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Hot Topics for Spinal Surgery For Postgraduate Orthopaedic Exams
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Hot Topics for Spinal Surgery For Postgraduate Orthopaedic Exams
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Language: EN.
Segment:0 .
Yes, thank you, Hannah. Good evening, everyone, and welcome to this Thursday teaching webinar organized jointly by orthopedic Research UK and the orthopedic Academy as part of our FRCS teaching webinar series.
So we welcome this evening. Our guest, sandesh Lacour, who is a spinal consultant working at the University Hospitals of Derby and Burton Mr. NICU La, coold deals with all aspects of spinal surgery, from degenerative conditions to trauma to metastatic spinal conditions. But he's especially interested in pediatric spinal treatment and scoliosis, so we're very pleased that he's accepted our invitation to present tonight, and I'm certain we will all learn a lot from him.
My name is Firas note. I'll be the host and I'll be moderating the session along with my colleagues from the UK team Hannah, Lydia and Ruth. So the session will include that include, as you can see, a presentation by Mr larkhall, he was going to focus on three hot topics for the FARC exam. He's going to go through the key concepts in these topics. Following that, we will have three markers as well.
We will present to you and Paul and answers will be completely anonymous. Four so please encourage you all to try and they will be based on mainly on what's about the lectures, but there will be some new concepts as well. Mr Lacroix will go through the answers with us following. So all this will be recorded. Following that, there will be unrecorded session where we have some Viva questions.
Very interesting related to spine. And we encourage you all to try to take part. Obviously, exams coming up soon and we will give priority to those going for the exam. So please, if you are interested in taking part in the Viva component of this teaching session, please express your interest by writing on the chat box or raising your hand simple and we will allocate it on first come, first served basis.
For those of you who obviously we encourage you to ask questions and we will endeavor to answer all your questions within the session. And that if you miss any part, don't worry, it's been recorded, and we will post it on our YouTube channel later on within a few days. At the end of this session, we will ask you will send you a communication email asking you for your feedback.
And if you would like a CBD certificate, which we can provide to you. So that's all from me. And without further ado, I will leave you with Mr Lacroix. Thanks, Chris. Thanks for your introduction. Many Thanks very much. So I work in a City Hospital in Burton. And so basically, I thought rather than going to a single topic, we can cover quite a few hot topics, which commonly come in.
We're for a first year. So basically, I'm not going to dwelling to the nitty gritty of each topic, but I'll give you some form of food for thought. Some form of Armory so that you can survive those kind of situations if you get in the exam. So these are the common topics in common emergency fractures, cord injuries, infections, metastases, their bog standard, they will come one of them either in other basic science or in any of those in stations.
Some elective cases elective cases are slightly rare, but allopathic tenodesis list disease or scoliosis, a contemplation NF are quite common in clinical, so knowing them will help. So I'm going to start by giving a scenario. So think about this case. First case is a 58-year-old male, but anyway, it's celebrating.
A friend's birthday fell asleep in a dining chair cell, Bangui said he's got a severe pain and weakness in important and unsteady gait. No significant possible, no significant medications. So this kind of scenario would be thrown at you. So what are you thinking? You have to look at the age there to look at injury bang with that sort of extension typekit and then look at what symptoms, you have to get pain, weakness in the hands and steady gait, unsteady gait that some element of called into acute care.
So basically, you're dealing with the person who has an injury to the cervical spine with the possibility of some element of spinal cord injury. So that's what you're looking at. So basically, we're going to talk about or know more about spinal cord injury, how you can approach a patient with a neck or suspected neck and spinal cord injury in any age or any form, right? OK Uh, so basically, how can you how do you examine them?
History, examination, Asia score what resuscitation and resuscitation is important? You have to keep the map more than 85 mercury to keep the perfusion of the spine. How can you prevent further injury, log rolling, et cetera? How how can you medically optimize this patient? How can you transfer this? This patient needs to transfer. The patient requires involvement with spinal center.
And does this patient require surgery? If at all, it means safety. So these are the kind of have to start thinking about all these things when some kind of a case is thrown at you. So that how you're going to manage this patient. So what a spinal cord injury. Spinal cord injury is an insult to the spinal cord, resulting in loss of complete or incomplete function one of the functions of the spinal cord at this motor.
Sensory, autonomic or reflexive? It's always nice to have some form of definition in your hand so that it can. You can start as a opening centers if somebody starts a conversation. So the 1,000 cases for the 45,000 people living annually with spinal cord injury commonly male in young people with the advancement in treatment, their life expectancy has increased.
And it does, why it is important because it costs a lot, but case more than one point one, two million and four annually, it has significantly increased. Common cause is road traffic accidents, domestic violence, industrial injuries, sports injuries, violence, assaults, guns four. 5% common hysteria is silicon spine. Always think of other areas point in moment. Don't just think about cervical spine only, so around three to 25% of the cases.
Most of the injuries happened because of improper immigration and during the transport. So this is quite important, so the two types of injury happens in spinal cord. The primary injury and the secondary injury, the primary injury happens at the time of injury or road traffic accident or assault. That's irreversible. There is no way we can reverse that with the secondary injury, which in part that depends on systemic factors, extracellular factors and intracellular factors.
They are the ones which we, as clinicians have control and we can optimize for the patient so that they don't develop, for example, of hypoxia. Hypothermia can stick them on oxygen, give them fluids, blood, whatever is required to stop the hemorrhage and prevent hypothermia. So, interstellar factors, you know, we're aware that lipid peroxidation free radicals several times of stasis and caused secondary damage to the spinal cord.
So we are said in the medical and surgical treatment is optimizing the second range. So I've come to that in the next. The slide of the treatment. So, no, some definition, what is complete, what is incomplete spinal cord injury complete means that no motor or sensory and function below the level of the neurological level, what we call, let's say, six or D 10 or 12.
The incomplete is there is some residual knowledge. Can function still exist? No, the ulnar nerve moment. But the words is quadriplegic. Quadriplegic is because the patient has a spinal cord injury at the cervical spine in both political sense. But I like Visa strategies. That paraplegic is the thoracic or lumbar sexual involvement with the involvement of trunk or legs and visitor, depending on the level of injury.
Um, no, the incomplete spinal cord injuries they do come quite often in Central cord syndrome is one of the commonest to know them well, I can't go. Each one of them, because it's going to have to tell the rest of the topics as well. Cross section is quite key. So if there is a spinal cord station slowing the spinal cord cross section, drawing it loudly, it is key.
So predominantly there are two descending planks and ascending trunk the descending cracks of lateral corticospinal tract and ventral corticosterone. Ascending dorsal column for fine touch and proprioception lateral cortex contract for pain and temperature control for life. Touch the important one you need to remember or the one you need to draw is when you are asked either central cord syndrome or entity syndrome or bas status.
Comedy central for less is the. The way that the nerve roots are organized through the fibers of the networks are organized in the spinal cord, cervical being the Central Policy number and sacral being the farthest. That's why you would have upper limit involvement more than the lower limb in Singapore syndrome. So basically, I'm not going to say, how are you going to be the.
You know, when you get this patient, you're going to say, I'm going to do a head to toe examination of this patient from the second can say we're making sure this patient is in line immobilized. So you will do an acid chart on admission and also don't be swayed by spinal cord injury and distract from your assessment of other things like shock or what is the pulse and look for destructive injuries as well.
How can you start planning for them? What kind of imaging you require for patients with spinal cord injury? You definitely want to see this scan of the neck safely and definitely will require an MRI scan either of local or a full spinal MRI scan, depending on how much or what is the extent of injury and how you can optimize the medical management, whether the surgical management is required, whether the mdc-t or any vessel, the spinal center is decline in spinal cord injury patients, so it should know them very well.
There's a newer one International standard for tuberosity classification of spinal cord injury, I see. And it's mainly looking at how we can classify or grade the motor and sensory examination. But you can just stick to the and know about neurogenic shock and spinal shock. Be aware how we can differentiate. Neurogenic shock is basically a loss of sympathetic tone with hypertension and bradycardia.
Spinal shock always. A joint document reflects the best way of doing it all the spinal cord injury patients, you will have categorized them. You log roll through the catheter and do appear whether they have any contraction of the. So that's the most civilized way of doing to flex apart from whatever is described in the textbooks.
So it's a basic empowerment. K is based on what is the motor function and what is the sensory function is time. It is good where normal motor and sensory function B is normal to function, incomplete sensory. So C and D is the one where you have to differentiate. C is that the key group muscle below the level of power less than 3D is where the key it will have power of more than three.
So that's the best way you can describe here in Parliament Square. OK so how will you work up any patient if you get a spinal cord injury? You need a CT as I said, my blood test, you need to brace them, maybe basically the same patient. If you think about this patient when required, ask them, call it of some form of mobilization. Ask them for bed rest, low growth catheter analgesia, IV fluid EXOGEN blood.
Make sure that the blood pressure is optimal for a cord perfusion and maybe should be more than 85. Contrary to what we think for spinal cord injury. But for them better to have either normal term or hypothermia. A lot of people suggesting that hypothermia is good for spinal cord injury patients. Think of they can document it from the beginning.
Think of DVT prophylaxis and always the question comes whether to give it or not. No stealer unless you get the patient within eight hours of injury, which is very clear. It's all you. Or if you're suppose, if you want to give a steroid, if you're not the person who is going to do the surgery. Speak to the person who does the surgery to see whether he needs to.
This person needs to have steroid or not. So the current sort of. Approach is spinal cord injury. We don't generally give steroids because the risks of complications are high, mainly with the high dose Tehran. So the one line answer is no unless within eight hours, because there is a McFarlane's paper sort of statement from a rule suggesting that you can give a high dose treatment if the patient comes within eight hours.
In reality, that option getting patients within eight hours to spinal center is less likely, so the safest answer is save the complications. 5, 4. I will not give any steroid. All right, speak to this final sentence and see if. Was so surgical treatment. Why do we need them all in complete neurological injuries?
You need to stop the secondary injury. Basically, the surgery is to prevent the secondary. Spinal cord injury in complete spinal cord injuries. It is basically to make them stable so that they can get rehabilitation with patients of Asia C or d, they're more likely to get better or incomplete neurological injuries.
They are likely to get better if they act early and if you do, if you offer them surgical management. So the goal of surgery is to minimize the secondary injury. This is what I'm going to say decompress the area of the interest, stabilize and maybe have timing. When do you want to do the surgery? As soon as you get the patient, you're going to take the call to either the original spinal center and tell them and transfer them.
If you are the person who is dealing with this patient earlier, the better in a safest environment. For example, if you get the patient evening or night, the best time is to do For the patient surgery in the morning. So the window period from the time of the injury to get surgical treatment is anything between 24 to 36 hours. So is there evidence this is quite a landmark trial in the trial statistics trial?
It's a multicenter International prospective cohort study. Basically, they look at the primary outcome of Asian employment scale grade in patients who are treated with decompression surgery within 24 hours, and they looked at patients who had surgery within 24 hours and more than 24 hours. So patients who had decompression surgery within 24 hours after spinal cord injury had better outcome, and they improve their vision impairment.
Scale grade by 2 at six months followed. So you can certainly mention this saying that why earlier surgery is better. And also the recent Lancet paper, which kind of accumulated not just the science paper, but other papers as well, which is a four independent prospective multicenter data of 2,500 patients. They looked at patients who went early surgical decompression versus late decompression.
They found that patients who have surgical decompression within 24 hours of electricity injury had a better outcome in comparison to the patients who had surgery after 24 36 hours. So the crucial window is, you can say, within 24 to 36 hours from the onset of spinal cord injury. So that's kind of nutshell of spinal cord injury. So the next kind of common sort of scenario is 46-year-old female bilateral sciatica numbness to feed, which is from 2 days, is progressive.
The history of lifting a heavy basket of shoes four days ago and then the pane on the left leg now has bilateral leg, which is progressive numbness. And increasingly becoming a mobile. So if you look at this history, it was a young person, female started unilaterally on the left like four days ago. Progress toward the two days to bilateral. There is a numbness and there is weakness in mobility.
So you're looking at somebody who had this collapse becoming more and more worse and was developing into politics on axilo. So that's how you can think and put your thought process into it. If this kind of a scenario comes into it. So the cortex-a9 syndrome is an emergency condition where lumber supply routes are compressed within the number of families presenting with combination of symptoms of altered sensory and motor function of the lower limbs in perineal bowel bladder function confirmed by an MRI scan.
This is I like definitions because it kind of puts everything in one nutshell and you can always, you know, it gives you an overview of what this condition is. So after that, that scenario will be kind shown this kind of a picture. So, you know, what can you see and how we approach it? They can say it was an accidental and axilo view two images of four five this collapse and four or five of the lumbar spine showing all four or $0.05 disk prolapse with complete.
If it's almost completely assessment of the CSF, my concern is, of course, a single. And then so why does connection syndrome happen or what are the normal displacements some people have the huge disconnect that never developed correct when it's incorrect. There are two things. One is the mechanical compression that happens, which decreases the nutrient delivery to the nauru, decreased blood flow and CSF diffusion.
The secondary is something like compartment syndrome, which is a time dependent factors, which will progress if we don't act quickly and if we don't pick up symptoms quickly. So where there is a condition, condition, internal edema and from a hypoperfusion injury with decreased further decrease in the actual perfusion and nerve ischemia, therefore? And then you got autonomic dysfunction of the bowel and now so it's a progressive cascade, which happens once the primary injury when the mechanical compression happens.
So therefore the connection of presentation is always suspect from the patient, and the patient always goes from one stage of cardiac syndrome to another state. I'll come to that in the next slide. So the early stages, and I'm not going to say, you know, what is the incidence, prevalence and all those things? So what are the early stages where you have to be very careful while you take a history.
And when you examine them is for looking for bilateral numbness or weakness in the leg? Carefully ask and assess for pain or pérignon sensory disturbance. If they have a bomb or genitals and the bladder dysfunction, can they feel the full bladder? Can the can they get the desire to pursue it? And when the path you are aware of doing? So this is the quite key early red flags.
Life is the host of symptoms of bilateral, you know, red flag symptoms. It look up in nice website, but I'm sure you all aware. Uh, in history and examination from the west, look for whether they had unilateral s.a., did they develop bilateral state if they develop any more thoughts into the changes that they start having sudden or back pain, which would suddenly worsen?
Is there any in anesthesia that happens to usher in a sexual dysfunction. And then bladder dysfunction or dysfunction? If they develop all those things, then you're kind of in the final stages of product planning. So that is the history. Apart from the general other history you're going to take in correct the examination, along with motor, sensory, and reflexes, the pain and sensation and tone and an alarming sign is something which is useful.
The question is the mask is in and tone is very sensitive in picking a product. There's a lot of studies have shown that drone is not that accurate test in detecting early chloroquine or correction incomplete syndrome patients. So but in fact, what is more important is carefully assessing perineal or in sensation and documenting it clearly in comparison to the rest of the labor, rest of the body.
Important one. Every patient would correct one if you get a patient with chronic pain that you must do pre and post wide, scan normally around 50 to 100 in every trust or every region networks, but the networks have certain criteria. What is normal? What is the cutoff for scan? One of the study done in Nottingham by Mike Leavitt at all of the group.
They looked at the patient who came with suspected chronic one and how many of them had that pre and post virus scan. And their kind of take-home message is if the post-war risk is less than 200, then it's 97% negative predictive value for protection. So 90% chance that it could not be so in that group, only 3% chance that they could have cortex-a9 syndrome.
So in a sense, you can say the cutoff is 200 handle. So if the patient has less than 200 well, we can say the chances are less likely, but you can carefully observe. You will admit the patient. You will do a serial post-war residents. Can they get into more than 200 members? Then it's a very that means they're progressing. But if it is more than 200, remember that the chances of chronic fatigue syndrome is, I think in this study alone.
47% or so around that, you can look it, look it up. So it's something important because it's a UK study and this is one of the important clinical signs. You must do in connection with. So I'm going to spend quite a lot of time. In this slide because this is what you need to know, because this is kind of a natural evolution of called epicondyle when you suspect what I call, what happens, what happens in early contact, incomplete in retention and incomplete.
So when you suspect correction in people who either had long standing back pain or long standing leg pain, who start developing bilateral sciatica with more sensory loss, this is called clinical consequences. This patient with no bowel bladder generating very mild symptoms. And when you confirm it, it's called virologically confirmed or suspected polyclonal syndrome. The early stage of contact point is they still have normal bladder, normal Bowl of sexual function, but they do have sensory loss around a parental area and then they have some change in maturation.
The key stage, which. To pick up when you assess this patient, this is the patient in complete contact, a symptom wanes. This patient has good, has control of the bladder, but has altered sensation in the bladder function or sensory bladder sensation or representation. But if there is any peritoneal changes or sexual or sensitive functional changes.
So this is quite a subtle stage of correction syndrome, where if you catch them early and the surgical intervention will have some impact on their outcome of urinary function. So if you leave this, if this patient with a large disk will say, oh, bladder is a bit funny, the sensation is not that oh, he's got control so we can just leave him alone if we don't pick these patients.
They will go into retention. So that's the next step to see is that the painless bladder retention and also the first stage is correct, complete where they have incentive there to overflow incontinence. No perinatal perinatal sensation, no undertone. Very possibly. And it's like completely lacks in in-person. And so the boss has made it easy for you.
You can mention boss classification of products where you suspected the absence of sphincter dysfunction incomplete with the Syria agency or the situation with retention, Kessler retention and confidence. The reason I go back to the slide is because the early if the treatment or surgical treatment or early surgical treatment of suspected nephrotic syndrome or early correction syndrome or incomplete production syndrome, they are certainly better in comparison for patients with CSR or complete product.
So as long as you can tell that in a coherent way in the exam. I think it's a good brownie points, I would say. So then if you're going to examine must know the two key things is. Went to the MRI scan. And who should do and what I scan, the MRI needs to be done at the earliest opportunity as soon as possible.
If your place has an MRI, my advice is if your face doesn't, if the scenario is your place hasn't got MRI facility, the best is to depending on the clinical scenario. I speak to the spinal services, get that advice, whether the advice could be that as a first thing in the morning so that they can wait for a slot for the surgery or some centers do advise for transfer or NIPE if there is a convincing evidence that the patient is in contact and deteriorating rapidly.
So the boscalid is that the person who is examining first time or reference must do MRI scan and then transfer to the local services. Some centres, some visitors, may not have the facility to do MRI scans, so you have to keep that in mind. But, for example, you can almost do whatever is there in the guidelines.
So regards to surgery. I will come back to it. The two can talk about we can finish it. So So when you need to do the surgery for chronic pain syndrome, so. The best is at list as soon as possible and as safely as possible, taking into account of symptoms and the duration and the progression.
We love this heart. So there is a caveat to it. We need to consider the potential for increased morbidity if you're operating in the NIPE so you're not going to operate. Somebody comes at 10 o'clock with complete retention, which has been already established for more than 10, 12 hours, but nothing you can gain by operating in the middle of the NIPE.
But if a person? Came in with intact bowel from bladder function to Eddie while waiting in Eddie donors. Or goes into detention, even if it is around, say, eight, nine, 10 o'clock. And these are the patients probably subset of patients who have deteriorated in a short span where. Urgent or emergency surgery may make a difference to these patients, so we need to take the multiple options at the same time, you have to say I will also, I mean, if the question comes back to you saying that you are this policy, that response center, what would you do?
It is I will still look at the patient progression and the availability of theater and staff and resources. And then I'll take the executive decision whether to do it in the NIPE or in the morning until it is safest. So the best is within 24 hours of onset of symptoms or within 48 hours within 48 hours, it's considered acceptable because most often all these patients, they don't present straight away.
So it's very difficult to cast them within 24 hours from onset of symptoms. Certainly, we can do it within 24 hours of presentation to Ed, but within 24 hours of onset of symptoms, it's quite difficult. But at least we need to try to get these patients treated within 48 hours. But the answer is as soon and safely as possible. So what kind of surgery are you going to offer?
What you're going to say or what? What will you write in the. So all these patients will have a large disk so microscopic to me, even though it is described as an option of treatment, there's a high chance of that or complication. Therefore, we will offer them central decompression in district to me. And again, you need to go through the consent and what are you going to say and all of those things in case you go to that level of.
Off the topic in your discussion. Um, so there's a recent paper from Ireland that is comparing the timing of surgery and correction syndrome classification based on both guidelines. They had 136 patients, 69 in retention, 22 and incomplete and fortifying the suspected group.
Surprisingly, in their study, they didn't find a significant difference in improvement in the bladder function if they had surgery within 24 hours or after 24 hours, mainly in chronic conditions of detention or incomplete. So they conclude, saying that early stage can decompression within 24 hours from the onset of symptoms does not appear to significantly improve the bowel or bladder dysfunction.
But, you know, this is a retrospective study, and it's very difficult to. Sort of without a randomized trial, you can clearly say that such a strong statement of early stage in the competition will not have a significant impact. But contrary to that, we can mention another paper which is slightly old.
But again, they looked at the collection of incomplete patients, and therefore they reported that the normal bladder function can return in around 90% of the patient at 88.9% of the patients. If you treat them within 24 hours, that's quite significant. So I would say still if the patient has correct an incomplete, then the early surgery will have a better outcome.
So there are quite a lot of other studies, but some of them are historical now, it can know, but there may be questions asked. Is there evidence for this? And you can throw one of these papers into this patient? Any more questions on this story? I'm going with fast now brilliance, and you're not going fast at all, actually excellent pace because it's good.
Very good. Concise slides, so we all enjoying it. So I think you have one more topic, but if you like, I can give you maybe a bit of everyone a little break and ask some questions. Is that right? I was doing that. So So question from villas. He asked about the cauda equina secondary to mix.
Are any particular guidelines on management you're aware of? So for the Mets. Yeah secondly, to me, called the cauda equina secondary to Mets. I mean, my next talk is about that good. That's a good thing. So I think listen carefully, the next stock answer might come through. I mean, I don't know what the I mean, there is a nice guideline on spinal cord metastasis that is something which you need to.
I think that will apply, but that's mainly for spinal cord compression. But the same kind of rules apply for, yeah, save for chloroquine as well. Bear in mind that the commonest area of spinal metastatic compression is toxic level because of the battery plexus. So you really have quite a quantitative compression. And another thing is the cardiac monitor.
The tumors tend to have the spine. Canada is large and there are no rules so that even with the significant compression, you don't seem to see the extent of sudden degradation of the neurological function, what you would observe in a trust level. Tumors Yeah. Metastatic fracture compression or tumor compression. Oh, that's interesting.
That's interesting, but it's not. I'm not saying it's not, it is. Slightly there, but communist is what you get is the lowest level of completion in the tumor case. Yeah, because of the vets in Texas and all the. Thank you. We have one more question from Muhammad Neal. He's asked if the post avoiding residual is less than 200.
Would what would you do, would you do an MRI scan or would you just admit and observe? But it depends, you know? Never a single entity will determine a patient's fate. You go back and examine history, carefully things and every jigsaw puzzle needs to make you a proper informed decision. If a patient has more convincing symptoms or signs, I would still get an MRI scan even if it's less than 200.
Just based on just because most this world is 200 I'm not going to send the patient back home if I'm clinically. When I examine and when I take on a history, I'm convinced that this patient might have a correct one that I was never going to say go back. But I would. Still, if I'm a, you know, if I think clinically this person is in the clinic collection of incomplete type of scenario, I will sort of nag the whole local services or things to do the MRI scan or take this patient for an MRI scan, you know.
So that number is just to so that you need to have some standard number to say which which in turn is normal, which is abnormal, et cetera and some hospitals have very strict rules for what is a cutoff of Nottingham in a local hospital. They have they used to run the numbers part. We in our hospital is 100 MLS.
So some hospitals may use even 50. But that is purely based on the whole entire examination of the patient. I think I agree with you totally. It's multifactorial, isn't it's never one when deciding factor, you have to look at the whole picture. And, for example, purposes the number one priority is being safe. Exactly no, you have to be safe.
If you're not safe, you don't pass the question. No matter how much evidence you you, you could. You got to be safe. And then for the exam, MRI, scan your MRI, scan everyone, you know, there's no point in the then obviously you can argue the cases and argue the risks and things like this. And you can put on your support. Yeah, I mean, I agree with that.
I mean, you can always argue, you know, there are a lot of papers who are done, whether it is justifiable to transfer patients overnight to from $0.2. And they followed that the only fraction of patients turned out to be positive, and they compared it with people who came to their own set up and found that who had all NIPE MRI scan. So they said, there's no point in transferring all NIPE to a specialist centre, and you can argue and debate and you can throw those kind of evidences.
But at the end of the day, as far as you always say, I want to say make sure that this patient has no product, but my I go back examined and I really specifically look for these things. So as long as you demonstrate that you're going to, you're not going to just leave the patient in the lurch and you're going to make sure that this patient is safe. Probably not to have a moral scan and demonstrate that inside and how you demonstrate that inside is the key.
You can't just say, oh, just because you said, oh, less than 200, oh, I'm not going to divulge it's probably that's not the right approach. Yes, absolutely, I think, yeah, you can. It's a very, very hot topic, very hot topic. And to be honest, you know, most of the people stay away from contact with such a controversial without. Yes Yeah.
Not an easy one to take on. There's nothing, you know, for whatever is there in the boss guidelines to say something for the candidates to talk important and read more about basically nothing more. I'm not giving everything that was just some of the business. But so shall I go next to him? Yes, please. So the next typical case is a 60-year-old lady come to clinic with more than 12 weeks history of low back pain radiating the right.
Progressively worsening walking distance is limited due to pain. Significant amount of pain flits from one tired keeping the. So it looks like way history, but there are bas status 60 more than 60 patients of cancer, 20 weeks kind of a short duration, which you consider for a back pain patient and one month progressively worse. So there is a short sudden burst and sleep nighttime pain.
So the three four quick, big things in the history itself will sort of give you a hint that it could be a tumor of really an infection. So that's how you have a line. So if your throat. If somebody say what's going on in the mind, you know, you'd say 60, 80. And this is a short history, and I'm a bit concerned that this could be a tumor.
And that's my differential. How how are you going to do a clinical assessment? How are you going to take a history from looking at the pain or region past medical needs to see if they have any questions and symptoms of. Cancer, any history related to primary breast or prostate, lung, et cetera. And then you do an examination from head to toe and looking from primary and neurological examination and looking for lumps and bumps, et cetera.
And then you go for the investigations. What kind of blood test, imaging, medical management, whether this MDT involvement and what kind of a surgical treatment. So these are the whole spectrum of sort of questions and sort of answers you may encounter during this kind of scenario. So the. Common customers, which is bad to the bone from breast, lung, and prostate in that order.
So the survival is good for thyroid and then for prostate, breast reasonably so for this kidney and lung, they were pushed out. But these are all historical figures from the paper, I think, from 2005. But they are up to date certainly definitely will be much better than this. Prognosis won't cause this, but at least, the order that people.
What is the third most common mistake from a distance? The first is the lungs, liver and bone. So that's why you always see the chest and the pelvis to see if there any visitor involvement in bone spine is the most common. And then open muscular and in inspiring stories is the most common story. So the physiology part of the spine, they can cause us to like this or blasted off to us like this is caused by.
The tuberosity declaration of two-plus again mediated by cytokines, interleukin six, interleukin 11 parathyroid hormone, and to return the stability of the blast to release ankle and then the binds to rank and then stimulate the osteoclast and osteoclasts activity osteoblasts. It's to the blast and also activists the Department so long primarily like 60% of the breast blast, 90% of the prostate is plastic.
So after you've gone through this patient, you've taken a history of pain and onto the symptoms, except as I mentioned before. And what next, the last. So next is we're going to test the investigation basis. SPC differentials is susceptible to the infection, metabolic profile, cancer attention, while the left is, et cetera, which is denied the screening for specific cancers as well.
But this is a place in basic consumers to in every patient. Do you see in a suspected metastatic cancer patient the general image workup to see the chest of the pelvis and then bone scan to see if there is any extent of bone metastases apart from spine itself, and in some cases where the cold spot in myeloma or tumor you have to do a collecting x-rays as well.
And specific, you know, that is being said, just in case, if had this kind of a patient and if an X-ray nowadays you generally jump to. Of the dilemma really lack of action. But the recommended normal sort of. Investigation strategy is to have a little of that in spine, preferably holds by standing to see if they have any deformity.
Ct scan is important. At least at the area of involvement or we can. To see if it is a light or Black humor, and also to know the bony architecture if you're planning for surgery. Best or the standard treatment standard protocol now is to get a whole spine MRI as a screening for any other areas of metastatic metastasis, if you suspect one.
So if you have a patient who have no primary carcinoma, so then biopsy is the key. So if the patient has no neurological deficit, then you do a biopsy, send a specimen for histology and wait for the histology to come back and then plan treatment. If the patient comes with metastatic sort of a lesion in the spine with no primary or quadruplets, a cop cancer of unknown primary with cord compression, then we'll do a biopsy.
At the same time, the compression and stabilization rate for the histology to plan for as radio or chemo, or whatever we can to. So then how do you drive to the level of who gets to serve you? I mean, patients with primary cancer with metastases, they're not the fittest of the lot. So who and how you can decide who will require surgery or decompression or stabilization, etc.? The couple of tools, which you need to know is Takahashi's scroll, which is based on general condition of the patient.
How many extra spinal bone metastases are there? How many vertebral bodies are involved? Is there any residual metastases? What kind of a primary tumor? And if there's any neurological compromises, you can see the rectal thyroid cancer breast, they have got a higher score. But if you have a lung, esophagus, pancreas or the liver cancer, they got a very low score.
So the scoring is collection. Of all these things, you put together 0 to 8 less than six months. So mean survival 9 to 11 more than six months, 10 to 15 or more than 12. So often this is proposed in 1990, the worst by the same authors in 2005, and they did their own validation. They said it's around 87% accurate, but again, it's been regularly contested.
And one of the studies done by a Nottingham group again showed the usefulness of this is around 66 percent, and some of the other papers have suggested even lower accuracy in predicting their survival. Yeah, so but this is definitely need to say that. How can you predict the survival before deciding for surgery? The other one is the non-school, depending on location type of bone lesion.
Is there any spinal alignment? How much collapse is there? Is the involvement of most likely involvement with the lower the score, better for the patient, better for the patient. Up to 6 is stable. Up to 12 7 to 12 is probably unstable. 13 to 18 is definitely unstable. So again, it's just not the score itself you're going to treat.
You are going to look at the patient, you're going to look at the other scores and you're going to enroll. The mdc-t and the norms is another framework which is commonly used for consideration of who gets what kind of treatment. So you look at the neurological function, you look at the oncological diagnosis, look at the mechanical stability and look at the systemic illness, for example, if you have the high grade.
Epidural spinal cord compression. And then they require surgery then radiotherapy. And if somebody has mechanical instability, then they require surgery. If they have mechanical instability with just a burst of compression fracture, then we can consider careful posture what we do. So if somebody has a really resistant tumor, then they without compression, they'll go for just as a really resistant tumor.
With compression, they'll go for surgery. And again, we can't forget the fact that you will always look and look at the patient, a systemic illness, you know, what is the overall outlook looks like, whether they're capable of handling this amount of morbidity of the surgery? Because these cancer operations are not small, they're big, they bleed, and it takes long to time to recover.
So you look into all these aspects before this happens again. It's never a single person decision. It's always a multidisciplinary team approach, an empty decision. So palliative care, you have to think about palliative care. If the person has a life expectancy, as is talked about, they're less than six months, then primary care. Also, in some patients, the radiation alone is useful.
So the surgery is mainly for neurological decompression stabilization. And then. You plan for postoperative radiation. The cut of most of the hospitals, most of the spinal centers uses more than six months at least, so I will to decide whether this patient should go for surgery or not. Um, so this is a landmark paper from Roy Pritchett right back in 2005, I think after that, the NICE guidelines of MSFC came into play, which is a randomized, multi-institutional trial looking into surgery, followed by radiotherapy and radiotherapy alone in their group, patients who have surgery and radiotherapy had better ability to walk after treatment at their final follow up in comparison to people who just have aided therapy alone.
So this kind of change the scenario from treating all these patients with metastatic spinal. And cord compression with from the steroid and radiotherapy to decompression, surgery and radiotherapy. So even in this paper, the patients who had surgery needed less steroid and opioid analgesics, which again is beneficial to the patients. So, so that is it.
Guys from my side. Any questions? That's wonderful. Mr akula is really amazing, I think each of these three topics is a whole lecture on its own, and you managed to put the 3 in them in one. That's really one. It's just a little bit of food for thoughts, isn't it? I haven't given anything.
Yeah, it's perfect for my point of view. Have you been teaching for a case for a long time? I think you don't any for exams. You don't need to know anything about, you know, above and beyond what's in this presentation. So I think wonderful, wonderful one, and I encourage you all guys to come back and see it see the replay when it becomes available in a few days.
Yes, we have some questions. Obviously, as you know, the Kodak equine always had topic, but question from Sharon asking, can Kodak China syndrome present with the unilateral sciatica? It can. Yeah one line answer is it can. Yeah that's good, that's good, that's good, you know? Yeah, absolutely, because I know today, if somebody has unilateral symptoms, has very numbness again and retention.
Yeah you know, not always. Patients should have bilateral symptoms. Yeah, exactly, it's a whole multiple factors. Again, if someone just coming with the unilateral attack and everything else is fine, then that's not the codec, y'know, but you know. But unilateral does not exclude codec. Yeah, no, no, no. Just because station has one unilateral simple, but I've seen patients come in with unilateral symptoms with completely Black dots.
Yes so it's. So one more question we have here. And from faizal, he's asking is, is the radiologic, is there a logical correlation? with the clinical classification of code the equine. And how would the radiological features correlate with the clinical presentation, I think in terms of acute or pending decline, I think.
I mean, that is, you know. And how is the progression timescale as well? I mean, I think it's unpredictable, isn't it? It's a good question. I mean, I think what he's trying to ask is if you know, depending on the degree of compression, can you predict? I mean, it's not the correct compression is not that it's going to progress. Progress, progress.
You know, the quite iconic compression has happened. I go back to the pathophysiology slide, where the mechanical compression happens in the secondary injury, intra neural pressure develops. So that is where it's happening. So it's actually the clinical scenario that changes the radiological picture remains the same. If you are trying to ask, I am not aware of any paper which correlated the degree of stenosis of one and their association with collagen in tension, or I don't think it has any significance in decision making.
My decision making is my patient and look at the patient, examine and take history. And then you confirm it with the MRI scan. And MRI scan is to confirm not to grade. Yeah maybe. I think generally in order to accepted the correlation between the radiological findings and the clinical findings, not always the standard or they don't follow each other all the time, isn't it?
So I think the question was, do I think he was trying to ask whether you can grade suspected incomplete retention based on mri? If if I understand correctly? Yeah no, I think that's difficult, isn't it? That's difficult. Yeah so we have one more question about first talk about in relation to the Asia classification type C and D. And how the question is how.
From Dylan, he's asking how do you choose the key muscles to examine? Who knew that there is an ICC in charge? Yeah, you can Google it, and it'll show you exactly how you need to examine the key groups, the specific way it'll give a demonstration exactly from each mile, from each dermatome.
How to examine. So I think it's in the I mean, that's a talk in itself, actually. So that's what I would suggest you to go back and read ICC. I don't know the full form, but that's the normal charge, which most of the spinal cord injury units are using nowadays. Thank you. Thank you.
Now, one more question from Jamie. If a patient with metastatic spinal cord compression attains and they are off legs. How would you what's your standard approach, do you go for MDT or do you decompress urgently before final MDT decision is made? And I think that's if you are working a spinal unit now, isn't it?
Yeah, I mean it, you know, it depends on the primary and it depends on if the patient is off legs. Is that what you? Yes patient off legs. Yeah, Yeah. Again, you go back to what is the primary? What is a known primary know? Is it an aggressive tumor? Is, you know, you do the hits.
Everything has always said you do the blood, you do the seed chest of the police seal, you get a whole spine MRI scan. If somebody has, you know, if that person has a life expectancy of less than two months, you know, making that person go through a big. I mean, there are some patients we have said, you know, person is off, but he has, you know, life expectancy is weeks.
So for that person to have a big operation, you discuss with the patient, you know, whether you want to have a surgery with the hope that there is a chance of improvement, you know, it's this cord compression patient will not have a significant improvement in neurological function in cord spinal cord compression patients. Your operation is to stop the progression somebody's already off legs unless the person has a big, long prognosis.
From a cancer perspective, we're not going to have say again, it's a conversation you need to have with the patient. You're not going to operate on the middle of the NIPE. Definitely not. And again, in those patients, you still give them still. Yeah, if cancer patients you do, you do give them therapy. So, yeah, not in spinal cord injury patients. OK, thank you. I think we got to remember again, we are here focused on the FARC as level kind of questions and exam scenarios.
And I think if you are, they'll assume you are a PTH consultant when they ask you the questions in the exam. So for a digital age consultant, when you get this case, you are discussing. With the spinal surgeons on call. With a spinal center and you are discussing there's always oncologist on call. So you so you can have a mini MDT, even if it's no matter how urgent, you can always have a mini MDT between a general orthopedic and the spinal and oncologist.
So yeah, I mean, if I need, I will speak to the oncologist. Yeah, you know, but again, it's good just going off like because of the cancer, but I'm going to jump and operate is not the thing and just always go back, look into all aspects and again, involve the patient. Sometimes you involved family as well. OK it wasn't a question went to do an MRI if you suspect Mates, but there are no clinical signs.
Apart from pain. If you suspect let's get this kind of. Yeah, Yeah. Absolutely, it's no. At no point waiting all and any role for steroids, I think you answered that and Najee asked. Any role for steroids in China syndrome? Not for the. But you've already answered that.
So that's secondary to tumor then? Certainly, yes, there is the role not for core compression injury. So thank you. Thank you. Well, Mr Blackwell, thank you very much indeed for this wonderful, very comprehensive lecture. Recovered three very hot topics as the title says you would actually deliver what you promised.
Definitely it's a wonderful, very focused, very focused lecture, and I've certainly learned a lot and I'm sure everyone is watching has also learned a lot from this. The reviewing this again, and I'll use a lot of the papers and things to update my book on it all. With your permission, I'll use that. So thank you and for answering all the questions from the audience.
Now we'll move on to the section, so Mr. is kindly prepared. Three excuse please. May I? People attending now may ask everyone to please answer. The answers are anonymous, so you know, you could say you could give it your best guess. You won't be judged. No one will know what you answered.
Um, and just to check your understanding of the topics and also just to consolidate what you've learned tonight and we will go. Mr Latco will go through the answers shortly, so we'll give you about three, four minutes maximum to answer these. While we're waiting, I will. On the chat box, I will share some information about some of our upcoming courses.
We have a FRC smoke. Really, there are some observer places available, and we have other fast courses, I would share some information on the chat box for you guys later on. So people through them. Yes, please, if you could kindly go through the answer, the first one is. Please select the most appropriate statement in relation to product manager syndrome, I gave four or five options, so the correct answer is actually the fifth one is incorrect when a complete patient may have reduced bladder or sensation or sadness into the disturbance, but retain bladder control.
Yeah so the first question, if you look at it, it looks like it is true, but there are significant a lot of papers showing that, you know, basically you can have normal tone, even incorrect when a patient can have an abnormal tone and have a. And the normal skin, so it's not that reliable again, another thing is objective loss of anal and genital sensation is confirmatory actually, in comparison to adulto, the objective loss of burial and gentle sensation is more superior in diagnosing chloroquine.
But again, it's not confirmatory. Yeah, the third one is patient with incomplete cauda. Epicondyle syndrome has completely normal examination. No, they don't patient to introduce the anal tone and loss of innocence and always have protection and know both of them that they can have both and then still not have protection. So there are rare cases, so that is the correct one. And then the second is.
Which of the following statements is true regarding management of spinal cord compression? And the first one is prognosticator using revised to a conscious code is very useful in predicting is not very useful today. I've said it, it's around 60% since code alone determines the need for certainty.
No, it doesn't. That's good. Everybody said no surgery for decompression is based on life expectancy, nature and origin of tumor and spinal instability only. Not only because whenever there is only or it's confirmatory, so never that is the correct answer. So patients treated with direct decompression surgery plus post-operative therapy superior outcome in comparison to patients treated with radiotherapy alone.
That's the correct answer. I think. They worked in a '63 verdict. That's correct, perioperative embolization should be considered in all renal and myeloma patients, not in myeloma thyroid patients. Not of renal and thyroid patients, not my patients. OK which of the following statements regarding the management of spinal cord injury is not true?
But the first is a spinal cord injury patients need to manage with optimal hypothermia or normal tibia, which is true. Spinal cord patients presenting within 12 hours. High dose prednisolone should be considered to prevent secondary injury. That's strong. You you don't consider that unstable complete spinal cord injury require.
Surgery yes, decompression prior to 24 hours is associated with improved neurological outcome as at least two grade improvement at six month follow. Actually, that is more. Strong, positive answer and compared to unstable complete spinal cord injury.
Yeah, your sepsis is the commonest cause of amongst the commonest cause of death amongst the spinal cord patient is again true. So that's the true statement, which is. Not true is the second one. The answer is quite reflective of the reality and. These questions in the exams are tough, and we would not expect 100% of people to answer that.
I think an answer rate of between 60 to 75 or 80 is the normal expected range. I think they are a bit difficult as well. I mean, made it. So that's quite good, actually. Yeah, Yeah. Anyway, it's not the exam here. It's just here to make people think and see what. Also, they need to prepare to get ready for the exam, so.
That's wonderful. Thank you very much. Well, thank you very much, Sandy. I think.
Segment:0 .
Yes, thank you, Hannah. Good evening, everyone, and welcome to this Thursday teaching webinar organized jointly by orthopedic Research UK and the orthopedic Academy as part of our FRCS teaching webinar series.
So we welcome this evening. Our guest, sandesh Lacour, who is a spinal consultant working at the University Hospitals of Derby and Burton Mr. NICU La, coold deals with all aspects of spinal surgery, from degenerative conditions to trauma to metastatic spinal conditions. But he's especially interested in pediatric spinal treatment and scoliosis, so we're very pleased that he's accepted our invitation to present tonight, and I'm certain we will all learn a lot from him.
My name is Firas note. I'll be the host and I'll be moderating the session along with my colleagues from the UK team Hannah, Lydia and Ruth. So the session will include that include, as you can see, a presentation by Mr larkhall, he was going to focus on three hot topics for the FARC exam. He's going to go through the key concepts in these topics. Following that, we will have three markers as well.
We will present to you and Paul and answers will be completely anonymous. Four so please encourage you all to try and they will be based on mainly on what's about the lectures, but there will be some new concepts as well. Mr Lacroix will go through the answers with us following. So all this will be recorded. Following that, there will be unrecorded session where we have some Viva questions.
Very interesting related to spine. And we encourage you all to try to take part. Obviously, exams coming up soon and we will give priority to those going for the exam. So please, if you are interested in taking part in the Viva component of this teaching session, please express your interest by writing on the chat box or raising your hand simple and we will allocate it on first come, first served basis.
For those of you who obviously we encourage you to ask questions and we will endeavor to answer all your questions within the session. And that if you miss any part, don't worry, it's been recorded, and we will post it on our YouTube channel later on within a few days. At the end of this session, we will ask you will send you a communication email asking you for your feedback.
And if you would like a CBD certificate, which we can provide to you. So that's all from me. And without further ado, I will leave you with Mr Lacroix. Thanks, Chris. Thanks for your introduction. Many Thanks very much. So I work in a City Hospital in Burton. And so basically, I thought rather than going to a single topic, we can cover quite a few hot topics, which commonly come in.
We're for a first year. So basically, I'm not going to dwelling to the nitty gritty of each topic, but I'll give you some form of food for thought. Some form of Armory so that you can survive those kind of situations if you get in the exam. So these are the common topics in common emergency fractures, cord injuries, infections, metastases, their bog standard, they will come one of them either in other basic science or in any of those in stations.
Some elective cases elective cases are slightly rare, but allopathic tenodesis list disease or scoliosis, a contemplation NF are quite common in clinical, so knowing them will help. So I'm going to start by giving a scenario. So think about this case. First case is a 58-year-old male, but anyway, it's celebrating.
A friend's birthday fell asleep in a dining chair cell, Bangui said he's got a severe pain and weakness in important and unsteady gait. No significant possible, no significant medications. So this kind of scenario would be thrown at you. So what are you thinking? You have to look at the age there to look at injury bang with that sort of extension typekit and then look at what symptoms, you have to get pain, weakness in the hands and steady gait, unsteady gait that some element of called into acute care.
So basically, you're dealing with the person who has an injury to the cervical spine with the possibility of some element of spinal cord injury. So that's what you're looking at. So basically, we're going to talk about or know more about spinal cord injury, how you can approach a patient with a neck or suspected neck and spinal cord injury in any age or any form, right? OK Uh, so basically, how can you how do you examine them?
History, examination, Asia score what resuscitation and resuscitation is important? You have to keep the map more than 85 mercury to keep the perfusion of the spine. How can you prevent further injury, log rolling, et cetera? How how can you medically optimize this patient? How can you transfer this? This patient needs to transfer. The patient requires involvement with spinal center.
And does this patient require surgery? If at all, it means safety. So these are the kind of have to start thinking about all these things when some kind of a case is thrown at you. So that how you're going to manage this patient. So what a spinal cord injury. Spinal cord injury is an insult to the spinal cord, resulting in loss of complete or incomplete function one of the functions of the spinal cord at this motor.
Sensory, autonomic or reflexive? It's always nice to have some form of definition in your hand so that it can. You can start as a opening centers if somebody starts a conversation. So the 1,000 cases for the 45,000 people living annually with spinal cord injury commonly male in young people with the advancement in treatment, their life expectancy has increased.
And it does, why it is important because it costs a lot, but case more than one point one, two million and four annually, it has significantly increased. Common cause is road traffic accidents, domestic violence, industrial injuries, sports injuries, violence, assaults, guns four. 5% common hysteria is silicon spine. Always think of other areas point in moment. Don't just think about cervical spine only, so around three to 25% of the cases.
Most of the injuries happened because of improper immigration and during the transport. So this is quite important, so the two types of injury happens in spinal cord. The primary injury and the secondary injury, the primary injury happens at the time of injury or road traffic accident or assault. That's irreversible. There is no way we can reverse that with the secondary injury, which in part that depends on systemic factors, extracellular factors and intracellular factors.
They are the ones which we, as clinicians have control and we can optimize for the patient so that they don't develop, for example, of hypoxia. Hypothermia can stick them on oxygen, give them fluids, blood, whatever is required to stop the hemorrhage and prevent hypothermia. So, interstellar factors, you know, we're aware that lipid peroxidation free radicals several times of stasis and caused secondary damage to the spinal cord.
So we are said in the medical and surgical treatment is optimizing the second range. So I've come to that in the next. The slide of the treatment. So, no, some definition, what is complete, what is incomplete spinal cord injury complete means that no motor or sensory and function below the level of the neurological level, what we call, let's say, six or D 10 or 12.
The incomplete is there is some residual knowledge. Can function still exist? No, the ulnar nerve moment. But the words is quadriplegic. Quadriplegic is because the patient has a spinal cord injury at the cervical spine in both political sense. But I like Visa strategies. That paraplegic is the thoracic or lumbar sexual involvement with the involvement of trunk or legs and visitor, depending on the level of injury.
Um, no, the incomplete spinal cord injuries they do come quite often in Central cord syndrome is one of the commonest to know them well, I can't go. Each one of them, because it's going to have to tell the rest of the topics as well. Cross section is quite key. So if there is a spinal cord station slowing the spinal cord cross section, drawing it loudly, it is key.
So predominantly there are two descending planks and ascending trunk the descending cracks of lateral corticospinal tract and ventral corticosterone. Ascending dorsal column for fine touch and proprioception lateral cortex contract for pain and temperature control for life. Touch the important one you need to remember or the one you need to draw is when you are asked either central cord syndrome or entity syndrome or bas status.
Comedy central for less is the. The way that the nerve roots are organized through the fibers of the networks are organized in the spinal cord, cervical being the Central Policy number and sacral being the farthest. That's why you would have upper limit involvement more than the lower limb in Singapore syndrome. So basically, I'm not going to say, how are you going to be the.
You know, when you get this patient, you're going to say, I'm going to do a head to toe examination of this patient from the second can say we're making sure this patient is in line immobilized. So you will do an acid chart on admission and also don't be swayed by spinal cord injury and distract from your assessment of other things like shock or what is the pulse and look for destructive injuries as well.
How can you start planning for them? What kind of imaging you require for patients with spinal cord injury? You definitely want to see this scan of the neck safely and definitely will require an MRI scan either of local or a full spinal MRI scan, depending on how much or what is the extent of injury and how you can optimize the medical management, whether the surgical management is required, whether the mdc-t or any vessel, the spinal center is decline in spinal cord injury patients, so it should know them very well.
There's a newer one International standard for tuberosity classification of spinal cord injury, I see. And it's mainly looking at how we can classify or grade the motor and sensory examination. But you can just stick to the and know about neurogenic shock and spinal shock. Be aware how we can differentiate. Neurogenic shock is basically a loss of sympathetic tone with hypertension and bradycardia.
Spinal shock always. A joint document reflects the best way of doing it all the spinal cord injury patients, you will have categorized them. You log roll through the catheter and do appear whether they have any contraction of the. So that's the most civilized way of doing to flex apart from whatever is described in the textbooks.
So it's a basic empowerment. K is based on what is the motor function and what is the sensory function is time. It is good where normal motor and sensory function B is normal to function, incomplete sensory. So C and D is the one where you have to differentiate. C is that the key group muscle below the level of power less than 3D is where the key it will have power of more than three.
So that's the best way you can describe here in Parliament Square. OK so how will you work up any patient if you get a spinal cord injury? You need a CT as I said, my blood test, you need to brace them, maybe basically the same patient. If you think about this patient when required, ask them, call it of some form of mobilization. Ask them for bed rest, low growth catheter analgesia, IV fluid EXOGEN blood.
Make sure that the blood pressure is optimal for a cord perfusion and maybe should be more than 85. Contrary to what we think for spinal cord injury. But for them better to have either normal term or hypothermia. A lot of people suggesting that hypothermia is good for spinal cord injury patients. Think of they can document it from the beginning.
Think of DVT prophylaxis and always the question comes whether to give it or not. No stealer unless you get the patient within eight hours of injury, which is very clear. It's all you. Or if you're suppose, if you want to give a steroid, if you're not the person who is going to do the surgery. Speak to the person who does the surgery to see whether he needs to.
This person needs to have steroid or not. So the current sort of. Approach is spinal cord injury. We don't generally give steroids because the risks of complications are high, mainly with the high dose Tehran. So the one line answer is no unless within eight hours, because there is a McFarlane's paper sort of statement from a rule suggesting that you can give a high dose treatment if the patient comes within eight hours.
In reality, that option getting patients within eight hours to spinal center is less likely, so the safest answer is save the complications. 5, 4. I will not give any steroid. All right, speak to this final sentence and see if. Was so surgical treatment. Why do we need them all in complete neurological injuries?
You need to stop the secondary injury. Basically, the surgery is to prevent the secondary. Spinal cord injury in complete spinal cord injuries. It is basically to make them stable so that they can get rehabilitation with patients of Asia C or d, they're more likely to get better or incomplete neurological injuries.
They are likely to get better if they act early and if you do, if you offer them surgical management. So the goal of surgery is to minimize the secondary injury. This is what I'm going to say decompress the area of the interest, stabilize and maybe have timing. When do you want to do the surgery? As soon as you get the patient, you're going to take the call to either the original spinal center and tell them and transfer them.
If you are the person who is dealing with this patient earlier, the better in a safest environment. For example, if you get the patient evening or night, the best time is to do For the patient surgery in the morning. So the window period from the time of the injury to get surgical treatment is anything between 24 to 36 hours. So is there evidence this is quite a landmark trial in the trial statistics trial?
It's a multicenter International prospective cohort study. Basically, they look at the primary outcome of Asian employment scale grade in patients who are treated with decompression surgery within 24 hours, and they looked at patients who had surgery within 24 hours and more than 24 hours. So patients who had decompression surgery within 24 hours after spinal cord injury had better outcome, and they improve their vision impairment.
Scale grade by 2 at six months followed. So you can certainly mention this saying that why earlier surgery is better. And also the recent Lancet paper, which kind of accumulated not just the science paper, but other papers as well, which is a four independent prospective multicenter data of 2,500 patients. They looked at patients who went early surgical decompression versus late decompression.
They found that patients who have surgical decompression within 24 hours of electricity injury had a better outcome in comparison to the patients who had surgery after 24 36 hours. So the crucial window is, you can say, within 24 to 36 hours from the onset of spinal cord injury. So that's kind of nutshell of spinal cord injury. So the next kind of common sort of scenario is 46-year-old female bilateral sciatica numbness to feed, which is from 2 days, is progressive.
The history of lifting a heavy basket of shoes four days ago and then the pane on the left leg now has bilateral leg, which is progressive numbness. And increasingly becoming a mobile. So if you look at this history, it was a young person, female started unilaterally on the left like four days ago. Progress toward the two days to bilateral. There is a numbness and there is weakness in mobility.
So you're looking at somebody who had this collapse becoming more and more worse and was developing into politics on axilo. So that's how you can think and put your thought process into it. If this kind of a scenario comes into it. So the cortex-a9 syndrome is an emergency condition where lumber supply routes are compressed within the number of families presenting with combination of symptoms of altered sensory and motor function of the lower limbs in perineal bowel bladder function confirmed by an MRI scan.
This is I like definitions because it kind of puts everything in one nutshell and you can always, you know, it gives you an overview of what this condition is. So after that, that scenario will be kind shown this kind of a picture. So, you know, what can you see and how we approach it? They can say it was an accidental and axilo view two images of four five this collapse and four or five of the lumbar spine showing all four or $0.05 disk prolapse with complete.
If it's almost completely assessment of the CSF, my concern is, of course, a single. And then so why does connection syndrome happen or what are the normal displacements some people have the huge disconnect that never developed correct when it's incorrect. There are two things. One is the mechanical compression that happens, which decreases the nutrient delivery to the nauru, decreased blood flow and CSF diffusion.
The secondary is something like compartment syndrome, which is a time dependent factors, which will progress if we don't act quickly and if we don't pick up symptoms quickly. So where there is a condition, condition, internal edema and from a hypoperfusion injury with decreased further decrease in the actual perfusion and nerve ischemia, therefore? And then you got autonomic dysfunction of the bowel and now so it's a progressive cascade, which happens once the primary injury when the mechanical compression happens.
So therefore the connection of presentation is always suspect from the patient, and the patient always goes from one stage of cardiac syndrome to another state. I'll come to that in the next slide. So the early stages, and I'm not going to say, you know, what is the incidence, prevalence and all those things? So what are the early stages where you have to be very careful while you take a history.
And when you examine them is for looking for bilateral numbness or weakness in the leg? Carefully ask and assess for pain or pérignon sensory disturbance. If they have a bomb or genitals and the bladder dysfunction, can they feel the full bladder? Can the can they get the desire to pursue it? And when the path you are aware of doing? So this is the quite key early red flags.
Life is the host of symptoms of bilateral, you know, red flag symptoms. It look up in nice website, but I'm sure you all aware. Uh, in history and examination from the west, look for whether they had unilateral s.a., did they develop bilateral state if they develop any more thoughts into the changes that they start having sudden or back pain, which would suddenly worsen?
Is there any in anesthesia that happens to usher in a sexual dysfunction. And then bladder dysfunction or dysfunction? If they develop all those things, then you're kind of in the final stages of product planning. So that is the history. Apart from the general other history you're going to take in correct the examination, along with motor, sensory, and reflexes, the pain and sensation and tone and an alarming sign is something which is useful.
The question is the mask is in and tone is very sensitive in picking a product. There's a lot of studies have shown that drone is not that accurate test in detecting early chloroquine or correction incomplete syndrome patients. So but in fact, what is more important is carefully assessing perineal or in sensation and documenting it clearly in comparison to the rest of the labor, rest of the body.
Important one. Every patient would correct one if you get a patient with chronic pain that you must do pre and post wide, scan normally around 50 to 100 in every trust or every region networks, but the networks have certain criteria. What is normal? What is the cutoff for scan? One of the study done in Nottingham by Mike Leavitt at all of the group.
They looked at the patient who came with suspected chronic one and how many of them had that pre and post virus scan. And their kind of take-home message is if the post-war risk is less than 200, then it's 97% negative predictive value for protection. So 90% chance that it could not be so in that group, only 3% chance that they could have cortex-a9 syndrome.
So in a sense, you can say the cutoff is 200 handle. So if the patient has less than 200 well, we can say the chances are less likely, but you can carefully observe. You will admit the patient. You will do a serial post-war residents. Can they get into more than 200 members? Then it's a very that means they're progressing. But if it is more than 200, remember that the chances of chronic fatigue syndrome is, I think in this study alone.
47% or so around that, you can look it, look it up. So it's something important because it's a UK study and this is one of the important clinical signs. You must do in connection with. So I'm going to spend quite a lot of time. In this slide because this is what you need to know, because this is kind of a natural evolution of called epicondyle when you suspect what I call, what happens, what happens in early contact, incomplete in retention and incomplete.
So when you suspect correction in people who either had long standing back pain or long standing leg pain, who start developing bilateral sciatica with more sensory loss, this is called clinical consequences. This patient with no bowel bladder generating very mild symptoms. And when you confirm it, it's called virologically confirmed or suspected polyclonal syndrome. The early stage of contact point is they still have normal bladder, normal Bowl of sexual function, but they do have sensory loss around a parental area and then they have some change in maturation.
The key stage, which. To pick up when you assess this patient, this is the patient in complete contact, a symptom wanes. This patient has good, has control of the bladder, but has altered sensation in the bladder function or sensory bladder sensation or representation. But if there is any peritoneal changes or sexual or sensitive functional changes.
So this is quite a subtle stage of correction syndrome, where if you catch them early and the surgical intervention will have some impact on their outcome of urinary function. So if you leave this, if this patient with a large disk will say, oh, bladder is a bit funny, the sensation is not that oh, he's got control so we can just leave him alone if we don't pick these patients.
They will go into retention. So that's the next step to see is that the painless bladder retention and also the first stage is correct, complete where they have incentive there to overflow incontinence. No perinatal perinatal sensation, no undertone. Very possibly. And it's like completely lacks in in-person. And so the boss has made it easy for you.
You can mention boss classification of products where you suspected the absence of sphincter dysfunction incomplete with the Syria agency or the situation with retention, Kessler retention and confidence. The reason I go back to the slide is because the early if the treatment or surgical treatment or early surgical treatment of suspected nephrotic syndrome or early correction syndrome or incomplete production syndrome, they are certainly better in comparison for patients with CSR or complete product.
So as long as you can tell that in a coherent way in the exam. I think it's a good brownie points, I would say. So then if you're going to examine must know the two key things is. Went to the MRI scan. And who should do and what I scan, the MRI needs to be done at the earliest opportunity as soon as possible.
If your place has an MRI, my advice is if your face doesn't, if the scenario is your place hasn't got MRI facility, the best is to depending on the clinical scenario. I speak to the spinal services, get that advice, whether the advice could be that as a first thing in the morning so that they can wait for a slot for the surgery or some centers do advise for transfer or NIPE if there is a convincing evidence that the patient is in contact and deteriorating rapidly.
So the boscalid is that the person who is examining first time or reference must do MRI scan and then transfer to the local services. Some centres, some visitors, may not have the facility to do MRI scans, so you have to keep that in mind. But, for example, you can almost do whatever is there in the guidelines.
So regards to surgery. I will come back to it. The two can talk about we can finish it. So So when you need to do the surgery for chronic pain syndrome, so. The best is at list as soon as possible and as safely as possible, taking into account of symptoms and the duration and the progression.
We love this heart. So there is a caveat to it. We need to consider the potential for increased morbidity if you're operating in the NIPE so you're not going to operate. Somebody comes at 10 o'clock with complete retention, which has been already established for more than 10, 12 hours, but nothing you can gain by operating in the middle of the NIPE.
But if a person? Came in with intact bowel from bladder function to Eddie while waiting in Eddie donors. Or goes into detention, even if it is around, say, eight, nine, 10 o'clock. And these are the patients probably subset of patients who have deteriorated in a short span where. Urgent or emergency surgery may make a difference to these patients, so we need to take the multiple options at the same time, you have to say I will also, I mean, if the question comes back to you saying that you are this policy, that response center, what would you do?
It is I will still look at the patient progression and the availability of theater and staff and resources. And then I'll take the executive decision whether to do it in the NIPE or in the morning until it is safest. So the best is within 24 hours of onset of symptoms or within 48 hours within 48 hours, it's considered acceptable because most often all these patients, they don't present straight away.
So it's very difficult to cast them within 24 hours from onset of symptoms. Certainly, we can do it within 24 hours of presentation to Ed, but within 24 hours of onset of symptoms, it's quite difficult. But at least we need to try to get these patients treated within 48 hours. But the answer is as soon and safely as possible. So what kind of surgery are you going to offer?
What you're going to say or what? What will you write in the. So all these patients will have a large disk so microscopic to me, even though it is described as an option of treatment, there's a high chance of that or complication. Therefore, we will offer them central decompression in district to me. And again, you need to go through the consent and what are you going to say and all of those things in case you go to that level of.
Off the topic in your discussion. Um, so there's a recent paper from Ireland that is comparing the timing of surgery and correction syndrome classification based on both guidelines. They had 136 patients, 69 in retention, 22 and incomplete and fortifying the suspected group.
Surprisingly, in their study, they didn't find a significant difference in improvement in the bladder function if they had surgery within 24 hours or after 24 hours, mainly in chronic conditions of detention or incomplete. So they conclude, saying that early stage can decompression within 24 hours from the onset of symptoms does not appear to significantly improve the bowel or bladder dysfunction.
But, you know, this is a retrospective study, and it's very difficult to. Sort of without a randomized trial, you can clearly say that such a strong statement of early stage in the competition will not have a significant impact. But contrary to that, we can mention another paper which is slightly old.
But again, they looked at the collection of incomplete patients, and therefore they reported that the normal bladder function can return in around 90% of the patient at 88.9% of the patients. If you treat them within 24 hours, that's quite significant. So I would say still if the patient has correct an incomplete, then the early surgery will have a better outcome.
So there are quite a lot of other studies, but some of them are historical now, it can know, but there may be questions asked. Is there evidence for this? And you can throw one of these papers into this patient? Any more questions on this story? I'm going with fast now brilliance, and you're not going fast at all, actually excellent pace because it's good.
Very good. Concise slides, so we all enjoying it. So I think you have one more topic, but if you like, I can give you maybe a bit of everyone a little break and ask some questions. Is that right? I was doing that. So So question from villas. He asked about the cauda equina secondary to mix.
Are any particular guidelines on management you're aware of? So for the Mets. Yeah secondly, to me, called the cauda equina secondary to Mets. I mean, my next talk is about that good. That's a good thing. So I think listen carefully, the next stock answer might come through. I mean, I don't know what the I mean, there is a nice guideline on spinal cord metastasis that is something which you need to.
I think that will apply, but that's mainly for spinal cord compression. But the same kind of rules apply for, yeah, save for chloroquine as well. Bear in mind that the commonest area of spinal metastatic compression is toxic level because of the battery plexus. So you really have quite a quantitative compression. And another thing is the cardiac monitor.
The tumors tend to have the spine. Canada is large and there are no rules so that even with the significant compression, you don't seem to see the extent of sudden degradation of the neurological function, what you would observe in a trust level. Tumors Yeah. Metastatic fracture compression or tumor compression. Oh, that's interesting.
That's interesting, but it's not. I'm not saying it's not, it is. Slightly there, but communist is what you get is the lowest level of completion in the tumor case. Yeah, because of the vets in Texas and all the. Thank you. We have one more question from Muhammad Neal. He's asked if the post avoiding residual is less than 200.
Would what would you do, would you do an MRI scan or would you just admit and observe? But it depends, you know? Never a single entity will determine a patient's fate. You go back and examine history, carefully things and every jigsaw puzzle needs to make you a proper informed decision. If a patient has more convincing symptoms or signs, I would still get an MRI scan even if it's less than 200.
Just based on just because most this world is 200 I'm not going to send the patient back home if I'm clinically. When I examine and when I take on a history, I'm convinced that this patient might have a correct one that I was never going to say go back. But I would. Still, if I'm a, you know, if I think clinically this person is in the clinic collection of incomplete type of scenario, I will sort of nag the whole local services or things to do the MRI scan or take this patient for an MRI scan, you know.
So that number is just to so that you need to have some standard number to say which which in turn is normal, which is abnormal, et cetera and some hospitals have very strict rules for what is a cutoff of Nottingham in a local hospital. They have they used to run the numbers part. We in our hospital is 100 MLS.
So some hospitals may use even 50. But that is purely based on the whole entire examination of the patient. I think I agree with you totally. It's multifactorial, isn't it's never one when deciding factor, you have to look at the whole picture. And, for example, purposes the number one priority is being safe. Exactly no, you have to be safe.
If you're not safe, you don't pass the question. No matter how much evidence you you, you could. You got to be safe. And then for the exam, MRI, scan your MRI, scan everyone, you know, there's no point in the then obviously you can argue the cases and argue the risks and things like this. And you can put on your support. Yeah, I mean, I agree with that.
I mean, you can always argue, you know, there are a lot of papers who are done, whether it is justifiable to transfer patients overnight to from $0.2. And they followed that the only fraction of patients turned out to be positive, and they compared it with people who came to their own set up and found that who had all NIPE MRI scan. So they said, there's no point in transferring all NIPE to a specialist centre, and you can argue and debate and you can throw those kind of evidences.
But at the end of the day, as far as you always say, I want to say make sure that this patient has no product, but my I go back examined and I really specifically look for these things. So as long as you demonstrate that you're going to, you're not going to just leave the patient in the lurch and you're going to make sure that this patient is safe. Probably not to have a moral scan and demonstrate that inside and how you demonstrate that inside is the key.
You can't just say, oh, just because you said, oh, less than 200, oh, I'm not going to divulge it's probably that's not the right approach. Yes, absolutely, I think, yeah, you can. It's a very, very hot topic, very hot topic. And to be honest, you know, most of the people stay away from contact with such a controversial without. Yes Yeah.
Not an easy one to take on. There's nothing, you know, for whatever is there in the boss guidelines to say something for the candidates to talk important and read more about basically nothing more. I'm not giving everything that was just some of the business. But so shall I go next to him? Yes, please. So the next typical case is a 60-year-old lady come to clinic with more than 12 weeks history of low back pain radiating the right.
Progressively worsening walking distance is limited due to pain. Significant amount of pain flits from one tired keeping the. So it looks like way history, but there are bas status 60 more than 60 patients of cancer, 20 weeks kind of a short duration, which you consider for a back pain patient and one month progressively worse. So there is a short sudden burst and sleep nighttime pain.
So the three four quick, big things in the history itself will sort of give you a hint that it could be a tumor of really an infection. So that's how you have a line. So if your throat. If somebody say what's going on in the mind, you know, you'd say 60, 80. And this is a short history, and I'm a bit concerned that this could be a tumor.
And that's my differential. How how are you going to do a clinical assessment? How are you going to take a history from looking at the pain or region past medical needs to see if they have any questions and symptoms of. Cancer, any history related to primary breast or prostate, lung, et cetera. And then you do an examination from head to toe and looking from primary and neurological examination and looking for lumps and bumps, et cetera.
And then you go for the investigations. What kind of blood test, imaging, medical management, whether this MDT involvement and what kind of a surgical treatment. So these are the whole spectrum of sort of questions and sort of answers you may encounter during this kind of scenario. So the. Common customers, which is bad to the bone from breast, lung, and prostate in that order.
So the survival is good for thyroid and then for prostate, breast reasonably so for this kidney and lung, they were pushed out. But these are all historical figures from the paper, I think, from 2005. But they are up to date certainly definitely will be much better than this. Prognosis won't cause this, but at least, the order that people.
What is the third most common mistake from a distance? The first is the lungs, liver and bone. So that's why you always see the chest and the pelvis to see if there any visitor involvement in bone spine is the most common. And then open muscular and in inspiring stories is the most common story. So the physiology part of the spine, they can cause us to like this or blasted off to us like this is caused by.
The tuberosity declaration of two-plus again mediated by cytokines, interleukin six, interleukin 11 parathyroid hormone, and to return the stability of the blast to release ankle and then the binds to rank and then stimulate the osteoclast and osteoclasts activity osteoblasts. It's to the blast and also activists the Department so long primarily like 60% of the breast blast, 90% of the prostate is plastic.
So after you've gone through this patient, you've taken a history of pain and onto the symptoms, except as I mentioned before. And what next, the last. So next is we're going to test the investigation basis. SPC differentials is susceptible to the infection, metabolic profile, cancer attention, while the left is, et cetera, which is denied the screening for specific cancers as well.
But this is a place in basic consumers to in every patient. Do you see in a suspected metastatic cancer patient the general image workup to see the chest of the pelvis and then bone scan to see if there is any extent of bone metastases apart from spine itself, and in some cases where the cold spot in myeloma or tumor you have to do a collecting x-rays as well.
And specific, you know, that is being said, just in case, if had this kind of a patient and if an X-ray nowadays you generally jump to. Of the dilemma really lack of action. But the recommended normal sort of. Investigation strategy is to have a little of that in spine, preferably holds by standing to see if they have any deformity.
Ct scan is important. At least at the area of involvement or we can. To see if it is a light or Black humor, and also to know the bony architecture if you're planning for surgery. Best or the standard treatment standard protocol now is to get a whole spine MRI as a screening for any other areas of metastatic metastasis, if you suspect one.
So if you have a patient who have no primary carcinoma, so then biopsy is the key. So if the patient has no neurological deficit, then you do a biopsy, send a specimen for histology and wait for the histology to come back and then plan treatment. If the patient comes with metastatic sort of a lesion in the spine with no primary or quadruplets, a cop cancer of unknown primary with cord compression, then we'll do a biopsy.
At the same time, the compression and stabilization rate for the histology to plan for as radio or chemo, or whatever we can to. So then how do you drive to the level of who gets to serve you? I mean, patients with primary cancer with metastases, they're not the fittest of the lot. So who and how you can decide who will require surgery or decompression or stabilization, etc.? The couple of tools, which you need to know is Takahashi's scroll, which is based on general condition of the patient.
How many extra spinal bone metastases are there? How many vertebral bodies are involved? Is there any residual metastases? What kind of a primary tumor? And if there's any neurological compromises, you can see the rectal thyroid cancer breast, they have got a higher score. But if you have a lung, esophagus, pancreas or the liver cancer, they got a very low score.
So the scoring is collection. Of all these things, you put together 0 to 8 less than six months. So mean survival 9 to 11 more than six months, 10 to 15 or more than 12. So often this is proposed in 1990, the worst by the same authors in 2005, and they did their own validation. They said it's around 87% accurate, but again, it's been regularly contested.
And one of the studies done by a Nottingham group again showed the usefulness of this is around 66 percent, and some of the other papers have suggested even lower accuracy in predicting their survival. Yeah, so but this is definitely need to say that. How can you predict the survival before deciding for surgery? The other one is the non-school, depending on location type of bone lesion.
Is there any spinal alignment? How much collapse is there? Is the involvement of most likely involvement with the lower the score, better for the patient, better for the patient. Up to 6 is stable. Up to 12 7 to 12 is probably unstable. 13 to 18 is definitely unstable. So again, it's just not the score itself you're going to treat.
You are going to look at the patient, you're going to look at the other scores and you're going to enroll. The mdc-t and the norms is another framework which is commonly used for consideration of who gets what kind of treatment. So you look at the neurological function, you look at the oncological diagnosis, look at the mechanical stability and look at the systemic illness, for example, if you have the high grade.
Epidural spinal cord compression. And then they require surgery then radiotherapy. And if somebody has mechanical instability, then they require surgery. If they have mechanical instability with just a burst of compression fracture, then we can consider careful posture what we do. So if somebody has a really resistant tumor, then they without compression, they'll go for just as a really resistant tumor.
With compression, they'll go for surgery. And again, we can't forget the fact that you will always look and look at the patient, a systemic illness, you know, what is the overall outlook looks like, whether they're capable of handling this amount of morbidity of the surgery? Because these cancer operations are not small, they're big, they bleed, and it takes long to time to recover.
So you look into all these aspects before this happens again. It's never a single person decision. It's always a multidisciplinary team approach, an empty decision. So palliative care, you have to think about palliative care. If the person has a life expectancy, as is talked about, they're less than six months, then primary care. Also, in some patients, the radiation alone is useful.
So the surgery is mainly for neurological decompression stabilization. And then. You plan for postoperative radiation. The cut of most of the hospitals, most of the spinal centers uses more than six months at least, so I will to decide whether this patient should go for surgery or not. Um, so this is a landmark paper from Roy Pritchett right back in 2005, I think after that, the NICE guidelines of MSFC came into play, which is a randomized, multi-institutional trial looking into surgery, followed by radiotherapy and radiotherapy alone in their group, patients who have surgery and radiotherapy had better ability to walk after treatment at their final follow up in comparison to people who just have aided therapy alone.
So this kind of change the scenario from treating all these patients with metastatic spinal. And cord compression with from the steroid and radiotherapy to decompression, surgery and radiotherapy. So even in this paper, the patients who had surgery needed less steroid and opioid analgesics, which again is beneficial to the patients. So, so that is it.
Guys from my side. Any questions? That's wonderful. Mr akula is really amazing, I think each of these three topics is a whole lecture on its own, and you managed to put the 3 in them in one. That's really one. It's just a little bit of food for thoughts, isn't it? I haven't given anything.
Yeah, it's perfect for my point of view. Have you been teaching for a case for a long time? I think you don't any for exams. You don't need to know anything about, you know, above and beyond what's in this presentation. So I think wonderful, wonderful one, and I encourage you all guys to come back and see it see the replay when it becomes available in a few days.
Yes, we have some questions. Obviously, as you know, the Kodak equine always had topic, but question from Sharon asking, can Kodak China syndrome present with the unilateral sciatica? It can. Yeah one line answer is it can. Yeah that's good, that's good, that's good, you know? Yeah, absolutely, because I know today, if somebody has unilateral symptoms, has very numbness again and retention.
Yeah you know, not always. Patients should have bilateral symptoms. Yeah, exactly, it's a whole multiple factors. Again, if someone just coming with the unilateral attack and everything else is fine, then that's not the codec, y'know, but you know. But unilateral does not exclude codec. Yeah, no, no, no. Just because station has one unilateral simple, but I've seen patients come in with unilateral symptoms with completely Black dots.
Yes so it's. So one more question we have here. And from faizal, he's asking is, is the radiologic, is there a logical correlation? with the clinical classification of code the equine. And how would the radiological features correlate with the clinical presentation, I think in terms of acute or pending decline, I think.
I mean, that is, you know. And how is the progression timescale as well? I mean, I think it's unpredictable, isn't it? It's a good question. I mean, I think what he's trying to ask is if you know, depending on the degree of compression, can you predict? I mean, it's not the correct compression is not that it's going to progress. Progress, progress.
You know, the quite iconic compression has happened. I go back to the pathophysiology slide, where the mechanical compression happens in the secondary injury, intra neural pressure develops. So that is where it's happening. So it's actually the clinical scenario that changes the radiological picture remains the same. If you are trying to ask, I am not aware of any paper which correlated the degree of stenosis of one and their association with collagen in tension, or I don't think it has any significance in decision making.
My decision making is my patient and look at the patient, examine and take history. And then you confirm it with the MRI scan. And MRI scan is to confirm not to grade. Yeah maybe. I think generally in order to accepted the correlation between the radiological findings and the clinical findings, not always the standard or they don't follow each other all the time, isn't it?
So I think the question was, do I think he was trying to ask whether you can grade suspected incomplete retention based on mri? If if I understand correctly? Yeah no, I think that's difficult, isn't it? That's difficult. Yeah so we have one more question about first talk about in relation to the Asia classification type C and D. And how the question is how.
From Dylan, he's asking how do you choose the key muscles to examine? Who knew that there is an ICC in charge? Yeah, you can Google it, and it'll show you exactly how you need to examine the key groups, the specific way it'll give a demonstration exactly from each mile, from each dermatome.
How to examine. So I think it's in the I mean, that's a talk in itself, actually. So that's what I would suggest you to go back and read ICC. I don't know the full form, but that's the normal charge, which most of the spinal cord injury units are using nowadays. Thank you. Thank you.
Now, one more question from Jamie. If a patient with metastatic spinal cord compression attains and they are off legs. How would you what's your standard approach, do you go for MDT or do you decompress urgently before final MDT decision is made? And I think that's if you are working a spinal unit now, isn't it?
Yeah, I mean it, you know, it depends on the primary and it depends on if the patient is off legs. Is that what you? Yes patient off legs. Yeah, Yeah. Again, you go back to what is the primary? What is a known primary know? Is it an aggressive tumor? Is, you know, you do the hits.
Everything has always said you do the blood, you do the seed chest of the police seal, you get a whole spine MRI scan. If somebody has, you know, if that person has a life expectancy of less than two months, you know, making that person go through a big. I mean, there are some patients we have said, you know, person is off, but he has, you know, life expectancy is weeks.
So for that person to have a big operation, you discuss with the patient, you know, whether you want to have a surgery with the hope that there is a chance of improvement, you know, it's this cord compression patient will not have a significant improvement in neurological function in cord spinal cord compression patients. Your operation is to stop the progression somebody's already off legs unless the person has a big, long prognosis.
From a cancer perspective, we're not going to have say again, it's a conversation you need to have with the patient. You're not going to operate on the middle of the NIPE. Definitely not. And again, in those patients, you still give them still. Yeah, if cancer patients you do, you do give them therapy. So, yeah, not in spinal cord injury patients. OK, thank you. I think we got to remember again, we are here focused on the FARC as level kind of questions and exam scenarios.
And I think if you are, they'll assume you are a PTH consultant when they ask you the questions in the exam. So for a digital age consultant, when you get this case, you are discussing. With the spinal surgeons on call. With a spinal center and you are discussing there's always oncologist on call. So you so you can have a mini MDT, even if it's no matter how urgent, you can always have a mini MDT between a general orthopedic and the spinal and oncologist.
So yeah, I mean, if I need, I will speak to the oncologist. Yeah, you know, but again, it's good just going off like because of the cancer, but I'm going to jump and operate is not the thing and just always go back, look into all aspects and again, involve the patient. Sometimes you involved family as well. OK it wasn't a question went to do an MRI if you suspect Mates, but there are no clinical signs.
Apart from pain. If you suspect let's get this kind of. Yeah, Yeah. Absolutely, it's no. At no point waiting all and any role for steroids, I think you answered that and Najee asked. Any role for steroids in China syndrome? Not for the. But you've already answered that.
So that's secondary to tumor then? Certainly, yes, there is the role not for core compression injury. So thank you. Thank you. Well, Mr Blackwell, thank you very much indeed for this wonderful, very comprehensive lecture. Recovered three very hot topics as the title says you would actually deliver what you promised.
Definitely it's a wonderful, very focused, very focused lecture, and I've certainly learned a lot and I'm sure everyone is watching has also learned a lot from this. The reviewing this again, and I'll use a lot of the papers and things to update my book on it all. With your permission, I'll use that. So thank you and for answering all the questions from the audience.
Now we'll move on to the section, so Mr. is kindly prepared. Three excuse please. May I? People attending now may ask everyone to please answer. The answers are anonymous, so you know, you could say you could give it your best guess. You won't be judged. No one will know what you answered.
Um, and just to check your understanding of the topics and also just to consolidate what you've learned tonight and we will go. Mr Latco will go through the answers shortly, so we'll give you about three, four minutes maximum to answer these. While we're waiting, I will. On the chat box, I will share some information about some of our upcoming courses.
We have a FRC smoke. Really, there are some observer places available, and we have other fast courses, I would share some information on the chat box for you guys later on. So people through them. Yes, please, if you could kindly go through the answer, the first one is. Please select the most appropriate statement in relation to product manager syndrome, I gave four or five options, so the correct answer is actually the fifth one is incorrect when a complete patient may have reduced bladder or sensation or sadness into the disturbance, but retain bladder control.
Yeah so the first question, if you look at it, it looks like it is true, but there are significant a lot of papers showing that, you know, basically you can have normal tone, even incorrect when a patient can have an abnormal tone and have a. And the normal skin, so it's not that reliable again, another thing is objective loss of anal and genital sensation is confirmatory actually, in comparison to adulto, the objective loss of burial and gentle sensation is more superior in diagnosing chloroquine.
But again, it's not confirmatory. Yeah, the third one is patient with incomplete cauda. Epicondyle syndrome has completely normal examination. No, they don't patient to introduce the anal tone and loss of innocence and always have protection and know both of them that they can have both and then still not have protection. So there are rare cases, so that is the correct one. And then the second is.
Which of the following statements is true regarding management of spinal cord compression? And the first one is prognosticator using revised to a conscious code is very useful in predicting is not very useful today. I've said it, it's around 60% since code alone determines the need for certainty.
No, it doesn't. That's good. Everybody said no surgery for decompression is based on life expectancy, nature and origin of tumor and spinal instability only. Not only because whenever there is only or it's confirmatory, so never that is the correct answer. So patients treated with direct decompression surgery plus post-operative therapy superior outcome in comparison to patients treated with radiotherapy alone.
That's the correct answer. I think. They worked in a '63 verdict. That's correct, perioperative embolization should be considered in all renal and myeloma patients, not in myeloma thyroid patients. Not of renal and thyroid patients, not my patients. OK which of the following statements regarding the management of spinal cord injury is not true?
But the first is a spinal cord injury patients need to manage with optimal hypothermia or normal tibia, which is true. Spinal cord patients presenting within 12 hours. High dose prednisolone should be considered to prevent secondary injury. That's strong. You you don't consider that unstable complete spinal cord injury require.
Surgery yes, decompression prior to 24 hours is associated with improved neurological outcome as at least two grade improvement at six month follow. Actually, that is more. Strong, positive answer and compared to unstable complete spinal cord injury.
Yeah, your sepsis is the commonest cause of amongst the commonest cause of death amongst the spinal cord patient is again true. So that's the true statement, which is. Not true is the second one. The answer is quite reflective of the reality and. These questions in the exams are tough, and we would not expect 100% of people to answer that.
I think an answer rate of between 60 to 75 or 80 is the normal expected range. I think they are a bit difficult as well. I mean, made it. So that's quite good, actually. Yeah, Yeah. Anyway, it's not the exam here. It's just here to make people think and see what. Also, they need to prepare to get ready for the exam, so.
That's wonderful. Thank you very much. Well, thank you very much, Sandy. I think.
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