in the Atlas approach where they want to hear some buzzwords, be it see spinal mobilization and airway, or if they say yes, it's fine. This is an isolated injury. You can park the rest of that stuff and then you can move on to the meat of your injury that's faced in front of you.
And it works for other injuries as well, be it a complex femoral microfracture or pelvic fracture, for example. Again, always include the age of chart or an age, your assessment rather of the patient. Now, the question that is asked most frequently with regards to. And with some actual facts, in this case, these be the units that were buying facets.
Is when does the imaging happen? My answer to this, usually for the sake of the exam, is the hospital you work in for the Fox's the best hospital that has ever been built, which has 24/7 MRI scanners. It has 24/7 theater and it has access to absolutely everything. Therefore, your answer should always be emergency imaging. This is from the cervical spine trauma group, which is headed up by a guy called Alex Vaccaro in New York.
And this is the algorithm that they have proposed is your set your treatment for cervical facet dislocations. I disagree with this slightly, mostly on the grounds of the fact that you will never regret getting imaging, but the essence of the imaging conundrum is whether or not the disk has slipped within the canal and whether or not. It requires extraction prior to surgery from the back to unlock the facet joint so we can go through that slightly later.
But in my mind, someone who has a serious neurological deficit, I don't believe that there should be emergent closed reduction without getting an MRI scan in the UK practice because an MRI scan can happen relatively quickly in an emergency situation for someone with a spinal cord injury. And I think therefore, that should usually be your answer. That bear in mind that this does exist, this algorithm. So my algorithm for treating this is to say these injuries should be managed in the tertiary center equipped to handle major trauma.
And if you don't work in one of those, you are perfectly welcome to say my unit. It's not one of these. And this is the next most important sentence after the can. I assume this is an isolated injury? It's to turn around and say, however, the principles of their management are as follows. So you don't want to be the kind of person that says, I don't know what I'm doing, I'm not going to talk about it.
I'm going to send it up the road. You want to be the person sitting in the exam that says, I don't do this regularly, which is your Warning shot to say my unit isn't one of these. But then you say, however, I do know that the principles of the management are as follows and you treat the life threatening injuries first and you get an emergency tianzhou and MRI scan with the question of being where the disk is.
The variance to this are if they're unconscious and you can't assess their neurological status. Well, that's easy. You get some imaging, they're conscious and they're intact. That's again, very easy. You get the imaging because you can only stand to make them worse. They're conscious, but they've got a complete spinal cord injury to me.
I would still get some imaging because you want to know what is causing compression. Is it disc? Is it epidural hematoma? Is it something else? And that's a really important thing to me to want to be able to know what's going on and also what you're going to expect conscious with a stable neurological deficit.
I think that's still again inappropriate to get your imaging. And if they're conscious, whether they've got a rapidly deteriorating neurological deficit, this is where you may be. Try clothes reduction, but ideally again, get immediate imaging. So onto the next bit of how you reduce them, there are two different philosophies for this.
You can put Gordon wells tongs on, and they attached to the occipital protrusions just behind the ear lobe, and you essentially apply increasing weights over a ring in line and body in line with body weight and against the counterweight, which is the body in this case. And you start at 10 pounds in most places, you say you go up to a maximum of about 70 out. There are case reports of people needing to use 140 pounds to reduce by facet fractures, dislocations.
I would suggest that that's potentially a failure of analgesia in the case of the reduction, rather than necessarily requiring more brute force. It's done in theater under fluoroscopy, and you do repeat neurological examinations throughout after every weight that you add and you give it time at least 5 to 10 minutes after you've put on the extra weight and the patient is awake. However, they have analgesia and you have an anesthetist present because if it all goes horribly wrong, the person who's going to it out needs to be the person who's putting the traction on to resolve it.
What do you do if they worsen, you take the traction off and you see if they improve. And if they don't improve, you get an urgent MRI scan. There is an often quoted degree of subluxation, and I use the word probably here is quite a heavy caveat. It's talking about in the sagittal view and in the sagittal view. It's talking about the degree of this thesis, a degree of mondale's thesis.
If it's 25 percent, it's probably a unique facet of it's 25% or less. And if it's more than 50 percent, is probably by facet. However, there are lots of different variations to that. If you look at the plain film that's in the center of the screen, you can see the two red lines. Unfortunately, they're quite thick, but what it does show you is if you look at the longer of the two red lines that lines up to the spinous processes.
Of six, 7 and then down to the thoracic spine. The smaller one next to it lines up with the spinous processes of the upper cervical spine, and as you can see, there's been a step change. And that's because there is a rotational abnormality there. And that stands to reason that obviously one of the facets is hitched or is moved. In this case, you can actually see it here on the AP that there's asymmetry in that subluxation.
And therefore, there's a rotational moment which has moved the spinous processes. Now, if you look on the gap here, however, if you imagine that this is a big fat on the lateral side, if you imagine that there's a big facet dislocation, there's no reason why the spinous processes should change their rotation in this plane, so they would normally stay in roughly the same position.
So that's just an additional way of assessing that. So your treatment depends very much on where the disk is and whether or not the facet is locked or fractured. And also the status of the posterior ligaments is complex now. The disk is the important thing, because if you reduce the fracture dislocation or the locked facet and you've got disk which is wedged up and in and behind the cranial vertebral body, when you reduce it, you push that disk back and you knock it against the spinal cord.
And you can potentially worsen or cause catastrophic spinal cord injury. Hence, why you need to know where it is. If the facet is fractured, that's pretty good news, because actually with a little bit of traction, it usually all lines up quite nicely. If it's locked, then you have a different situation and that's where reduction becomes quite important.
The status of your posterior ligaments is complex. A rotational injury to your cervical spine in the form of a unit facet fracture dislocation doesn't always injure your posterior ligaments is complex because it puts it through torsion rather than through tension, and it fails under tension rather than under torsion. So you can often have an intact posterior ligament as complex in someone with a uni facet, fracture dislocation or unique facet dislocation.
However, with a facet by nature of the fact that both of the joints of slap lux, you often have a posterior ligaments complex injury, and you can see that with gapping of the spinous processes as they move apart. Now, knowing where the disk is important because I'm sorry, my spelling is terrible there, but if you have a disk that is going to push back against the spinal cord when you reduce it, you obviously can't reduce the fracture first.
And therefore your first port of call with surgery ends up being your anterior cervical disk to me to go in and to free out the disk and remove it from causing any potential problem when you reduce it. You then have to turn the patient prone. You do posterior release of the facet. Or rejection in some cases, you actually just have to bear away the locked part of the superior articulating process of the vertebrae below to allow it to reduce and then perform a posterolateral fusion with usually lateral mass screws or with pedicle screws, you then turn the patient back over again and you put in a usually bone block or an allograft into there and disk space, and then you play across the front of it to get them to fuse in the fullness of time.
But that obviously is a worst case scenario, but it all depends, as you can see on the position of the disk, because if the disk isn't a., you can actually say, well, this is fine, I'm going to go straight to the back. I'll do the posterior release of the facets, do the fusion, then go to the front, remove the disk and put it in a cage or a graft and a plate at that level. This is a 36-year-old man who was allegedly run over by his partner in a car park that morning.
I think the truth of the matter is that the partner met. The girlfriend is about 6 o'clock in the morning and the patient was unresponsive on the scene and bystander CDR was commenced. There was a ambulance paramedic crew that arrived who witnessed poor quality CPR, but the pulse of presence and they were ineffective restorations and the patient was clearly shocked and there was a rapid sequence induction at the scene.
And it was also felt there was decreased air entry on the right side with hypotension, so finger tracheostomy was performed on the scene. So it's a real, a real case, and you can see they've got the chest tube in place and the tube inside you there. Now, real case, obviously significant injuries, however, we're going to move on to the important part of the bit that we're talking about.
However, again, the same response again, always a less approach, distracting or associated injuries. In this case, you obviously can't assume it's an isolated injury, but you can ask if you can assume that this is the injury that we're discussing. And then your next question is what do you do next?
So we've got our seat trauma gram, which shows our midsagittal slide seat on the far left of the screen, you have to parasitical images there through the facet joints there. And as you can see, those facets have gapped open on the furthest to the right and there's a fracture through the one on the middle image there. If you look at the far left image as well, you can see that the disk space is widened posteriorly.
It's hinging at the front. There's also significant anterior soft tissue swelling. And if you look at the gap between the spinous processes posteriorly, there is a significant increase in that gap at that level, which is the L4 5 level that we're talking about. So things that I personally hate and think that is a very good trick to or very good habits get out of is don't say the most obvious.
One of the most obviously abnormality is because if you say it and you get it wrong, you look stupid because you've missed something even more obvious. So get into the habit of saying being confident if you are confident, obviously, and say there is so going back to that one, you would say. There is increase in disk space height at the back of the C4 five level, there's an increase in the spineless gap.
At the corresponding level, there is a fracture through one of the facets and there is a perched or significantly blocks facet on the contralateral side. So then we come on to this investigation, and this shows how important it is, and this is a CT angiogram, so you can see here in the intervertebral frame and you've got nice view there. And you've got a nice view there of an artery, and this is obviously at the higher level because it's at the level of the mandible.
And this corresponds to roughly the sea floor level. Now the interesting thing here is there is absolutely no flow lower down. So this is below the level, there is no flow there. So this is retrograde flow coming back through the vertebral through the Circle of Willis and then passing back down through the vertebral arteries. So there is no flow at this level and putting those things together, it stands to reason that probably what's happened is this patient's had a vertebral artery dissection or vertebral artery complete occlusion during the trauma, because remember is the same with every accident and every displacement you see, it's always looked worse than it did at the time where you see it in the scanning.
So his chin was probably against his sternum for a period of time at the injury. And therefore, he is almost certainly had a significant brain injury as well as having a significant cervical spine injury. The other important point to remember when we're looking at these injuries, remember we said we were dealing at the four or five level is that there is also phrenic nerve innervation.
And therefore there could be a significant risk of respiratory compromise as a result of this injury. Next, we move on to the MRI scan in order from left, right and the left side of the image, we've got a T1 weighted scan where you can see the anatomy quite nicely. Middle slices 82 important things to see on the T2 are you can see that the disk is injured.
The posterior longitudinal ligament is injured. If you trace the PLL down the back of the vertebral bodies, you see that suddenly there is a gap. And it's actually flicked up a part of the PLL. And you can also see that the anterior longitudinal ligament has ruptured anteriorly, and it's therefore as he's flexed forward, it's peeled off the front of the vertebral body below, which is C5.
You can also see some cord edema in this case. It's not myeloma. Later, in the acute setting, it's edema. And then at the back, you can see that there's again, this increased into spinal space. The far right image is a short sequence of fat saturation image, which shows edema very nicely, and you can see how much that posterior ligament is complex lights up and it also accentuates the spinal cord edema there.
And again, you can see that there's actually some hematoma that tracks further down inside the epidural space or the interior space. In this case, with a cord bleed or a cord a hematoma, sorry present their epidural hematoma. This shows you the degree of cord compression as a general rule, the spinal cord, this is an actual slice. As a general rule, the spinal cord should usually look like.
A fried egg with around area of CSF, with the cord being the central yolk. And here you can see the huge amount on the stair sequence of the. A dimmer that's associated with the injured posture, a lateral posterior ligament complex as well, and there also you can see where the disk has been injured has been extruded through onto that side. So if we go back, you can see that in this case, if you reduce this patient and say by some miracle, he was neurologically normal, if you reduced him back down again, you stand a very high chance of driving that, driving that disk further into the cord and therefore exaggerating his injury and his spinal cord injury, giving him a second hit.
So what happened to him? He had as a first stage, as we said, an anterior cervical disk to me, the interesting part here is that actually as his a cervical dissecting me as performed because he was so unstable, it actually reduced his by facet dislocation and therefore brought him back down again. So there wasn't need to do back front back because it reduced him back down there.
And therefore, as he was reduced into an anatomical position, he had the cage or a bit of bone block in this case, put in with screws going into the vertebral body above and below with a plate over the front. He was then placed prone and then from the back he had lateral mass screws inserted. This is the fracture lateral mass here, and therefore the anatomy is so distorted that they weren't able to place the screw at this level.
But he had two above and one below on this side as a tip for recognizing radiographs. Lateral mass screws go out and then pedicle screws go in. So these are all lateral mass screws as they're heading out of the outwards away from the spinal canal, whereas a pedicle screw. If you do use the cervical spine, they tend to move inwards.
So some tips for recognizing these, as we've mentioned before, the posterior ligament is complex and unique. Facet fractures aren't always injured, and therefore it's whether or not you necessarily have to always perform 360 degree surgery. By that, I mean and posterior surgery. And I think there might be something coming up in the cases where there are some examples of when and when, not when that's not necessary.
And isolated nerve root injuries when they occur due to a facet fracture dislocation, you rely slightly on the principle of an indirect decompression with the reduction of the fracture, rather than directly going and decompressing around that nerve root. The important thing to remember with spinal cord injury and with neural injury is that the damage occurred at the time of the trauma, and your general principle is to stabilize things, to allow things to recover and nature to take its course.
As long as you free up the nerve and make sure that it's not under continuous direct compression anymore. Then there is a good chance that it will recover at root level unless there's been a range of ocean. Hence, why indirect decompression can actually work quite nicely because the ligaments are taxes that reduces everything, allows the root and the cord some space to breathe, and therefore you are hoping that things wake up.
Laminar fractures are an unpleasant beast. They signify in the cervical spine that there is a significant risk of there being and injury underneath it, and that is not something that you look forward to encountering when you're doing posterior surgery. Hence, why direct decompression reduction of the fracture and then fixation fusion is often felt to be the most appropriate course of action because a large neural defect in the cervical region can be very tricky to manage and can cause ongoing problems and certainly wound issues in the posterior cervical spine, in body selection, elite sportsmen and patient for trauma.
I would always tend to use either allograft or autograft autographed to be try cortical iliac crest with plate supplementation, and that's because you are relying on them fusing and therefore you want to be able to see that there is bony union across those across the desk space between the vertebral bodies. A metal cage doesn't allow you to do that. And certainly takes a lot longer and peak.
There are plastic spaces are notoriously bad for doing that. So certain if you have these injuries in elite athletes and want to get back to Contact sports quickly, you need to see bony traject. Can you bridging the disk space and therefore the best choice is autographed, although allograft can sometimes be utilized as well if you don't want the morbidity from the donor site.
Your end point of your exam is to be safe in an emergency, the examiners are very aware that you are not a spinal surgeon. You are probably not going to be a spinal surgeon because you're all too sensible to think of anything as silly as that, and you're therefore safe in managing an emergency and know the principles of managing an emergency. Please avoid being the phone a friend or refer everything consultant because no one wants to hear that from the other side of the examination table or the examining room.
You don't want to be the person who says, oh, I'm not sure this is outside my remit. I'd phone my spine colleague the way of getting around that to say I don't do this routinely. However, the principles of management are is a way of just diffusing the situation. Be aware of the principles of management, spinal cord injury, my catch phrase for this is the principles management, spinal cord injury to prevent secondary injury.
Hence, the patient needs to be managed on a high level care bed where they have invasive cardiac monitoring to ensure that they've got a decent mean arterial pressure that usually means or to you, and also to stabilize the spine so that they aren't reliant on such intensive nursing care for mobilization and they can get up and get going. You need to know how to put on halo vest, and if you haven't done it, say you haven't done it, but certainly be able to read, how to do it, and describe how you do.
And bear in mind that the person asking you a spinal question is almost certainly not a spinal surgeon. And you probably know more about it than they do just before the exam. So have a little bit of solace in that. And then some textbooks, which are very good, and I recommend that you spend your hard earned money on them. And thank you very much, will. So I think Joe now has some questions for us, so we'll move on to the questions next few questions here.
First, how to differentiate between a teardrop and an ossified fracture. So that's sort of the same thing. So a teardrop, an osteopathic type fracture tends to occur when you have extension. And what happens is across the disk space where you have that little sign Desmond fight. Yes and again, call it the Desmond fight rather than your fight and where there's a small ligament of motion to pull off.
And it tends to be a hyperextension type injury where you just get that little pull off there. They can signify that there's significant instability in the patient if there's been a high energy mechanism. What we all tend to see is we tend to see it in these trauma, grabs the very elderly patients, and therefore I think it's reasonable. Rather than putting those people through the rigmarole of an MRI scan to perform flexion extension views of their neck.
At that stage, a proper teardrop fracture is usually a decent fragment, and it's of the vertebral body itself rather than a sindisiwe fight. And you can see that because it extends into the cancellous bone of the vertebral body. Right so the second question will be how long should the patient be allowed to be left in an extrication caller and whether or not there is any literature to back up the time?
So no, there isn't. There is. I teach TLS pretty regularly and involved in that. And there is an uphill struggle to take out the extrication collar now. And actually certainly a lot of the pre hospital services at present are now not putting patients in college routinely. And certainly our pre-hospital service have got a lanyard that they put around the patient to say I have not had my C spine immobilized.
That hangs around there just to make sure that people are aware of it in terms of leaving people in their horrible. They are utilitarian, but they really can cause significant issues. I would recommend getting someone else's arm within a few hours, if at all possible. And obviously, there is a base guideline all about clearing cervical spines in the non-responsive patient that you will need to know again for the exam.
But it's a short term thing and actually falling more out of favor at the moment. I'm not aware of any literature as to how long you can leave them for. Thank you. And how would you decide the stability of the sub axilo cervical fracture regarding the surgical fixation? So that's tricky.
I have done unique facets where we didn't even do MRI scans because of logistics. And actually, the feeling was that they were going to be stabilized in a collar for 6 to 12 weeks afterwards. And therefore that would allow the ligaments to heal up. And an MRI scan will give you a huge amount of information. And for the sake of the exam, if you're not going to get involved in the nuances of spinal surgery as a spinal surgeon, your answer should be I would assess the posterior ligament as complex with an MRI scan, which would help me to decide whether or not the patient required supplementary posterior fixation or fusion.
And that's your safest answer. If you want to be pushed into it, then you can turn around and say, well, actually, it's a sprain. It's a capsular injury rather than an evolution of the posterior ligament is complex. Probably I'll put them in the collar, and I wouldn't back it up with the morbidity of posterior surgery.
But you're knocking on the doors of sevens and definitely eights if you're having that conversation with your examiners. Yes, totally agree. And is it always the case that we need to stabilize anterior posterior fusion? So I think we've sort of just touched on that there. No, is the answer. And bear in mind that you are dealing with the level of instability.
So obviously, in the case that I showed you, there's a really obvious posterior injury that if you fix the managerially or hinging everything over that cage in that plate, and that's not enough and for nursing needs, because you don't want to have to nurse this guy on a collar forever and do log rolls, fixing his neck and making him stable is still a sensible thing to do. So it depends.
It's a case by case discussion, but your MRI scan will help with that. And the last question just now, how can we decide see one key to stability or key to stability in terms of the fractured pattern? Yeah, so flexion extension views are still useful. It's a cause of great consternation for every radiographer in the world. As you send someone down and say, take the collar off and get them to nod and extend its.
It's tricky, and your stability depends mostly on the fact that whether or not there has been a significant cord injury at the time of the injury in the elderly, so in the elderly patient, the general pathway for those of you who ever have to phone your friendly local neurosurgical department, they will almost always say, put them in a collar 4, 3, 2 six weeks to three months. Actually, the reality of it is, we all know is they tolerate it for about a week or they're noncompliant or they have severe dementia, and therefore they take it off.
And those patients don't come to significant harm, and it's probably because actually their spines are so stiff and spawned a lot anyway that they confer a degree of stability. And in terms of radiological assessment, you're looking for separation on the coronal view of the lateral masses, if you're looking at the C one two interval and then you're also looking for flexion extension movement, and you can look at the anterior and atlantoaxial interval as well to see if that's increased and also the padding as well.
It thank you. And is it necessary to get a city Ngo for every c-spine trauma in the exam? Yes you are safest. You have. You have this wonderful hospital like you see in whatever the American soaps, you can get whatever you want, and you will only regret not getting one.
So a CT yangzhou is a very reasonable course of action and actually really doesn't take that much to do because it's a very fast sequence. It's very quick. The patient's been near the CT scan already anyway, and it really can change your management. So for the sake of the exam and you're looking for vertebral artery injury, vertebral artery dissection.
And that's your reason. So you should do it. Yeah, I think that I can find any other questions if I missed any, please can any of the participants write it again? And I will ask Mr. kiffer, thank you very much for now for answering all the questions. No worries. Thanks, Joe.
Thank you. It's a really interesting lecture. Yeah, I quite enjoyed that, because I don't see a lot of spine where I work at the moment, but I remember revising it for the exams. So what we're going to do next is we're going to move on to the MSCI polls, so Ruth will share that for us. As I said before, it's all anonymous, so the sooner that you complete it, the sooner we can move on to a discussion of the answers.
And then we'll move on to the best part of the evening, which is Survivor practice. So and this is essentially just an assessment of your knowledge of the ants and Alonso classification of soil fractures, a type Ii being the commonest in the elderly and being a high risk for non union for all of the reasons that we went through. You've picked up on the medical school trick of always is a bad word and doesn't tend to apply in any exam answer because medicine isn't an exact science.
And type I would be the one that tends to be confused with the knowledge an idiom. Is unstable because of the configuration tends to be communist in the older group and doesn't always involve disruption, the transverse ligament, in fact, rarely involves disruption the transverse ligament. So moving on to the next one, a C6 7 by facet dislocation. Often has an intact vertical disk is incorrect, because usually you ruptured at least the posterior wall of the disk with that increased disk space, so it often has an injured intervertebral disk is how I would rephrase that.
If it's the other way is not associated with significant neurological injury, no, it can be associated with devastating neurological injury. And occurs following a lateral flexion moment, and that is the trick about differentiating between your bypasses in your unique facet. So a uniform is a lateral flexion moment with a rotational force as well.
Often requires anterior and posterior surgery, yes, for the reasons that we've been through and whether or not that's anterior, posterior, anterior or just posterior anterior remains or just down to your posterior, sorry is obviously a patient specific problem, and it's beyond the remit of the exam, I would say. And would cause isolated lower extremity neurological deficit, again, just a small anatomy question note, because if it's going to cause neurological deficit, it's going to happen at the seven grassroots level or the C seven level, and therefore you're going to get up a limb neurological deficit as well.
Next one's a slight nuance of the Asia examination and the Asia examination chart for those who don't use it is pretty prescriptive and actually is a very useful language. So I appreciate why some of you have gone for contestant number one. Being biceps motor function, because obviously a lot of people are taught that. Five 6 is your biceps motor function.
However, for the sake of Asia, that is a C5 motor route, that's a C5 Maya time is your biceps motor function. However, your thumb index finger sensory function corresponds to C six wrist. Extensor motor function is what Asia calls your C six motor. And however, it's not your lateral elbow because that's your C five Dermot's triceps then being C8. That's right.
And then again, your small hand muscle function, it's quite vague. That usually associated with T. One with a small hand muscle function with your fingers spreading risk 6/10 of most function, yes, that's a C six my thumb and index finger sensory function. Yes, that's the C six attainment, according to Asia. So the trick here is the Asia charts and hence the way the question was phrased, the question on the chat.
How would a city and you change the management? So CCN changes the management in terms of whether or not you need to do an open approach. So if it's bilateral, you would probably need to perform repair of the virtual artery and you'd need your friendly vascular or neurosurgical colleagues to come and help you do that. And that's quite an involved process. You can shunt it.
You can basically do of spinal approach where you take down the foramen and then you shunt across it, and that's to try and return part of your vascular supply. If that's only if it's bilateral, if it's unilateral, it tells you where you've got to be really, really careful about not injuring the contralateral side. So therefore, your unilateral injury. First of all, if you go in and you are faced with a hell of a lot of bleeding on one side, when you're putting in your lateral mass screws, it's probably not because you've caused a vascular injury.
It's probably because there's been a dissection or an injury to the vertebral artery. So it just gives you a bit of advice about when you're a bit more information about when you're fixing and whether or not you need to phone a friend to be there in theater with you to try and re plumb this person.
Segment:0 .
Ruth and Hannah from OR UK and one of our mentors, Joe budda, who recently passed his FRCS exam, so the program for this evening will be the lecture on cervical spine trauma, which will be followed by invited questions.
And we ask that you place these questions in the chat box and we will ask them at the end. The questions will be followed by an NICU poll to check your understanding. It's completely anonymous and Mr. kiefel will talk through the answers after you've all completed it. Following this, Mr. Kiefer will then talk through some case discussions and give his top tips for the physics.
Exam will then move on to our ever popular vyver session. If you would like to have a vibe of this evening, then please raise your hand and send a message to Hannah, Ruth or myself. But ideally Hannah, including your name. And when you plan to set the part two exam, we will give priority to those candidates in the order in which they volunteer and those who are sitting in February.
We understand that having a vyver in this environment can be a stressful experience, but understand that we're here to guide you and this is the best way to prepare. As always, we recommend our textbooks the concise, orthopedic notes by the Fox mentors and the books by the UK. And of course, so I believe the 9th of January course has only observer spaces.
But there is another course coming up on the 6th of March, which you can find through the UK website. So I would like to introduce to Mr. kiffer, who is a consultant, orthopedic surgeon in Surrey and Sussex health trust. He completed two spinal fellowships one at frimley park and the other one in Auckland. He's actively involved in training at local and regional levels and teachers regularly on Fox courses, so I'm sure he has a lot to teach us this evening, and his experience as a clinician and a trainer will be invaluable to us all.
So I'll hand over to you. Will thank you. Thanks very much. It's always alarming as a consultant when you see people who you have had as shouse or registrars over the years, and some of them, I believe, even from the other side of the world, which is quite interesting to see. Anyway, I will start with.
My presentation, so this is Fox style. It's about cervical spine trauma now, it's not going to be. Exhaustive by any stretch of the imagination, but it will include two of the high yield topics which come up in the fox, and they include CT fractures and subaxial fracture dislocations. This is not the textbook of cervical spine injury. It does, however, give you the opportunity to hear in some detail the kind of conversations that come up and also the sort of questions that get asked and specifically the things that you'll be expected to discuss.
And then we'll, as we said, we will go through some different points of how to answer questions with regards to the FRCS as well and some top tips. Hopefully, the other areas notable by their absence that you do need to cover C1 fractures can still come up or they rarely sub actual vertical body fractures are also part and parcel of the trauma setting. However, less likely, it seems through past questions.
Spinal cord injury is something that you can be asked specifically in basic science or indeed in the trauma setting and 80s management. Mean, obviously you never forget that that's an important part of everything that you do. Sorry, getting used to the controls. So we started with CT fractures and it's a bimodal distribution. It tends to see that the young, the very high energy, these are the people that tend to do something silly, throwing themselves off things that are too high or into things that are too shallow.
And then they tend to get C1 fractures more than C2. So the team stoning phase that went through about four or five years ago was rife with C1 fractures. And then we have a different pattern for the CT fractures in the elderly well or upper cervical spine, where you tend to see more C2 than see one. Now, if you think about why that is, it was taught to me by one of my fellowship supervisors.
If you ever look around on planes, if they're ever allowed to fly again at people when they fall asleep, most of us, if we fall asleep on a plane, when we're sitting up, our heads fall forward, don't they? And if you think of that movement and where it occurs, it tends to occur in your upper cervical spine around the C1 C2 joints. Now, if you think about. We'll see naughty ones here and see 1 to two, if you think about an elderly person, they tend to sleep completely upright because their neck is so spondylitis and where it's under attack, it tends to fail at the areas where there is the most amount of movement, for example, around the level where there's the most mobility, which is the C 1 to articulation, which will be lateral rotation.
And it takes the C one, takes it on to a peg with it. And always remember that the areas of the body that have the most mobility because of their anatomy are also the most prone to injury because they're the most unstable. So less bony constraint tends to lead to it being more liable to injury. The young versus the elderly are two very different beasts, and you have to equally bear that in mind when you are treating the patient, you've got a fragility fracture on one side as opposed to a very high energy injury, which is often associated with trauma in the other.
They tend to be hyperextension or hyperflexion injuries, and in the cervical spine, you see that about 30% of all spinal injuries are incurred there. And that's because the great big pendulum of the head wobbling around relatively unsupported on a small stick of spine to amongst those is the most common. And then 50% of those are redundancy process fractures and 50% are of and remember, sorry, with your rotation and your movements intense, the mobility 50% of your cervical spine flexion extension occurs at C Nazi one, and then 50% of the rotation of your neck occurs at C1 to the other levels make up the remaining 7% per level of the spine.
The anatomy is quite common, and it's relatively common to be passed one of these. And it helps you to also understand the relative instability that can occur as a result of my hand up. So is that my hand was that someone else's and the relative instability that occurs where you've got the C naught and C1 articulation up here with a very strong ligaments that attach it to there?
And then you have your C one vertebral body in your seat with your adultery process that actually is and is embryologically probably a remnant of the vertebral body that gets of C1 that gets left behind and then gets stuck on to C to. Across the back, this is a PR view of the bony anatomy. You can see the same ligaments, but then you've got this very important transverse ligament and therefore you can understand why when there's a fracture across the base of the head onto a process across here, why the odometry process goes with the C one as it's a Biloxi's.
Because these joints here, the facet joints are lateral mass joints here. As it rolls forward, that can serve blacks, and there's no longer any constraint in these capsules are really very fragile and flimsy, so they don't really control it. You also have got a little bit of it, this is a useful diagram to tell you the different nomenclature of the fractures that can occur.
And it's all color coded you. The commonest one being the Jefferson fracture, which is the burst with an actual load of the head essentially being squashed on top of the C one, which blows out the lateral masses either side. It's a ring. It tends to fail in two points and therefore can injure then. Also worth bearing in mind that when you do have that separation, that this ligament, the transverse ligament can stay intact or it can tear or move apart, and therefore you have a very unstable situation.
If you've lost your transverse ligament integrity because you've got no ability or the Allen ligament, you've got no ability to control the dens against the anterior arch. You've got your two classification processes, the classifications here, and it essentially boils down to your advantage process versus your parsing traject class, the classification system for your to process being the and Alonso.
And then you've got the Levine Edwards classification across. On this side, the entry process is relatively straightforward, and it explains usefully the relative stability and also the relative likelihood of union of these. And we can go on a little bit later to the reasons why that's important. The important thing with your Levine Edwards is essentially boils down to the disk and the subluxation.
So your disk is intact here and we're talking about the C two three disk here. So the C2 three disk is here in two. By definition, the disk looks partly injured and angulation is your modifier, so you can have a 2a here where it's tipped very far forward. You can see that angulation has increased. And then a type three, you have an associated bi facet dislocation as these have blocked off.
So the facet joint sitting here and it's across the areas, it's moved forward. So that's your type three, your hangman's, which is bilateral paths into articulation fractures. It tends to be a hyperextension injury, which fractures through the pars. And then you have a flexion moment which causes your PLL to injure and the disk injury after that. So you get the extension followed by the flexion of the hangman's.
And it doesn't take much imagination or many Hollywood films to make you realize that's probably a fairly accurate mechanism for that to occur. So a general rule for your initial management and going through tips for this with how you would approach anyone with a spinal injury, you always approach it with an effortless approach. Significant distracting injuries can occur and associated injuries, and you have to remember that specifically a hangman's fracture for 30% of them have an associated other C spine injury, and therefore you should always make sure that you approach everyone in the 80s walk will use to.
The immobilization can prevent spinal cord injury in a neurologically intact person, and it can also prevent it from a secondary injury. And someone who already has a spinal cord injury and the age chart. For those of you that aren't aware of it, which is the American Spinal Injury association, Charles is now considered the norm for assessing people's spinal cord function and also for any level of spinal cord injury.
It's a really useful documentation, and I implore anyone that has seen anyone with spinal injury to use that time, stamp it, put it in the notes because it's incredibly useful. And it's actually what makes the spinal cord injury units in the UK certainly will use as well. Imaging is always an important. Aspects of cervical spine injury and CTs very important.
And also an MRI scan ct, obviously revealing the bony injury extent in the MRI scan, looking at the cord itself, whether there's any cord contusion, and also looking at whether or not any disks or engine location of the disc, the bony anatomy and the vascular anatomy of the cervical spine is relatively consistent to the level of C2. After C to the vertebral artery, all bets are off. It can do all sorts of weird and wonderful things.
And also, as you know, the brain stem supply runs off the vertebral arteries or they contribute to it, and therefore you have to be fairly sure that those are intact before you start considering doing anything to them. So it's always worthwhile, including CT angiography. And so it runs through the intervertebral frame and it's from C6 up to see three.
It can go through to it can wrap around two, and then there's a rather tortuous course around see one that lies over the back of the lateral mass before they coalesce higher up within the skull. The Levine Edwards, and this is shamelessly stolen from auto bullets, because it's probably the most reliable and most UK centric way of treating these fractures essentially boils down to the classification.
So it's one of the classifications where it is incredibly useful as it guides treatment. Now with one, you can use a semi rigid cervical or faces for 6 to 12 weeks. And by that, I mean your Aspen's or your Miami js, you obviously want to perform radiographic follow up to make sure there's been no subluxation. Your tos. Reduce with traction and then you can use a halo vest for 6 to 12 weeks, or you can perform an open reduction fixation, or you can do a C two, 3 and two.
I could just get some infusion or you can do a C1 to three posterior fusion. Essentially, it probably needs to be stabilized in some way in the halo vest and traction you're relying on bony union itself, secondary union. However, with the other methods, you're relying on fusion of itself or fixation and primary bone healing to cause that. Be very wary and the importance of just between differentiating between two and 2a because traction with Tua can cause a lot of problems and you can cause cord injury because of the dislocation, so you should avoid using traction in a two way.
Hence, it's important to identify whether or not that disk is injured and gaps open. And also what's happened to the angulation there, because reducing it can pinch off the cord. And then three. Is egawa reduction in posterior fixation tends to be the method because you have to reduce those facets to fuse across the back.
So just some examples here of the various types that you can have affecting it, so you can see here where there's. Subluxation across the T three joints you can see here are paths fracture and you can see very nicely where the vertebral artery runs. And across there as well, you've got the pars, intra articular fractures. But even here, you can see the difference in sizes of the vertebral artery Freeman.
And therefore, you can also realize that the anatomy is incredibly variable, hence the need for a yangzhou in a lot of these cases. So moving on to your azonto process fractures. Broadly speaking, it relates to the classification again. Now this is young and old included, and I've tried to subdivide it slightly here. The important point here is that your risk factors for nonunion occur mostly with your type 2 fractures.
There are several reasons for that. There is the relative paucity of cancer of Kinsella's bone within the center of the process. There's a high cortical tennis ratio. Which doesn't lend itself well to being a union. There is also retrograde blood supply and the same as the sky for it, the same as the tolerance. There is often a problem with union across these bones, and also it's in a synovial joint itself to the C1 two joints around the level of the dental processes synovial and that has entrainment of synovial fluid as well, for example.
And that also explains why in severe rheumatoid arthritis, you've got such severe C1 two instability because that synovial joint would develop a huge amount of Panis and erode those ligaments, leading to a C 1 to instability from that perspective. Now, a type, I can be confused with the nausea, Don told him, and therefore it is often treated non operatively. A semi rigid cervical orthotics and aspirin Miami J is treated the treatment, I think personally, mostly for the benefit of the surgeon that's looking after the patient.
And in reality, you could potentially leave them free. However, let's just remind them that they've hurt their neck and that they're going to need to be a mobile and be careful for six weeks. But in reality, they're a very stable injury and are unlikely in the majority of cases to move. I type two, the management differs significantly between the young and the elderly, a young person, a halo vest or closed reduction internal fixation, and that's the anterior screw or screws that can be placed across borders direct assistance.
This obviously open reduction is very difficult. It's not impossible, but very difficult with regards to this. It's onto a process against the body of C2, but it is done, but it's usually a closed reduction. And then failing that, there are the various modalities of see 1 to two fusion. In the elderly, a cervical arthritis is occasionally an appropriate option. And this is where part of your exam technique comes in because you equally have to have an appreciation that the cervical process is not a benign treatment for someone in the elderly, and they are associated with significant pressure areas.
They also tend to collect cornflakes quite well, rather than actually providing any stability for the patient's neck. But again, it's a marker of a disease process. The fact that they fall, the fact that are osteoporosis can have a spondylitis neck. But certainly, you should stay well away from the German perspective of putting these people into halo vest or closed, reducing them because there's not a huge amount of evidence that that's beneficial.
And actually, there is decent evidence now that the mortality of patients with two fractures in the elderly is probably worse than the hip fracture. If you look at them on a similar Nottingham hip fracture scoring system or on a frailty index. Type three are good. You've gone through the cancellous bone at the base of the Add onto a process you're through into the body proper of C2, and therefore you've got a lot of bleeding cancer, this bone and a semi rigid cervical, although this often does quite nicely.
In your type 2s, you have additional risk factors for nonunion, so the patient factors we discussed the age, for example, smoker diabetics, and if they have any other immune suppression, then you have other fracture characteristics, which include their angulation being more than 10 degrees, either in any direction, displacement of more than 5 combination. And a fracture gap of more than a millimeter.
The important discussion point for that is, is that all non unions are not symptomatic. And by that, I mean to say that if a patient doesn't have radiographic evidence of union across their CT fracture and they are an 80 year old, you actually, if you perform flexion extension, views may find that they are stable because they've gone on to fibrous union and therefore chasing bony union for the sake of operative morbidity is not necessarily particularly helpful.
So it's a discussion with the patient and with the patient's next of kin about the fact, yes, it might not heal. However, there's a good chance that it will be stable enough to live the rest of their life without any complications. And spinal cord injury in the elderly is remarkably rare for this type of injury because they tend to be canal expanding rather than canal narrowing injuries.
Hey, we've got some decent rate, he got a CT scan of the different fractures, so you've got to see type 2 across there and a borderline two three, probably more or 3 because it does extend across the body on this side there. And then you've got the retrograde blood supply. There is an apical arcade across there, but the majority of the blood supply runs in through the base and therefore separating those same as the slap capsule, a hip fracture and displacing it tends to lead to death of that, and it does arise from the vertebral artery that's been asked before.
These are various types of fusion methods, so you have transatlantic particular screws, which is the maghull technique usually supplemented with a bone block and subliminal wiring at the back across here. And then you have the gold Harms technique here, which is essentially pedicle screws and lateral screws. So pedicle screws of C1 natural massive C to. And roads across there, these are from a-o and the vertebral arteries, you can see that's what the textbooks would tell you they do, but I've seen them on this side of the transverse process.
I've seen them coming in side, wrapping around. They do all sorts of weird and wonderful things. So angiography is certainly vital if you're considering doing posterior surgery at the C1 two level. This is mostly just to show that halo this kill elderly people. They cause huge amounts of morbidity, they cause pressure sores, they cause enormous issues. They cause pressure areas even underneath the sheepskin lining.
And they are incredibly disabling for people and lots of statements from various national bodies with regards to spinal surgery and spinal trauma show that halo vests are in fact use less and less, not just in the elderly, but also in younger cervical spine trauma. With the majority of people now replacing it with a semi rigid cervical or thesis, it is, however, still a skill that is expected of someone sitting the fix.
And therefore it's one of the things you need to be able to reel off is how you would put on a halo halo ring and halo vest. So we'll move on to some axilo fractured discussions. And talk a little bit about that, and what we have here is the most common ones, which stands to reasons around the C6 or five six six seven or C 71. And that stands to reason because that is the area where you have transition of stiffness from the relatively mobile cervical spine coming down to the relatively immobile thoracic spine.
And that levels of transition of stiffness is where you tend to have injury again because the pendulum effect of the head. And the fact that it's stuck on top of the spine and eventually the thing that will fail is where the stiffness suddenly increases dramatically. They tend to occur from blunt trauma. You can equally have road traffic accidents, road traffic collisions and falls, and a nice way of thinking them is the energy required is roughly inversely proportional to the patient's age, so therefore fall from a standing height, not unreasonably cause some actual fractiousness occasion and someone in their 80s.
However, someone in their twenties, you usually have to do something slightly silly at speed with the assistance of a car. The forces dictate the type of injury and will come onto that slightly later. But remember that all of these also are associated with other types of fractures, including teardrops. And there are two different types as the flexion and extension type, the extension type tends to be a small abortion that comes just off the inferior corner of anterior inferior corner of the vertebral body on the sagittal slice.
And then you get your flexion type of teardrop, which is actually a large fragment which comes across because it shears off as the flexion moment occurs. You can still have burst fractures, and you can also have compression fractures occurring in the actual spine as well. So mostly because it's the hot topic and the high yield topic, we'll talk about facets, fractious occasions, and you have to bear in mind that there are two very different types of mechanism now.
Nothing's obviously perfect in real life, however, it tends to be associated with a flexion and vertical loading moment that causes a facet fracture dislocation. So when the neck is flexed, then there's a vertical load which hitches the facets and therefore ruptures the disk more often than not, causing that by facet dislocation. A lateral flexion with a rotation, a lateral flexion opens one facet and then rotate reloading can either punch off and fracture across a facet, or it can hitch a facet over onto the other side, and that tends to cause a uni facet fracture dislocation.
Now, it won't surprise you to see that this is the same approach as I had before, and these are the things that you need to be able to tick off in your vyver answer. That's it that I like to teach on bCourses that I tend to teach on is. If you are approaching a Viva station and you don't know whether or not it is a Viva about AIDS or its survivor, about spinal cord injury or a facet or unique facet fracture dislocation, a really nice way of starting it is to say I would approach this patient in accordance with the artlols approach.
And then I'd say, however, can I assume this is an isolated injury? What you've done there is you've tick the box, you are safe and then you've also turned around and asked the examiners essentially face to face, saying, am I talking about the spine or am I talking about this? And the answer that they give you next, we'll tell you which direction the vyver usually needs to go.
So if you say I'll approach this patient with, according to acls, can I assume that this is an isolated injury and they say no, then you've missed something in the Atlas approach where they want to hear some buzzwords, be it see spinal mobilization and airway, or if they say yes, it's fine. This is an isolated injury. You can park the rest of that stuff and then you can move on to the meat of your injury that's faced in front of you.
And it works for other injuries as well, be it a complex femoral microfracture or pelvic fracture, for example. Again, always include the age of chart or an age, your assessment rather of the patient. Now, the question that is asked most frequently with regards to. And with some actual facts, in this case, these be the units that were buying facets.
Is when does the imaging happen? My answer to this, usually for the sake of the exam, is the hospital you work in for the Fox's the best hospital that has ever been built, which has 24/7 MRI scanners. It has 24/7 theater and it has access to absolutely everything. Therefore, your answer should always be emergency imaging. This is from the cervical spine trauma group, which is headed up by a guy called Alex Vaccaro in New York.
And this is the algorithm that they have proposed is your set your treatment for cervical facet dislocations. I disagree with this slightly, mostly on the grounds of the fact that you will never regret getting imaging, but the essence of the imaging conundrum is whether or not the disk has slipped within the canal and whether or not. It requires extraction prior to surgery from the back to unlock the facet joint so we can go through that slightly later.
But in my mind, someone who has a serious neurological deficit, I don't believe that there should be emergent closed reduction without getting an MRI scan in the UK practice because an MRI scan can happen relatively quickly in an emergency situation for someone with a spinal cord injury. And I think therefore, that should usually be your answer. That bear in mind that this does exist, this algorithm. So my algorithm for treating this is to say these injuries should be managed in the tertiary center equipped to handle major trauma.
And if you don't work in one of those, you are perfectly welcome to say my unit. It's not one of these. And this is the next most important sentence after the can. I assume this is an isolated injury? It's to turn around and say, however, the principles of their management are as follows. So you don't want to be the kind of person that says, I don't know what I'm doing, I'm not going to talk about it.
I'm going to send it up the road. You want to be the person sitting in the exam that says, I don't do this regularly, which is your Warning shot to say my unit isn't one of these. But then you say, however, I do know that the principles of the management are as follows and you treat the life threatening injuries first and you get an emergency tianzhou and MRI scan with the question of being where the disk is.
The variance to this are if they're unconscious and you can't assess their neurological status. Well, that's easy. You get some imaging, they're conscious and they're intact. That's again, very easy. You get the imaging because you can only stand to make them worse. They're conscious, but they've got a complete spinal cord injury to me.
I would still get some imaging because you want to know what is causing compression. Is it disc? Is it epidural hematoma? Is it something else? And that's a really important thing to me to want to be able to know what's going on and also what you're going to expect conscious with a stable neurological deficit.
I think that's still again inappropriate to get your imaging. And if they're conscious, whether they've got a rapidly deteriorating neurological deficit, this is where you may be. Try clothes reduction, but ideally again, get immediate imaging. So onto the next bit of how you reduce them, there are two different philosophies for this.
You can put Gordon wells tongs on, and they attached to the occipital protrusions just behind the ear lobe, and you essentially apply increasing weights over a ring in line and body in line with body weight and against the counterweight, which is the body in this case. And you start at 10 pounds in most places, you say you go up to a maximum of about 70 out. There are case reports of people needing to use 140 pounds to reduce by facet fractures, dislocations.
I would suggest that that's potentially a failure of analgesia in the case of the reduction, rather than necessarily requiring more brute force. It's done in theater under fluoroscopy, and you do repeat neurological examinations throughout after every weight that you add and you give it time at least 5 to 10 minutes after you've put on the extra weight and the patient is awake. However, they have analgesia and you have an anesthetist present because if it all goes horribly wrong, the person who's going to it out needs to be the person who's putting the traction on to resolve it.
What do you do if they worsen, you take the traction off and you see if they improve. And if they don't improve, you get an urgent MRI scan. There is an often quoted degree of subluxation, and I use the word probably here is quite a heavy caveat. It's talking about in the sagittal view and in the sagittal view. It's talking about the degree of this thesis, a degree of mondale's thesis.
If it's 25 percent, it's probably a unique facet of it's 25% or less. And if it's more than 50 percent, is probably by facet. However, there are lots of different variations to that. If you look at the plain film that's in the center of the screen, you can see the two red lines. Unfortunately, they're quite thick, but what it does show you is if you look at the longer of the two red lines that lines up to the spinous processes.
Of six, 7 and then down to the thoracic spine. The smaller one next to it lines up with the spinous processes of the upper cervical spine, and as you can see, there's been a step change. And that's because there is a rotational abnormality there. And that stands to reason that obviously one of the facets is hitched or is moved. In this case, you can actually see it here on the AP that there's asymmetry in that subluxation.
And therefore, there's a rotational moment which has moved the spinous processes. Now, if you look on the gap here, however, if you imagine that this is a big fat on the lateral side, if you imagine that there's a big facet dislocation, there's no reason why the spinous processes should change their rotation in this plane, so they would normally stay in roughly the same position.
So that's just an additional way of assessing that. So your treatment depends very much on where the disk is and whether or not the facet is locked or fractured. And also the status of the posterior ligaments is complex now. The disk is the important thing, because if you reduce the fracture dislocation or the locked facet and you've got disk which is wedged up and in and behind the cranial vertebral body, when you reduce it, you push that disk back and you knock it against the spinal cord.
And you can potentially worsen or cause catastrophic spinal cord injury. Hence, why you need to know where it is. If the facet is fractured, that's pretty good news, because actually with a little bit of traction, it usually all lines up quite nicely. If it's locked, then you have a different situation and that's where reduction becomes quite important.
The status of your posterior ligaments is complex. A rotational injury to your cervical spine in the form of a unit facet fracture dislocation doesn't always injure your posterior ligaments is complex because it puts it through torsion rather than through tension, and it fails under tension rather than under torsion. So you can often have an intact posterior ligament as complex in someone with a uni facet, fracture dislocation or unique facet dislocation.
However, with a facet by nature of the fact that both of the joints of slap lux, you often have a posterior ligaments complex injury, and you can see that with gapping of the spinous processes as they move apart. Now, knowing where the disk is important because I'm sorry, my spelling is terrible there, but if you have a disk that is going to push back against the spinal cord when you reduce it, you obviously can't reduce the fracture first.
And therefore your first port of call with surgery ends up being your anterior cervical disk to me to go in and to free out the disk and remove it from causing any potential problem when you reduce it. You then have to turn the patient prone. You do posterior release of the facet. Or rejection in some cases, you actually just have to bear away the locked part of the superior articulating process of the vertebrae below to allow it to reduce and then perform a posterolateral fusion with usually lateral mass screws or with pedicle screws, you then turn the patient back over again and you put in a usually bone block or an allograft into there and disk space, and then you play across the front of it to get them to fuse in the fullness of time.
But that obviously is a worst case scenario, but it all depends, as you can see on the position of the disk, because if the disk isn't a., you can actually say, well, this is fine, I'm going to go straight to the back. I'll do the posterior release of the facets, do the fusion, then go to the front, remove the disk and put it in a cage or a graft and a plate at that level. This is a 36-year-old man who was allegedly run over by his partner in a car park that morning.
I think the truth of the matter is that the partner met. The girlfriend is about 6 o'clock in the morning and the patient was unresponsive on the scene and bystander CDR was commenced. There was a ambulance paramedic crew that arrived who witnessed poor quality CPR, but the pulse of presence and they were ineffective restorations and the patient was clearly shocked and there was a rapid sequence induction at the scene.
And it was also felt there was decreased air entry on the right side with hypotension, so finger tracheostomy was performed on the scene. So it's a real, a real case, and you can see they've got the chest tube in place and the tube inside you there. Now, real case, obviously significant injuries, however, we're going to move on to the important part of the bit that we're talking about.
However, again, the same response again, always a less approach, distracting or associated injuries. In this case, you obviously can't assume it's an isolated injury, but you can ask if you can assume that this is the injury that we're discussing. And then your next question is what do you do next?
So we've got our seat trauma gram, which shows our midsagittal slide seat on the far left of the screen, you have to parasitical images there through the facet joints there. And as you can see, those facets have gapped open on the furthest to the right and there's a fracture through the one on the middle image there. If you look at the far left image as well, you can see that the disk space is widened posteriorly.
It's hinging at the front. There's also significant anterior soft tissue swelling. And if you look at the gap between the spinous processes posteriorly, there is a significant increase in that gap at that level, which is the L4 5 level that we're talking about. So things that I personally hate and think that is a very good trick to or very good habits get out of is don't say the most obvious.
One of the most obviously abnormality is because if you say it and you get it wrong, you look stupid because you've missed something even more obvious. So get into the habit of saying being confident if you are confident, obviously, and say there is so going back to that one, you would say. There is increase in disk space height at the back of the C4 five level, there's an increase in the spineless gap.
At the corresponding level, there is a fracture through one of the facets and there is a perched or significantly blocks facet on the contralateral side. So then we come on to this investigation, and this shows how important it is, and this is a CT angiogram, so you can see here in the intervertebral frame and you've got nice view there. And you've got a nice view there of an artery, and this is obviously at the higher level because it's at the level of the mandible.
And this corresponds to roughly the sea floor level. Now the interesting thing here is there is absolutely no flow lower down. So this is below the level, there is no flow there. So this is retrograde flow coming back through the vertebral through the Circle of Willis and then passing back down through the vertebral arteries. So there is no flow at this level and putting those things together, it stands to reason that probably what's happened is this patient's had a vertebral artery dissection or vertebral artery complete occlusion during the trauma, because remember is the same with every accident and every displacement you see, it's always looked worse than it did at the time where you see it in the scanning.
So his chin was probably against his sternum for a period of time at the injury. And therefore, he is almost certainly had a significant brain injury as well as having a significant cervical spine injury. The other important point to remember when we're looking at these injuries, remember we said we were dealing at the four or five level is that there is also phrenic nerve innervation.
And therefore there could be a significant risk of respiratory compromise as a result of this injury. Next, we move on to the MRI scan in order from left, right and the left side of the image, we've got a T1 weighted scan where you can see the anatomy quite nicely. Middle slices 82 important things to see on the T2 are you can see that the disk is injured.
The posterior longitudinal ligament is injured. If you trace the PLL down the back of the vertebral bodies, you see that suddenly there is a gap. And it's actually flicked up a part of the PLL. And you can also see that the anterior longitudinal ligament has ruptured anteriorly, and it's therefore as he's flexed forward, it's peeled off the front of the vertebral body below, which is C5.
You can also see some cord edema in this case. It's not myeloma. Later, in the acute setting, it's edema. And then at the back, you can see that there's again, this increased into spinal space. The far right image is a short sequence of fat saturation image, which shows edema very nicely, and you can see how much that posterior ligament is complex lights up and it also accentuates the spinal cord edema there.
And again, you can see that there's actually some hematoma that tracks further down inside the epidural space or the interior space. In this case, with a cord bleed or a cord a hematoma, sorry present their epidural hematoma. This shows you the degree of cord compression as a general rule, the spinal cord, this is an actual slice. As a general rule, the spinal cord should usually look like.
A fried egg with around area of CSF, with the cord being the central yolk. And here you can see the huge amount on the stair sequence of the. A dimmer that's associated with the injured posture, a lateral posterior ligament complex as well, and there also you can see where the disk has been injured has been extruded through onto that side. So if we go back, you can see that in this case, if you reduce this patient and say by some miracle, he was neurologically normal, if you reduced him back down again, you stand a very high chance of driving that, driving that disk further into the cord and therefore exaggerating his injury and his spinal cord injury, giving him a second hit.
So what happened to him? He had as a first stage, as we said, an anterior cervical disk to me, the interesting part here is that actually as his a cervical dissecting me as performed because he was so unstable, it actually reduced his by facet dislocation and therefore brought him back down again. So there wasn't need to do back front back because it reduced him back down there.
And therefore, as he was reduced into an anatomical position, he had the cage or a bit of bone block in this case, put in with screws going into the vertebral body above and below with a plate over the front. He was then placed prone and then from the back he had lateral mass screws inserted. This is the fracture lateral mass here, and therefore the anatomy is so distorted that they weren't able to place the screw at this level.
But he had two above and one below on this side as a tip for recognizing radiographs. Lateral mass screws go out and then pedicle screws go in. So these are all lateral mass screws as they're heading out of the outwards away from the spinal canal, whereas a pedicle screw. If you do use the cervical spine, they tend to move inwards.
So some tips for recognizing these, as we've mentioned before, the posterior ligament is complex and unique. Facet fractures aren't always injured, and therefore it's whether or not you necessarily have to always perform 360 degree surgery. By that, I mean and posterior surgery. And I think there might be something coming up in the cases where there are some examples of when and when, not when that's not necessary.
And isolated nerve root injuries when they occur due to a facet fracture dislocation, you rely slightly on the principle of an indirect decompression with the reduction of the fracture, rather than directly going and decompressing around that nerve root. The important thing to remember with spinal cord injury and with neural injury is that the damage occurred at the time of the trauma, and your general principle is to stabilize things, to allow things to recover and nature to take its course.
As long as you free up the nerve and make sure that it's not under continuous direct compression anymore. Then there is a good chance that it will recover at root level unless there's been a range of ocean. Hence, why indirect decompression can actually work quite nicely because the ligaments are taxes that reduces everything, allows the root and the cord some space to breathe, and therefore you are hoping that things wake up.
Laminar fractures are an unpleasant beast. They signify in the cervical spine that there is a significant risk of there being and injury underneath it, and that is not something that you look forward to encountering when you're doing posterior surgery. Hence, why direct decompression reduction of the fracture and then fixation fusion is often felt to be the most appropriate course of action because a large neural defect in the cervical region can be very tricky to manage and can cause ongoing problems and certainly wound issues in the posterior cervical spine, in body selection, elite sportsmen and patient for trauma.
I would always tend to use either allograft or autograft autographed to be try cortical iliac crest with plate supplementation, and that's because you are relying on them fusing and therefore you want to be able to see that there is bony union across those across the desk space between the vertebral bodies. A metal cage doesn't allow you to do that. And certainly takes a lot longer and peak.
There are plastic spaces are notoriously bad for doing that. So certain if you have these injuries in elite athletes and want to get back to Contact sports quickly, you need to see bony traject. Can you bridging the disk space and therefore the best choice is autographed, although allograft can sometimes be utilized as well if you don't want the morbidity from the donor site.
Your end point of your exam is to be safe in an emergency, the examiners are very aware that you are not a spinal surgeon. You are probably not going to be a spinal surgeon because you're all too sensible to think of anything as silly as that, and you're therefore safe in managing an emergency and know the principles of managing an emergency. Please avoid being the phone a friend or refer everything consultant because no one wants to hear that from the other side of the examination table or the examining room.
You don't want to be the person who says, oh, I'm not sure this is outside my remit. I'd phone my spine colleague the way of getting around that to say I don't do this routinely. However, the principles of management are is a way of just diffusing the situation. Be aware of the principles of management, spinal cord injury, my catch phrase for this is the principles management, spinal cord injury to prevent secondary injury.
Hence, the patient needs to be managed on a high level care bed where they have invasive cardiac monitoring to ensure that they've got a decent mean arterial pressure that usually means or to you, and also to stabilize the spine so that they aren't reliant on such intensive nursing care for mobilization and they can get up and get going. You need to know how to put on halo vest, and if you haven't done it, say you haven't done it, but certainly be able to read, how to do it, and describe how you do.
And bear in mind that the person asking you a spinal question is almost certainly not a spinal surgeon. And you probably know more about it than they do just before the exam. So have a little bit of solace in that. And then some textbooks, which are very good, and I recommend that you spend your hard earned money on them. And thank you very much, will. So I think Joe now has some questions for us, so we'll move on to the questions next few questions here.
First, how to differentiate between a teardrop and an ossified fracture. So that's sort of the same thing. So a teardrop, an osteopathic type fracture tends to occur when you have extension. And what happens is across the disk space where you have that little sign Desmond fight. Yes and again, call it the Desmond fight rather than your fight and where there's a small ligament of motion to pull off.
And it tends to be a hyperextension type injury where you just get that little pull off there. They can signify that there's significant instability in the patient if there's been a high energy mechanism. What we all tend to see is we tend to see it in these trauma, grabs the very elderly patients, and therefore I think it's reasonable. Rather than putting those people through the rigmarole of an MRI scan to perform flexion extension views of their neck.
At that stage, a proper teardrop fracture is usually a decent fragment, and it's of the vertebral body itself rather than a sindisiwe fight. And you can see that because it extends into the cancellous bone of the vertebral body. Right so the second question will be how long should the patient be allowed to be left in an extrication caller and whether or not there is any literature to back up the time?
So no, there isn't. There is. I teach TLS pretty regularly and involved in that. And there is an uphill struggle to take out the extrication collar now. And actually certainly a lot of the pre hospital services at present are now not putting patients in college routinely. And certainly our pre-hospital service have got a lanyard that they put around the patient to say I have not had my C spine immobilized.
That hangs around there just to make sure that people are aware of it in terms of leaving people in their horrible. They are utilitarian, but they really can cause significant issues. I would recommend getting someone else's arm within a few hours, if at all possible. And obviously, there is a base guideline all about clearing cervical spines in the non-responsive patient that you will need to know again for the exam.
But it's a short term thing and actually falling more out of favor at the moment. I'm not aware of any literature as to how long you can leave them for. Thank you. And how would you decide the stability of the sub axilo cervical fracture regarding the surgical fixation? So that's tricky.
I have done unique facets where we didn't even do MRI scans because of logistics. And actually, the feeling was that they were going to be stabilized in a collar for 6 to 12 weeks afterwards. And therefore that would allow the ligaments to heal up. And an MRI scan will give you a huge amount of information. And for the sake of the exam, if you're not going to get involved in the nuances of spinal surgery as a spinal surgeon, your answer should be I would assess the posterior ligament as complex with an MRI scan, which would help me to decide whether or not the patient required supplementary posterior fixation or fusion.
And that's your safest answer. If you want to be pushed into it, then you can turn around and say, well, actually, it's a sprain. It's a capsular injury rather than an evolution of the posterior ligament is complex. Probably I'll put them in the collar, and I wouldn't back it up with the morbidity of posterior surgery.
But you're knocking on the doors of sevens and definitely eights if you're having that conversation with your examiners. Yes, totally agree. And is it always the case that we need to stabilize anterior posterior fusion? So I think we've sort of just touched on that there. No, is the answer. And bear in mind that you are dealing with the level of instability.
So obviously, in the case that I showed you, there's a really obvious posterior injury that if you fix the managerially or hinging everything over that cage in that plate, and that's not enough and for nursing needs, because you don't want to have to nurse this guy on a collar forever and do log rolls, fixing his neck and making him stable is still a sensible thing to do. So it depends.
It's a case by case discussion, but your MRI scan will help with that. And the last question just now, how can we decide see one key to stability or key to stability in terms of the fractured pattern? Yeah, so flexion extension views are still useful. It's a cause of great consternation for every radiographer in the world. As you send someone down and say, take the collar off and get them to nod and extend its.
It's tricky, and your stability depends mostly on the fact that whether or not there has been a significant cord injury at the time of the injury in the elderly, so in the elderly patient, the general pathway for those of you who ever have to phone your friendly local neurosurgical department, they will almost always say, put them in a collar 4, 3, 2 six weeks to three months. Actually, the reality of it is, we all know is they tolerate it for about a week or they're noncompliant or they have severe dementia, and therefore they take it off.
And those patients don't come to significant harm, and it's probably because actually their spines are so stiff and spawned a lot anyway that they confer a degree of stability. And in terms of radiological assessment, you're looking for separation on the coronal view of the lateral masses, if you're looking at the C one two interval and then you're also looking for flexion extension movement, and you can look at the anterior and atlantoaxial interval as well to see if that's increased and also the padding as well.
It thank you. And is it necessary to get a city Ngo for every c-spine trauma in the exam? Yes you are safest. You have. You have this wonderful hospital like you see in whatever the American soaps, you can get whatever you want, and you will only regret not getting one.
So a CT yangzhou is a very reasonable course of action and actually really doesn't take that much to do because it's a very fast sequence. It's very quick. The patient's been near the CT scan already anyway, and it really can change your management. So for the sake of the exam and you're looking for vertebral artery injury, vertebral artery dissection.
And that's your reason. So you should do it. Yeah, I think that I can find any other questions if I missed any, please can any of the participants write it again? And I will ask Mr. kiffer, thank you very much for now for answering all the questions. No worries. Thanks, Joe.
Thank you. It's a really interesting lecture. Yeah, I quite enjoyed that, because I don't see a lot of spine where I work at the moment, but I remember revising it for the exams. So what we're going to do next is we're going to move on to the MSCI polls, so Ruth will share that for us. As I said before, it's all anonymous, so the sooner that you complete it, the sooner we can move on to a discussion of the answers.
And then we'll move on to the best part of the evening, which is Survivor practice. So and this is essentially just an assessment of your knowledge of the ants and Alonso classification of soil fractures, a type Ii being the commonest in the elderly and being a high risk for non union for all of the reasons that we went through. You've picked up on the medical school trick of always is a bad word and doesn't tend to apply in any exam answer because medicine isn't an exact science.
And type I would be the one that tends to be confused with the knowledge an idiom. Is unstable because of the configuration tends to be communist in the older group and doesn't always involve disruption, the transverse ligament, in fact, rarely involves disruption the transverse ligament. So moving on to the next one, a C6 7 by facet dislocation. Often has an intact vertical disk is incorrect, because usually you ruptured at least the posterior wall of the disk with that increased disk space, so it often has an injured intervertebral disk is how I would rephrase that.
If it's the other way is not associated with significant neurological injury, no, it can be associated with devastating neurological injury. And occurs following a lateral flexion moment, and that is the trick about differentiating between your bypasses in your unique facet. So a uniform is a lateral flexion moment with a rotational force as well.
Often requires anterior and posterior surgery, yes, for the reasons that we've been through and whether or not that's anterior, posterior, anterior or just posterior anterior remains or just down to your posterior, sorry is obviously a patient specific problem, and it's beyond the remit of the exam, I would say. And would cause isolated lower extremity neurological deficit, again, just a small anatomy question note, because if it's going to cause neurological deficit, it's going to happen at the seven grassroots level or the C seven level, and therefore you're going to get up a limb neurological deficit as well.
Next one's a slight nuance of the Asia examination and the Asia examination chart for those who don't use it is pretty prescriptive and actually is a very useful language. So I appreciate why some of you have gone for contestant number one. Being biceps motor function, because obviously a lot of people are taught that. Five 6 is your biceps motor function.
However, for the sake of Asia, that is a C5 motor route, that's a C5 Maya time is your biceps motor function. However, your thumb index finger sensory function corresponds to C six wrist. Extensor motor function is what Asia calls your C six motor. And however, it's not your lateral elbow because that's your C five Dermot's triceps then being C8. That's right.
And then again, your small hand muscle function, it's quite vague. That usually associated with T. One with a small hand muscle function with your fingers spreading risk 6/10 of most function, yes, that's a C six my thumb and index finger sensory function. Yes, that's the C six attainment, according to Asia. So the trick here is the Asia charts and hence the way the question was phrased, the question on the chat.
How would a city and you change the management? So CCN changes the management in terms of whether or not you need to do an open approach. So if it's bilateral, you would probably need to perform repair of the virtual artery and you'd need your friendly vascular or neurosurgical colleagues to come and help you do that. And that's quite an involved process. You can shunt it.
You can basically do of spinal approach where you take down the foramen and then you shunt across it, and that's to try and return part of your vascular supply. If that's only if it's bilateral, if it's unilateral, it tells you where you've got to be really, really careful about not injuring the contralateral side. So therefore, your unilateral injury. First of all, if you go in and you are faced with a hell of a lot of bleeding on one side, when you're putting in your lateral mass screws, it's probably not because you've caused a vascular injury.
It's probably because there's been a dissection or an injury to the vertebral artery. So it just gives you a bit of advice about when you're a bit more information about when you're fixing and whether or not you need to phone a friend to be there in theater with you to try and re plumb this person.
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