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Spinal Trauma for Orthopaedic Exams
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Spinal Trauma for Orthopaedic Exams
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Language: EN.
Segment:0 .
Welcome, everyone again to the teaching session of tonight, delivered by far assessment to the group. The theme tonight is spine. We have the presenters. Arthur will talk about spinal trauma, very important FRC topic. And this will be followed later on by Ramesh. Also, we'll talk about another very commonly asked question of code coiner.
Each session will be around 30 minutes with a break in the middle, and that will be followed by a hot seat session for you guys to take part. We also have a Schwann here who is supporting the session tonight. Over to you, author. OK, guys. So my name is a For those who don't know, I'm one of the spine Fellows and my listing is not working.
And I will be teaching you spinal trauma not very long ago. I was like you and soon passed the exam. So exam is not very difficult to pass. It needs persistence, though I will not only give you a bit of teaching, I will also tell you what to say and how to decode the exam. People who pass first time don't learn it. You need to fail to do that.
And unfortunately, I have done that. But yes, if you fail, you learn more. That's my two for the exam. So, so let just come to the topic what we are trying to tell you. I will. I cannot cover the whole spinal trauma, but I will cover the two important questions that get asked in the exam.
One is first fracture, which comes in the exam at lumbar spine. The other one is facet joint dislocations. So these are the two things which I'm going to cover today. Anything else can come, and it's fair game for anything else to come. But this is most likely to come. And that is that a fair comment? Shawn, for us, these are common, common topics, and it's good to be focused on those high yield questions so high.
So basically, you need to know a bit of general knowledge for the exams like structure of intervertebral disk age related changes that happens in the exam, the biomechanics of a motion segment, everyone happy with motion segment. The primary motion segment consists of two vertebral bodies and the interval intervening intervertebral disk and the combination of flexion, extension, and rotation in 3 planes produce six degrees of movement.
So if the intervertebral disk goes away or it gets reduced in height and what happens is the facet joint started doing more and in return it becomes arthritic and the ligament flame hypertrophy and spinal tenodesis occur. So you need to have a structural answer to common things that is geared again. Intervertebral disk you need to know something about intervertebral disk.
There are two components annulus and nucleus analysis type one, nucleus type 2 and helix has got concentric rings that are a layer of oblique fibers, and they resist hoops, stresses and prevent excessive movement. Nucleus is gelatinous core. It allows elastic deformation, it is tied to collision and it resists compression, as you guys can imagine. Now, when will be covered by someone else?
So I will come to spinal trauma. So you always remember spinal trauma in lumbar or thoracic spine setting? You will. You will see a burst fracture. It will always be a burst fracture. And if you see it's the type fracture has been classified by you. Yes, in 1994.
It's been classified. We have the various. We have the Avogadro's one in 2005 which everyone now follows. And you need to know Felix for the purpose of this exam. But for now, just concentrate on type a compression fracture in lumbar spine. So what they will show, how the exam progressed is what I'm going to tell you.
And obviously in hot seat, someone is going to answer this as well, the exam going to progress by them, showing you an AP and lateral radiograph of a lumbar spine, which is visible on the screen. Everyone can see it. You guys can see it. Yes and on the. What you need to say is the entire particular distance. And can me see if I can move my mind?
This is the particular distance. I know it's very basic. Everyone should know that, but this is what you need to say to increase in particular distance, which is the distance from here to here, comparable to the top and the bottom vertebra, and decrease height on the lateral. And then you talk about all these classification system. So first which is compression distraction and and this translation, you are very, very unlikely to see the type B, and type C fracture.
And if you see that is not a spine question, that is a classic question because it will go to the spinal cord and management of patient in the acute bed again, even with this crash fracture. You can bring all this in management within ayeni, management, within the board and management in the interim as to what you do. Again, the spine is not available in all the trust, so you need to see what your questionnaire or what your examiner is expecting.
Is he expecting you to say, I'm going to refer it to the spinal unit? This thing, I cannot tell which examiner wants you to say that, and he is not going to get annoyed when you say that I'm going to refer this patient to regional spinal unit, or which examiners will say, you know, you are the spinal unit, just get on with it. So you just need to learn it from how much free your examiner is letting you go.
And then you tell again. So coming back to the classifications, there is various ways you can classify this, but I would recommend to classify it through what I call number of the skimlinks classification, which has been modified by Vaccaro at all. If you remember Vaccaro at all, you are quoting a paper, but don't say it first. First of all, yes, let's say it's been classified according to TLX.
And what does tee means? So again, you're going to say it's a system that is emphasizing the integrity of the posterior ligamentous is complex and neurological status. OK, now once you say that you need to because helix is so commonly asked, you need to have a logical structural answer to this. I can't stress it any further.
You need to have a logical structural answer to it. The logical answer again. So first of all, decoded. So you say the words you can progress and you pass that it is a system that based on not only the fracture, which is the morphology also on the integrity of the posterior ligamentous ligament is complex and neurological status. Then the question can go on to what are the ligament complex, then you can bring the tennis into it, that middle, anterior and posterior one third, all you say or you further says or the question can be why is this system?
Why is this new classification system important? And you say that this system made surgical decision making by indicating the likelihood of instability and the requirement for surgery in the absence of strong outcome data. It is not a validated system everyone used to, but it is not a validated system, but it's an opinion of very senior. Contributors and big names in Spain.
Ricardo is a very big name in Spain. And then if you remember the magic number, the magic number is 5. So score is out of 10 and the magic number is 5. Anything that is 5 or more is advisable to be treated surgically. You will assess it on case by case basis. Anything less than three, you're treated non operatively. OK, now the system, what is the system?
It I cannot teach you. This is there on the screen. You need to learn it and regurgitated it OK, this is something that I can. I can talk about it, but it is there. So morphology, neurological status, integrity of the posterior ligamentous complex. Now over there in exam, there is a very, very valid question that how would you assess this, all this?
So for this to say again, if you break your answer, that is better. If you if you break your answer, I will assess it clinically and I will assess it radiological so clinically. How would you assess it clinically? I will assess the neurological status. I will ask the mechanism of injury through the mechanism of injury. You can tell about whether it's compression burst if it's fall from height.
What is it likely to be compression or burst if it's. A motor vehicle accident. It can be a distraction injury, C seatbelt flexion distraction. OK, then you talk about the neurological status and you say whether the neurological symptoms are intact or intact and you need to know your dermatologist milestones by heart and then you say clinically, how will you assess clinically the integrity of the complex?
You can not, but you can say there are indicators like it's like, you know, how can you assess whether the medial meniscus is gone or not? You can say if you look at the back of the patient, there can be bruising. There may be tenderness that's all at the back. And that's all indicates that the injury has traveled down to the posterior ligamentous complex. Again, you cannot be sure.
So once you assess patient clinically, then you add further up your diagnosis by getting a multi directional imaging in form of CT scan that will give you the morphology of the injury. And MRI scan that will tell you about the integrity of the plaque. You cannot have the integrity of the plaque based on CT. OK, so so that's the key things you need to say.
And I think that covers mainly the curriculum curriculum, but anything else any one of the moderators needs to add. No, it's very good, but it might be worth going if you go back to that slide just for one second slide. Sorry, just if everyone just looks at that slide for one second, you can see why, why the numbers are done like that. It's very obvious what you're looking at is integrity PLC and the morphology.
But if you take a look distraction automatically, you worry about integrity. So even if you're not sure if your got integrity of the epilepsy, if you're indeterminate, you're already past five. That's why the classification system is designed that way. So you can even if you don't memorize it, you can have a system for learning how quick, how, which, which level this is going to be.
Also notice that incomplete code injury and code esquina injury rate three of the score, while a complete code injury rates are two again, because incomplete code injury means you can potentially recover more with an incomplete injury. So just to very good, just so that you guys kind of understand the logic behind the system? Well, that's of course, Yes. You know, I so this is what you have done.
Obviously, you have a spoon Fed them, but I was expecting them to know all that. Yeah so because, you know, if you're teaching them this as well, then good luck because it's good. Yeah, it's good to highlight the salient point. And I think after you have approached this very nicely actually covered quite a lot of concepts here. And I just tried to emphasize the importance of understanding the disk structure, be able to draw a disk and talk about the structure of nucleus and annulus and to be able to describe the changes that can happen with age and with arthritis.
This is commonly asked question. Also, it could pop up in the basic sciences. Viva, yeah, and this can be part of this can be a basic part of this can be a starter question. And if you don't know what is a motion segment is how many planes of movement are there, then you are stuck and that's it and your exam. Your next five minutes will be very, very difficult. Yeah, I think these are the buzzwords.
If you start saying those, you are winning, everyone remember that you're very unlikely to be quizzed by spinal surgeon on the spinal table. So the fact that you can describe the biomechanics of the spinal segment be able to describe the helix classification and talk sensibly about the management. You will really impress the examiners. So again, the next topic how much time do we have left so that I can have an idea in 10 minutes?
OK, so so the next topic is cervical spine trauma. OK, now over here, I'm going to talk about the facet, joint dislocations, guys. For every topic, every topic. Remember, there is buzzword, there is controversy, and exam is all about them buzzwords and the controversy. OK, so the buzzword for cervical spine? A joint dislocation is 25% or 50 percent, yes, so that you can identify whether it's unilateral or bilateral and then you can, then your survival will be easy.
The controversy is whether to get an MRI scan or not. And that we will talk about it. You know, that's something you need to know. The same thing is so the buzzword for critical lumbar spine burst fracture is feelings, and you need to know helix to pass the exam. And the controversy is again to treat it, whether to treat it or not. So if you know helix, you will know you will give a sensible answer.
How to treat it? OK, so for cervical spine trauma, again, look at these four lines, ok? It's very commonly asked. It's part of Atlas. It's part of everything else. You need to know them, you know, because the first thing they are going to show you is a lateral cervical spine. Whether it's a cervical spine fracture, whether it's a joint dislocation, whether it's a cervical spine tumor, or if these lines you are, your confidence will be high, and you will be on a winning path.
And it's not something which is out of this world. You learn this and as you learn this in any test and this is not the first time you are looking at this. So don't look at the X-ray as if you're looking at it first time, ok? There are only four lines anterior vertebral line or steeper vertebral line. The first line and the spinal line. If you say that that's a winner, then you have the soft tissue shadows, which is from vertebral bodies C to two C5 and varies with cases of respiration.
And it's normal if it's less than seven millimeters, OK, and all the rest you can, you can build up on the skeleton. But remember the soft tissue shadows and remember the four lines. OK, now anyone with cervical spine trauma? Remember this, ok? Anyone with facial joint dislocations? Once you see a lateral x-ray, you describe the lateral X-ray if it's 25% or less unilateral, if it's 50% translation or more, it's bilateral.
OK, following that, you need to know this table. This table is readily available. It's from orthopedics. I'm not going to hide it. And this is what you need to know. Patient oriented? Yes or no? If Yes. If their neurological deficit?
Yes if there is neurological deficit, then clause reduction. If the reduction successful, then you do MRI scan. If the and and we'll talk about the nitty-gritty, this is the controversy here. We'll talk about the nitty gritty of clause reduction. If patient is not oriented, then there is no question not to have MRI scan. People will push you left, right and center in the exam saying, oh, you are an idiot or your MRI.
People are saying they can't do it, they'll do it first thing in the morning. This incorrect, when you will wake the whole world, you need to get these scans done, OK, because according to China, you will end up, you will lose your bowel and bladder sensation and you will compromise on the patient ability to walk or move. So you have a paraplegic and the payouts in the radiologist may swear at you, but you don't.
You shouldn't be kidding. OK, now there are no classification system for a joint dislocations Allen and Ferguson classified with regards to flexion compression, vertical compression flexion distraction. But again, you don't need to know that and need to know is again, it all comes down to physical examination when you go and see the patient. What you should be looking at, whether it's a ready Cleopatra or if it's a low, but if it's a single symptom, if it's coming into one or two nerve root distribution, OK, then it's unilateral.
If it's. Upper motor neuron sites that is bilateral because your code is compromised. OK, so remember this and then remember the 25% and 50% subluxation on the X-rays. You need CT scan. Ct scan takes 15 minutes. Every A&E department has CT scan. You need CT scan, to make sure that there is.
There is no fracture. You need CT scan and then treatment non-operated. If it's unilateral, if there is no sensory deficit, you can treat it. After talking to this spinal unit, not operatively rigid koehler, they will follow the patient. Your exam will finish there. We can go into very fancy. I can tell you all about this, but you don't need it for the exam.
Yes, we can go into fancy treatment and I can brag how much I know about cervical spine, but you don't need to know it, and I don't need to tell it to you because you will get confused. The other thing is when to get MRIs scan attended patient. Say the word open-ended. If you see the word up, then they will know that you're working in NHS. You know that and there are people whenever it comes in.
In the general, it talks about often the patient with cervical spine trauma and you get the scan. The scan will tell you what the scan will tell you about the disk. The scan will tell you about the type and the scan will tell you about decode. So scan will tell you all that. Now what is easy to reduce? Again, a question over there which one is it unilateral, easy to reduce or bilateral?
It's always bilateral, easy to reduce because the PMC is gone and the PLL is torn. OK, so but you're not reducing bilateral and unilateral is stable because most of the ligament structures are there. Now, if the MRI is there and there is a risk, then you will do anterior cervical decompression fusion, followed by posterior. And if there is no disc, then you can simply go ahead and do the posterior cervical decompression fusion.
I think I'm going to stop there. The other 2x rays, all that will come to the hot seat. Thank you. I can go to the court. If if he's not, I should cover that. I would just like to just mention. There are three conditions in the spine. You shouldn't miss in the exam if you miss, if you don't diagnose, you'll definitely fail you at least, you know, quite badly.
Don't ever miss out on toilet paper fracture or facet dislocation or Kodak winner when it comes to cervical spine. They're not going to show you a normal cervical spine, you know, if they're otherwise, there's no point in the whole station. So if you can't, if there's an abnormality or if it's something you can't see, then always have a low threshold for further investigations. So don't say this is a normal X-ray because there must be something otherwise the question will not be asked.
So if there is a suspicion, then investigate further. Stay safe, ok? And your comment? Anything else to add any other comments from ramesh? I think it's pretty comprehensive. The only thing I don't know if you covered it initially, it's worthwhile learning the Nexus criteria. Well, I can tell you, it can be pretty commonly asked question is when do you do radiography for patients with neck pain?
Who's coming with trauma? Yeah, that's I think it's the same sort of thing like Ottawa rule for ankle fractures. Exactly Yeah. So specific criteria, I think, is quite elaborate. And I think it's quite useful if you confidently mention classifications and you can't describe them to the examiners confidently and clearly, that can go to the level of mentioning papers or evidence.
And sometimes the classification systems can get you more point in the exam. So it's worth, you know, describing those as long as you can describe them properly. Is that is that this classification something you can tell us about quickly or I think nexus criteria, it's not a classification is basically a criteria or mechanism of injury, which isn't what you do an X-ray for a patient in the end.
It's more to do with than anything else but is worthwhile knowing. Yes so basically, I'm basically reading it out from one of the websites saying that the patient can be suspected with suspected seaspan. Injury can be cleared, providing the following are present there's no posterior midline tenderness. No evidence of intoxication. Patient is normal level of consciousness, a neurological deficit, and the patient does not have any painful, distracting injury.
So if these are them, then you can safely clear the c-spine without an X-ray. What if any of these things are present, then obviously you need to do an X-ray at least. It's quite a wonderful shade. So I think if you Google for next criteria for c-spine, you'll be able to go through it quite easily.
I'll puts up the nice guidance. There's a nice pathway. I'll link the page to the group later on. Thank you, Sean. That'd be great. Yeah Arthur, you want to say something? No, no, that's fine. It's sometimes it's in recess as well. So in people recess, you can see the Nexus criteria.
And due to my uncle role, it's there. It's stuck to the wall if you're going to ask about time.
Segment:0 .
Welcome, everyone again to the teaching session of tonight, delivered by far assessment to the group. The theme tonight is spine. We have the presenters. Arthur will talk about spinal trauma, very important FRC topic. And this will be followed later on by Ramesh. Also, we'll talk about another very commonly asked question of code coiner.
Each session will be around 30 minutes with a break in the middle, and that will be followed by a hot seat session for you guys to take part. We also have a Schwann here who is supporting the session tonight. Over to you, author. OK, guys. So my name is a For those who don't know, I'm one of the spine Fellows and my listing is not working.
And I will be teaching you spinal trauma not very long ago. I was like you and soon passed the exam. So exam is not very difficult to pass. It needs persistence, though I will not only give you a bit of teaching, I will also tell you what to say and how to decode the exam. People who pass first time don't learn it. You need to fail to do that.
And unfortunately, I have done that. But yes, if you fail, you learn more. That's my two for the exam. So, so let just come to the topic what we are trying to tell you. I will. I cannot cover the whole spinal trauma, but I will cover the two important questions that get asked in the exam.
One is first fracture, which comes in the exam at lumbar spine. The other one is facet joint dislocations. So these are the two things which I'm going to cover today. Anything else can come, and it's fair game for anything else to come. But this is most likely to come. And that is that a fair comment? Shawn, for us, these are common, common topics, and it's good to be focused on those high yield questions so high.
So basically, you need to know a bit of general knowledge for the exams like structure of intervertebral disk age related changes that happens in the exam, the biomechanics of a motion segment, everyone happy with motion segment. The primary motion segment consists of two vertebral bodies and the interval intervening intervertebral disk and the combination of flexion, extension, and rotation in 3 planes produce six degrees of movement.
So if the intervertebral disk goes away or it gets reduced in height and what happens is the facet joint started doing more and in return it becomes arthritic and the ligament flame hypertrophy and spinal tenodesis occur. So you need to have a structural answer to common things that is geared again. Intervertebral disk you need to know something about intervertebral disk.
There are two components annulus and nucleus analysis type one, nucleus type 2 and helix has got concentric rings that are a layer of oblique fibers, and they resist hoops, stresses and prevent excessive movement. Nucleus is gelatinous core. It allows elastic deformation, it is tied to collision and it resists compression, as you guys can imagine. Now, when will be covered by someone else?
So I will come to spinal trauma. So you always remember spinal trauma in lumbar or thoracic spine setting? You will. You will see a burst fracture. It will always be a burst fracture. And if you see it's the type fracture has been classified by you. Yes, in 1994.
It's been classified. We have the various. We have the Avogadro's one in 2005 which everyone now follows. And you need to know Felix for the purpose of this exam. But for now, just concentrate on type a compression fracture in lumbar spine. So what they will show, how the exam progressed is what I'm going to tell you.
And obviously in hot seat, someone is going to answer this as well, the exam going to progress by them, showing you an AP and lateral radiograph of a lumbar spine, which is visible on the screen. Everyone can see it. You guys can see it. Yes and on the. What you need to say is the entire particular distance. And can me see if I can move my mind?
This is the particular distance. I know it's very basic. Everyone should know that, but this is what you need to say to increase in particular distance, which is the distance from here to here, comparable to the top and the bottom vertebra, and decrease height on the lateral. And then you talk about all these classification system. So first which is compression distraction and and this translation, you are very, very unlikely to see the type B, and type C fracture.
And if you see that is not a spine question, that is a classic question because it will go to the spinal cord and management of patient in the acute bed again, even with this crash fracture. You can bring all this in management within ayeni, management, within the board and management in the interim as to what you do. Again, the spine is not available in all the trust, so you need to see what your questionnaire or what your examiner is expecting.
Is he expecting you to say, I'm going to refer it to the spinal unit? This thing, I cannot tell which examiner wants you to say that, and he is not going to get annoyed when you say that I'm going to refer this patient to regional spinal unit, or which examiners will say, you know, you are the spinal unit, just get on with it. So you just need to learn it from how much free your examiner is letting you go.
And then you tell again. So coming back to the classifications, there is various ways you can classify this, but I would recommend to classify it through what I call number of the skimlinks classification, which has been modified by Vaccaro at all. If you remember Vaccaro at all, you are quoting a paper, but don't say it first. First of all, yes, let's say it's been classified according to TLX.
And what does tee means? So again, you're going to say it's a system that is emphasizing the integrity of the posterior ligamentous is complex and neurological status. OK, now once you say that you need to because helix is so commonly asked, you need to have a logical structural answer to this. I can't stress it any further.
You need to have a logical structural answer to it. The logical answer again. So first of all, decoded. So you say the words you can progress and you pass that it is a system that based on not only the fracture, which is the morphology also on the integrity of the posterior ligamentous ligament is complex and neurological status. Then the question can go on to what are the ligament complex, then you can bring the tennis into it, that middle, anterior and posterior one third, all you say or you further says or the question can be why is this system?
Why is this new classification system important? And you say that this system made surgical decision making by indicating the likelihood of instability and the requirement for surgery in the absence of strong outcome data. It is not a validated system everyone used to, but it is not a validated system, but it's an opinion of very senior. Contributors and big names in Spain.
Ricardo is a very big name in Spain. And then if you remember the magic number, the magic number is 5. So score is out of 10 and the magic number is 5. Anything that is 5 or more is advisable to be treated surgically. You will assess it on case by case basis. Anything less than three, you're treated non operatively. OK, now the system, what is the system?
It I cannot teach you. This is there on the screen. You need to learn it and regurgitated it OK, this is something that I can. I can talk about it, but it is there. So morphology, neurological status, integrity of the posterior ligamentous complex. Now over there in exam, there is a very, very valid question that how would you assess this, all this?
So for this to say again, if you break your answer, that is better. If you if you break your answer, I will assess it clinically and I will assess it radiological so clinically. How would you assess it clinically? I will assess the neurological status. I will ask the mechanism of injury through the mechanism of injury. You can tell about whether it's compression burst if it's fall from height.
What is it likely to be compression or burst if it's. A motor vehicle accident. It can be a distraction injury, C seatbelt flexion distraction. OK, then you talk about the neurological status and you say whether the neurological symptoms are intact or intact and you need to know your dermatologist milestones by heart and then you say clinically, how will you assess clinically the integrity of the complex?
You can not, but you can say there are indicators like it's like, you know, how can you assess whether the medial meniscus is gone or not? You can say if you look at the back of the patient, there can be bruising. There may be tenderness that's all at the back. And that's all indicates that the injury has traveled down to the posterior ligamentous complex. Again, you cannot be sure.
So once you assess patient clinically, then you add further up your diagnosis by getting a multi directional imaging in form of CT scan that will give you the morphology of the injury. And MRI scan that will tell you about the integrity of the plaque. You cannot have the integrity of the plaque based on CT. OK, so so that's the key things you need to say.
And I think that covers mainly the curriculum curriculum, but anything else any one of the moderators needs to add. No, it's very good, but it might be worth going if you go back to that slide just for one second slide. Sorry, just if everyone just looks at that slide for one second, you can see why, why the numbers are done like that. It's very obvious what you're looking at is integrity PLC and the morphology.
But if you take a look distraction automatically, you worry about integrity. So even if you're not sure if your got integrity of the epilepsy, if you're indeterminate, you're already past five. That's why the classification system is designed that way. So you can even if you don't memorize it, you can have a system for learning how quick, how, which, which level this is going to be.
Also notice that incomplete code injury and code esquina injury rate three of the score, while a complete code injury rates are two again, because incomplete code injury means you can potentially recover more with an incomplete injury. So just to very good, just so that you guys kind of understand the logic behind the system? Well, that's of course, Yes. You know, I so this is what you have done.
Obviously, you have a spoon Fed them, but I was expecting them to know all that. Yeah so because, you know, if you're teaching them this as well, then good luck because it's good. Yeah, it's good to highlight the salient point. And I think after you have approached this very nicely actually covered quite a lot of concepts here. And I just tried to emphasize the importance of understanding the disk structure, be able to draw a disk and talk about the structure of nucleus and annulus and to be able to describe the changes that can happen with age and with arthritis.
This is commonly asked question. Also, it could pop up in the basic sciences. Viva, yeah, and this can be part of this can be a basic part of this can be a starter question. And if you don't know what is a motion segment is how many planes of movement are there, then you are stuck and that's it and your exam. Your next five minutes will be very, very difficult. Yeah, I think these are the buzzwords.
If you start saying those, you are winning, everyone remember that you're very unlikely to be quizzed by spinal surgeon on the spinal table. So the fact that you can describe the biomechanics of the spinal segment be able to describe the helix classification and talk sensibly about the management. You will really impress the examiners. So again, the next topic how much time do we have left so that I can have an idea in 10 minutes?
OK, so so the next topic is cervical spine trauma. OK, now over here, I'm going to talk about the facet, joint dislocations, guys. For every topic, every topic. Remember, there is buzzword, there is controversy, and exam is all about them buzzwords and the controversy. OK, so the buzzword for cervical spine? A joint dislocation is 25% or 50 percent, yes, so that you can identify whether it's unilateral or bilateral and then you can, then your survival will be easy.
The controversy is whether to get an MRI scan or not. And that we will talk about it. You know, that's something you need to know. The same thing is so the buzzword for critical lumbar spine burst fracture is feelings, and you need to know helix to pass the exam. And the controversy is again to treat it, whether to treat it or not. So if you know helix, you will know you will give a sensible answer.
How to treat it? OK, so for cervical spine trauma, again, look at these four lines, ok? It's very commonly asked. It's part of Atlas. It's part of everything else. You need to know them, you know, because the first thing they are going to show you is a lateral cervical spine. Whether it's a cervical spine fracture, whether it's a joint dislocation, whether it's a cervical spine tumor, or if these lines you are, your confidence will be high, and you will be on a winning path.
And it's not something which is out of this world. You learn this and as you learn this in any test and this is not the first time you are looking at this. So don't look at the X-ray as if you're looking at it first time, ok? There are only four lines anterior vertebral line or steeper vertebral line. The first line and the spinal line. If you say that that's a winner, then you have the soft tissue shadows, which is from vertebral bodies C to two C5 and varies with cases of respiration.
And it's normal if it's less than seven millimeters, OK, and all the rest you can, you can build up on the skeleton. But remember the soft tissue shadows and remember the four lines. OK, now anyone with cervical spine trauma? Remember this, ok? Anyone with facial joint dislocations? Once you see a lateral x-ray, you describe the lateral X-ray if it's 25% or less unilateral, if it's 50% translation or more, it's bilateral.
OK, following that, you need to know this table. This table is readily available. It's from orthopedics. I'm not going to hide it. And this is what you need to know. Patient oriented? Yes or no? If Yes. If their neurological deficit?
Yes if there is neurological deficit, then clause reduction. If the reduction successful, then you do MRI scan. If the and and we'll talk about the nitty-gritty, this is the controversy here. We'll talk about the nitty gritty of clause reduction. If patient is not oriented, then there is no question not to have MRI scan. People will push you left, right and center in the exam saying, oh, you are an idiot or your MRI.
People are saying they can't do it, they'll do it first thing in the morning. This incorrect, when you will wake the whole world, you need to get these scans done, OK, because according to China, you will end up, you will lose your bowel and bladder sensation and you will compromise on the patient ability to walk or move. So you have a paraplegic and the payouts in the radiologist may swear at you, but you don't.
You shouldn't be kidding. OK, now there are no classification system for a joint dislocations Allen and Ferguson classified with regards to flexion compression, vertical compression flexion distraction. But again, you don't need to know that and need to know is again, it all comes down to physical examination when you go and see the patient. What you should be looking at, whether it's a ready Cleopatra or if it's a low, but if it's a single symptom, if it's coming into one or two nerve root distribution, OK, then it's unilateral.
If it's. Upper motor neuron sites that is bilateral because your code is compromised. OK, so remember this and then remember the 25% and 50% subluxation on the X-rays. You need CT scan. Ct scan takes 15 minutes. Every A&E department has CT scan. You need CT scan, to make sure that there is.
There is no fracture. You need CT scan and then treatment non-operated. If it's unilateral, if there is no sensory deficit, you can treat it. After talking to this spinal unit, not operatively rigid koehler, they will follow the patient. Your exam will finish there. We can go into very fancy. I can tell you all about this, but you don't need it for the exam.
Yes, we can go into fancy treatment and I can brag how much I know about cervical spine, but you don't need to know it, and I don't need to tell it to you because you will get confused. The other thing is when to get MRIs scan attended patient. Say the word open-ended. If you see the word up, then they will know that you're working in NHS. You know that and there are people whenever it comes in.
In the general, it talks about often the patient with cervical spine trauma and you get the scan. The scan will tell you what the scan will tell you about the disk. The scan will tell you about the type and the scan will tell you about decode. So scan will tell you all that. Now what is easy to reduce? Again, a question over there which one is it unilateral, easy to reduce or bilateral?
It's always bilateral, easy to reduce because the PMC is gone and the PLL is torn. OK, so but you're not reducing bilateral and unilateral is stable because most of the ligament structures are there. Now, if the MRI is there and there is a risk, then you will do anterior cervical decompression fusion, followed by posterior. And if there is no disc, then you can simply go ahead and do the posterior cervical decompression fusion.
I think I'm going to stop there. The other 2x rays, all that will come to the hot seat. Thank you. I can go to the court. If if he's not, I should cover that. I would just like to just mention. There are three conditions in the spine. You shouldn't miss in the exam if you miss, if you don't diagnose, you'll definitely fail you at least, you know, quite badly.
Don't ever miss out on toilet paper fracture or facet dislocation or Kodak winner when it comes to cervical spine. They're not going to show you a normal cervical spine, you know, if they're otherwise, there's no point in the whole station. So if you can't, if there's an abnormality or if it's something you can't see, then always have a low threshold for further investigations. So don't say this is a normal X-ray because there must be something otherwise the question will not be asked.
So if there is a suspicion, then investigate further. Stay safe, ok? And your comment? Anything else to add any other comments from ramesh? I think it's pretty comprehensive. The only thing I don't know if you covered it initially, it's worthwhile learning the Nexus criteria. Well, I can tell you, it can be pretty commonly asked question is when do you do radiography for patients with neck pain?
Who's coming with trauma? Yeah, that's I think it's the same sort of thing like Ottawa rule for ankle fractures. Exactly Yeah. So specific criteria, I think, is quite elaborate. And I think it's quite useful if you confidently mention classifications and you can't describe them to the examiners confidently and clearly, that can go to the level of mentioning papers or evidence.
And sometimes the classification systems can get you more point in the exam. So it's worth, you know, describing those as long as you can describe them properly. Is that is that this classification something you can tell us about quickly or I think nexus criteria, it's not a classification is basically a criteria or mechanism of injury, which isn't what you do an X-ray for a patient in the end.
It's more to do with than anything else but is worthwhile knowing. Yes so basically, I'm basically reading it out from one of the websites saying that the patient can be suspected with suspected seaspan. Injury can be cleared, providing the following are present there's no posterior midline tenderness. No evidence of intoxication. Patient is normal level of consciousness, a neurological deficit, and the patient does not have any painful, distracting injury.
So if these are them, then you can safely clear the c-spine without an X-ray. What if any of these things are present, then obviously you need to do an X-ray at least. It's quite a wonderful shade. So I think if you Google for next criteria for c-spine, you'll be able to go through it quite easily.
I'll puts up the nice guidance. There's a nice pathway. I'll link the page to the group later on. Thank you, Sean. That'd be great. Yeah Arthur, you want to say something? No, no, that's fine. It's sometimes it's in recess as well. So in people recess, you can see the Nexus criteria.
And due to my uncle role, it's there. It's stuck to the wall if you're going to ask about time.
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