this will work now. So I think cervical spine trauma is something that bothers a lot of people for a lot of different reasons and one is that cervical spine trauma is often associated with cranial trauma so it's not isolated and cervical spine trauma can also be associated with vascular trauma and so it can be a really complex situation. I don't think that 45 minutes is enough to give you that full breath. It's really a residency worth of time that you'd need, but I do think that if I can give you some basics, for instance, some pointers as to how to evaluate cervical trauma, at least you should feel a little bit more comfortable and let's see if I'll be successful in that endeavor. So I have no disclosures and I give talks a lot about neurosurgery and even when I give talks that aren't necessarily directly neurosurgically related, I'd like everyone to understand that when you come to this profession, whether it's at the level of a nurse, advanced practice person, or a physician, it's really an old profession. As a matter of fact, and I don't think that you necessarily need to, but there's something called the Edwin Smith surgical papyrus. This was the first time historically where diseases were treated not just as mystical entities, but in a rational fashion. The Egyptians did this and they knew so much about the body that for the first time there's, I don't know if you can necessarily see my cursor, but in the center part of the screen where there is this eagle, that's where the first time the notion of brain was written in any kind of text. So if we go to the Edwin Smith papyrus, and I promise we're not going to talk about medicine from 5,000 years ago, we will talk about current modern day medicine, but if you go there you'll see that there are also pictures and images and if you look at it, this could be the back table of some of our ORs where there's drills and hooks and forceps and saws. Of course, we don't use things like vases for burning incense or things like that, but I think that this does point out to you that we really are very, very part of a long tradition of humanity and in turn medicine. I'd like to bring your attention again, this is still medicine from 5,000 years ago, but I think it's very relevant to today because I think what I'd like you to get from this is the observation piece. Remember, 5,000 years ago, there's no MRI, there's no CT scan, there's no anything aside from observation. And here is a case, and these are the way the cases were presented, and you'll see that while you might not agree with some things, they are at least laid out in a way that's not just magical or mystical. And here it says, case 32, examination. If you examine somebody who has a displaced vertebra in his neck, and you know this because his face is fixed and he can't turn, then your diagnosis would be that this is a displacement of the vertebra of the neck, and most importantly, it says it's an ailment which I'll treat. Now, the treatment, of course, is nothing that we would do today. It says bind it with fresh meat for the first day and loosen the bandages and apply grease and things like that. That may not be right, but necessarily, I want you to point out that they saw something, they came up with a diagnosis, and then they did have a treatment. This is exactly what happened. It's a jump to the set, and we'll get into that a little bit more, but in this picture here on the left-hand side of the screen, this is a CT scan of somebody's neck, and the arrangement here, we call this a hamburger sign, or maybe that's just what I call it because I'm hungry, where this is one facet and another facet, and this is a normal articulation of facets. When the facets are abnormal, they have this appearance on this picture on the right-hand, well, on the left, actually. If you're looking at CTs, this is the left side, but it's the right side of the screen, and this is called a jump facet, and then if you look at that illustration over here, you'll see on the illustration on the right-hand side, there's just a shingling. One facet fills over, another facet fills over, another facet, whereas on the left-hand side, you can see something is out of alignment, and so that's actually impeding the motion of the facet. I'd like you to really keep in mind that the spine is in a way no different from the elbow. It's a multi-articulated joint. We don't necessarily think about this that the spine is like your knee or your shoulder or your elbow, but it is. Every single element in the spine contributes to the overall movement of the spine, and so when you have a facet disruption, there is definitely going to be disruption in mobility. Here's another case. Again, I promise that we're going to get out of 5000 BC, but this I think is really also important. It says if you examine somebody and he's got dislocation of the vertebra of the neck and he's unconscious in his arms and he basically cannot control his urine. This would be something where fundamentally cut to the chase, this is a spinal cord injury, basically a high cord injury with dislocation that makes the arms basically quadriplegic. It says concerning him, this is a dislocation in the neck where he's unconscious in his arms and his urine dribbles. This is an ailment not to be treated because back then they had no way of saving somebody with a high spinal cord injury. This would be sort of, for instance, an example of that where you have a total dislocation of the cervical spine in this situation at C5 on C7 and that would cause you basically to lose arm function, you'd lose leg function, you'd have loss of sympathetic tone, you'd have priapism and bowel and bladder dysfunction. So I think it's just really interesting to see that the Egyptians kind of understood this. Again, this is weird that it would say that, you know, be careful medical texts or do not try to attempt to diagnose from medical ancient texts. I hope you all understand that. The spine, as I said, is a very, very complex multi-articulated joint. You think of the elbow or the shoulder, it kind of does one thing, but the spine flexes, it bends, and it twists. And all of that I want you to keep in mind is not just because of the arrangement of the osseous structures or the bones, but a little bit more we'll talk about the ligaments. And fundamentally, when you're looking at the spine, this is a little bit facetious, this song about, you know, the foot bones connected to the heel bone. But right about here in this song, it says that, you know, the hip bone is connected to the back bone and the back bone is connected to the shoulder bone and the shoulder bone is connected to the neck bone and the neck bone is connected to the head. And fundamentally, that's really true. You just want to make sure all these things are connected. And when you're looking at a scan, whether it's an MRI or a CT scan, you want to see that normal alignments and anatomies are preserved. This is basically a grave site, an ancient grave site. And I want to point out to you that it's not the bones so much that I think I want you to focus on when you're looking at any kind of scans, but it's actually the ligamentous integrity. So bones are held together by ligaments and tendons. And so bones actually heal really well. And if there's just an injury to the bone, the bone will likely heal. But if there's ligamentous violation, that's when there tends to be a problem. What are some of the ligaments in the neck? Well, we could spend a lot of time on that. But I think the most important things to think about are that the disc is a structure that helps to maintain the integrity of the cervical spine. There is a ligament in front of the bones of the neck called the anterior longitudinal ligament. There's a ligament behind the vertebral bodies in the spine called the posterior longitudinal ligament. And then there are other structures I think that might be a little bit too much out of the realm of this discussion. But I do want to point out to you that when the radiologists are reading their scans, it's really important for you, if you have a question to ask them, how is the ligamentous integrity? And I think that is really the term that I want you to leave with ligamentous integrity. If that's disrupted, even if the bones look normal, then the entire structure will fall apart and probably will need surgery. I don't think it's possible to talk about the cervical spine without talking about the elements of the cervical spine. And I think the cervical spine is a little bit challenging for a lot of different reasons. And that's because the elements change. C1 looks very different from any other bone. C2 looks very different from any other bone. And then even C3, C4, C5, C6, and C7 are a little bit different from the rest of the spine in the thoracic spine to the lumbar spine. I just want to point out on this CT scan on the left that you can see how that shingling occurs. You've got one bony element called the facet or the lateral mass shingled on top of the next. And that's a normal orderly process. If you look at the CT scan of the cervical spine in an axial plane, you can see I've kind of highlighted here in this light blue what we call the lateral mass. That's also the facet, so the lateral mass for the facet. This is a very important structure for integrity of the spine. If there's a fracture to the facet, a facet fracture, there can oftentimes be a problem in the ligamentous integrity. The other thing that I'd like you to notice is that in the cervical spine, this area here is the canal, if you're not aware of that. There's the body, there's the pedicle. The pedicles in the cervical spine tend to be very small. We don't really use them as much as we do in the thoracic spine or lumbar spine. You have the lamina and the spinous process. But equally, there's a little ghosting over here on both sides. Well, that's for the vertebral artery. And that's where I said that the cervical spine is such a complex structure because other structures can become affected, such as arterial structures like the vertebral artery in this instance. Here's just a lateral view and up front cartoon. And I'd like you to bring this up later, but I do want you to see how C1 looks very, very different. That's up here, looks very different. And you can see it up here from C2, which has this kind of pillar type of shape to it. And then once we get to C3 down to C7, there's more of a regularity to this. When you get down to T1, you're in the thoracic spine. And aside from just the shape and the size, most of those structures look all about the same. Another thing that I'm pointing out here, although I'll make a better point of that later, is just notice how the nerve roots exit above the pedicle in the cervical spine. It changes when you get to C7, where the C7 nerve root comes above still, but then the C8 nerve root comes below. So keep that in mind, especially if there's something that's going on with the hand and intrinsic function. Could be in the area of C7, T1, because there are very critical roots that exist there. Just for some vernacular, think of your head as the world. And the ancient Greeks used to think that there was a titan called Atlas that actually supported the earth on his shoulders. And hence, C1 is called the Atlas. It is supporting the head. Believe it or not, the head is actually very heavy structure. It's almost like a bowling ball sitting on top of your spine. And the ligamentous integrity of that is very critical, or else your head would roll off your spine. Just below this unique bone, the Atlas, or C1, is C2. And C2, and C stands for cervical, if I didn't make that clear. So there's C1 through 7, or cervical 1, 2, 3, 4, 5, 6, and 7. C2 is the next one in line. C2 is just below the Atlas. And it's called the Axis because it has this funny peg-like structure, which is called the Dense. And I'll show you what the Dense does. The Dense is responsible for acting as a pivot point for the Atlas to be able to turn. So since the Atlas is connected to the skull, you can see that this allows you to have your no kind of motion, your side-to-side motion. Whereas the integration of the skull onto the Atlas allows for the nodding or the yes motion. About 50% of the motion in the spine is at this, what we call the occipito-cervical C1-C2 junction. I don't think it's possible to talk about spinal cord injury without also knowing about the brain. I think it would be impossible to be able to decide where the injury is, how to pinpoint it and locate it, if you didn't know what's going on in the brain. And I'm not going to focus on too much, but you do need to know at least some rudimentary kind of structures and areas, like the motor cortex, the somatosensory cortex. Those are really going to be critical. And obviously the brain is very complex. There are multiple other areas that could be involved. For instance, if you have a multi-trauma and there's a brain injury and a cervical spine injury and they can't talk, maybe there's some kind of injury to the language function or Broca's area or their aphasic. But I don't want to get into all of that. I just probably really want to focus on motor and somatosensory. Motor is, of course, in the precentral gyrus and somatosensory is in the postcentral gyrus. If you want to really get technical, there are motor functions in the postcentral gyrus, but let's just use that as a rough approximation. Here's just a real cartoon. It seems like oversimplified, but I think if you can understand this cartoon, you'll have 90% of your ability to localize where dysfunction is happening, especially in somebody who has spinal cord injury. There are ascending tracts and descending tracts. The ascending tracts are called afferents and the descending tracts are called efferents. The afferents are sensory information that's going from your body to your brain. For instance, pain temperature. You can see it's in the spinal thalamic tract. It's depicted here. Information crosses over generally at the level that it's received and then ascends in the spinal thalamic tract. There is a posterior column tract that gives proprioception. That's when you're testing a patient. Is your thumb up? Is your thumb down? Is your foot pointing away? Is it pointing up or down? That's information that comes in the posterior columns and that usually ascends in the ipsilateral side, the same side, and then it crosses over at the level of the brain stem. There's also light touch that you can see is in both tracts, both the posterior columns and the spinal thalamic tract. That's why it's very difficult to lose light touch because you have dual representation of that. I'm not really going to talk about unconscious proprioception. That's really important for things like walking, but that is ipsilateral in the spinal cerebellar tract. That's in the spinal cord, obviously. Then the major descending tract is the motor cortex and that decassates at the brain stem level. You know that if you have a spinal cord injury on one side, the injury here will be ipsilateral even though in the brain it would be contralateral. There's also the notion between the upper motor neuron and the lower motor neuron that gets more into the exam of whether somebody's hyperreflexive or not and maybe outside the scope of what we're going to talk about in this brief conversation today. I do want you to know that imaging is really crucial. In our business right now, even though the Egyptians 5,000 years ago were able to make these kind of determinations based on really careful clinical exam, I think now a clinical exam is very, very important, but imaging is paramount. Certainly when I started my training, CT scans were very readily available, but MRI scans are really what changed the game. I mean, I would say that we relied on our neurology colleagues so much for localization, but now I think a good neurosurgeon that understands neuroanatomy and neuroimaging should be able to make a lot of these kind of determinations on their own. Here's one spot, the craniocervical junction at the medulla. Here's an interesting way to remember it. It's basically right here, just at the fourth ventricle. You can see the fourth ventricle back here. I always think of it, the medulla, as mariposa. Mariposa is Spanish for butterfly. I think of that butterfly and I think about all the different crossing tracks that are happening there, so keep that in mind. If you see some kind of damage to the medulla, there's likely going to be significant damage to the patient and that might be then a spinal cord injury or it might be a lower brainstem injury. I don't think that it's very valuable to go through all of this, but I do think you do need to know this. I don't think that you necessarily have to be able to draw a circle and say, here's the spinal cord, but I do want you to make sure you remember motor tracks are efferent and they go from the brain down. Sensory tracks are afferent and they go from the periphery up. There are certain things that you do have to know. The posterior columns are really important because they give you proprioception and that's one of our sensory modalities that we talked about. You do need to know that the posterior column is arranged in a way where it's somatotopic. In other words, the legs, the sacrum are most medial and then as you go out over here, as you can see, the most medial tracks are called the gracile fasciculus and then the more lateral tracks are the cuneatus fasciculus. The gracile, think of graceful like a dancer or a ballet person with their legs more medial. Cuneatus is more lateral and that will be the upper thoracic and arms. That information there. I don't want you to have to remember everything, but remember we talked about spinal thalamic tracks. Those are important because those are pain, temperature, light touch, and that's something that we do in our exams. So you want to understand if there's any kind of spinal thalamic track injury because that will give you a side as to where the problem might be. Light touch is a little bit more difficult because I said it's represented dually, both with crossing over and ipsilateral fibers. Then you have motor tracks that are going down. There are some really fancy words. Some people might like to sound impressive and then say oh these are the pyramidal tracks or these are the extra pyramidal tracks. I wouldn't get too caught up on that. I would just know where the tracks are and that they're crossing at the level of medulla. I think I'm going to skip this but I'm going to go here and I'd like you to really really remember this. So you've got somatosensory proprioception is posterior and if I didn't point this out this is posterior or dorsal or this is ventral okay so motor is here a little bit lateral to the proprioceptive tracts or the posterior columns but all the motor fibers come out here remember these are myelinated fibers these are the neurons in here this butterfly represents neurons again it may or may not matter but I'd like you to think that there is a somatosensory architecture to this when you're looking at the posterior columns the dorsal part of the spinal cord the legs are more medially represented and the upper body is more laterally represented and it flips for the motor aspect and over here these are very very critical cells these are the ventral motor horn cells that's what the long tracts coming from the motor cortex synapse onto and that's how we have our function out to our periphery and this is again that junction will give you the distinction between an upper motor injury and a lower motor injury upper motor injury being the more hyper-reflexive injury lower motor neuron injury being more of the flaccid injury if you can't really remember where is sensory and where is motor just think evolutionarily as this like slime mold on the bottom of the ocean uh kind of crawling around 500 million years ago stimulation comes from the back and it reacts to that stimulation by quote-unquote walking with its feet so sensory is on the back motor functions are ventral okay it's not really perfect but I think it's an easy way for you to kind of remember that when it comes to the spine and I know we're coming up with our time only 20 more minutes uh this is kind of uh the hallmark of spine is the spine stable if spine is stable there's often very little that we have to do because in in fact I like to tell people that when we're doing spine surgery we're carpenters and we're electricians but it's often impossible for us to fix the electric if you have a spinal cord injury it's impossible to fix that spinal cord injury uh we can debate about that but it fundamentally for this conversation it is but if the carpentry is off we can always fix that so sometimes the electric is out and uh the carpentry is uh or the mechanics are off well we can fix the mechanics with the carpentry but we can um not necessarily help the electrical aspects of it so stable is obvious when the ligaments are intact when the bones are intact when the discs are intact that's stable like the pyramids uh in Egypt unstable is also pretty obvious like when the alignment is absolutely off well then you know that it's unstable and also with their symptoms I can't move my arm I can't move my leg I can't control my bowel or my bladder things like that but it's this uh kind of picture here the leaning tower of Pisa that I think has us all fretting and that's I think why spine surgery is kind of very very challenging as a tumor surgeon when I do tumors if there's a tumor in somebody's head it's kind of easy it's like I don't mean it's easy but just take it out it's understood it's not something that you're going to watch but spine surgery uh is very very very nuanced in terms of understanding will the surgery help this patient will it not is this patient unstable do they need surgery if they're unstable are they meta stable can they get away with bracing so these are the things I think that confront all of us in spine surgery every day I do want to point out to you again in this image this is a cta or ct angiogram basically there are very critical neurovascular structures that are right next to the spine by now hopefully you'll remember that this kind of funny shape is the shape of the cervical spine the carotid artery is just ventral to the bony elements but the vertebral arteries are actually intimately associated in the osseous elements of the spine and over here you can see that there's this flow of the vertebral artery intimately associated with the cervical spine going up into and meeting at the basilar junction and creating the posterior circulation so this is something that you have to realize that when you have a cervical spine injury there can be arterial injury more likely in the vertebral artery or the posterior circulation than in the anterior circulation but the anterior circulation can still have injury too again this just simply highlights the carotid artery and the vertebral artery the vertebral artery again is the one that's more intimately associated as it passes within the bony elements of the cervical spine I don't want to make too much of it because I think you can get caught up in jargon but there are different levels of the vertebral artery called v1 to v4 and you have this ability to see here in particular on this cartoon generally the vertebral artery enters at c6 so if you have a c7 injury it's unlikely that the vertebral artery will be damaged at least by the osteostructures but if you have some kind of injury anywhere above that vertebral artery can easily be potentially damaged or dissected or there could be a problem there and I think in most of your institutions you probably do have protocols where if there's cervical spine injury there's also a cta that gets ordered and I think that's reasonable let's talk about problems because I think that's that's what you're going to see you're not in the hospital to you know to just basically expound about oh the virtues of the spine it's really to take care of patients that come in and are hurting so this is a nine-year-old and I know this is not a pediatric session but I think it's important to keep that in mind this is what's called the clivus and this is the c1 and the c2 segment and there is extended space here so there's extended space of the base of the skull the top of the spine and then there's also an extended space from the back part of c1 and the back part of c2 and the back part of c2 so there is this distraction injury occurring here I made this arrow here to ask a question is there a fracture here no you do have to know and I do take care of kids that kids have growing anatomy and that is an ossification center so that's not a fracture if it was just that and we were looking at that and this young child came into a adult center and maybe a radiologist that wasn't as facile with pediatric imaging they might call that a fracture that is not the problem the problems are here with the yellow arrows and the green arrows and this is basically occipital cervical dislocation that means that this young lady did not have her head attached to her neck except for the muscles that were holding her together remarkably she was neurologically intact this is an example of just simply looking how you can see here's c1 here's c2 and the space between c1 and c2 is just so much more than the space between any of the other elements and you can also although it's not the focus of this discussion see that how the base of the skull right here the clivus and you'll have to take my word for it is distracted from its normal position with the c1 c2 articulations this is an mri because mri is really the gold standard you don't in this patient you know you don't even have to fret about wondering is there ligamentous damage we know there's ligamentous damage we just got the mri to make sure what was going on with the soft tissue elements in particular the brain stem and the spinal cord and to see if there were any hematomas or things like that that we might also have to be mindful of taking care of again this is just simply showing you the mri that's showing you the ligamentous injury here's our solution and i know this is not a course about solutions but we basically in a child had to wire her head to her neck it sounds like a dramatic move but it's a lot better than your head rolling off your neck and being quadriplegic so let's go through some other injuries high cervical injury this is hopefully now you'll remember this funny peg-like bone is called c2 it's the dens the dens portion of c2 you can see over here that this arrow is pointing to the fact that there's a break over here at this part of the bone and this patient was initially managed what we call conservatively in a collar but you can see that this is now slid forward the dens has slid forward you can see the position of the c1 ring in the back is now compromising the spinal canal so that's not a suitable situation effectively this person's head is rolling off too so the way to stop this situation from happening is we instrumented c1 to the lower part of the spine c3 and c4 and we're able to realign the dens back onto the body and give them a good outcome again there are a lot of i don't want to have you guys think that there are only certain ways to deal with spine trauma and how to fix them i think there are a lot of different ways to deal with them over here is another injury to c2 the dens again hopefully you're getting familiar and comfortable with that this is a 90 year old patient i normally don't operate on 90 year old patients but her head was not stuck to her neck and we had to do something so being very mindful of these arteries remember these are the vertebral arteries we put very long screws into c1 and c2 to hold her together there's degenerative disease keep in mind that trauma happens but most of us have degenerative disease degenerative disease is just a nice way of saying you're getting older here is somebody that has what's called spinal stenosis central canal stenosis you can call it arthritis they fell and they presented with something called central cord syndrome we're not going to get into that aside from the fact it's an acute presentation of arm weakness so the solution here even though this was a long-standing problem it came to light because of fall from a trauma so we had to do an anterior cervical set of discectomies and fusions again here's somebody else who has central cord syndrome again this is something that wasn't from a trauma but exacerbated the presentation by a trauma these are degenerative problems that we see frequently in circle trauma over here there's an mri at c2 you can see the white signal around the gray cord at c4 you see this white signal around the gray cord but at c3 at that level it's absolutely pinched there you know if somebody says oh you should have just done anterior surgery or just a posterior surgery i i ended up doing both because there was compromise to both and i certainly not want you to think and leave this conference or this conversation thinking there's only one way to do spine we're kind of tying up on time and i did want to point out to you that even though cervical spine trauma happens a lot just degenerative spine things happen and understanding degenerative spine will let you be a better traumatologist here for instance is a disc herniation at c6 and c7 this is the disc herniating this is the normal side outlined here this is the disc pushing on the left c7 nerve root you should remember c7 does tricep function extension of the forearm and so that's what's going to happen in this person they showed up after a trauma i don't think that the trauma necessarily caused the disc herniation but perhaps there was some exacerbation by that my solution here was an artificial disc we don't have to get into that but what i did want to show you here is that these nerves come over the pedicle so if you have a c67 disc herniation the c7 nerve root is coming over if you have a c56 disc herniation the c6 nerve is coming over in other words your bicep here is somebody who is having frequent falls they were having they have parkinson's disease and i want you to realize that you will see patients in the hospital that won't be clean patients in the sense that they have other diseases they might have ms so their weakness could come from that they might have a tumor they might have epilepsy they might have parkinson's disease so the point is understanding and really listening to the patient very closely and trying to figure out what their problem is and how it might relate to their cervical spine or how it might relate to something that's other than their cervical spine and their other pre-existent disease entities in this patient we did again he was young enough and we put an artificial disc in i like doing artificial discs because it maintains the integrity of the flexion of the spine but there's certainly no problem with saying that if you're going to fuse somebody that's an operation that we've been doing far longer than artificial disc surgery over here i want you to realize that if you have somebody that has hand clumsiness and leg dysfunction it's not coming from the brain it's coming from the cervical spine if they have a problem in just their legs it could be coming from the thoracic spine or the lumbar spine bilateral clumsiness in the hands you have to look at the neck and in this person they had clearly uh again degenerative changes that were causing them to fall so again their presentation is with trauma but it's really in the setting of degenerative problems and here i performed a corpectomy to decompress the ventral spine i want to point out to you that when you're seeing patients in the trauma room and if their blood pressure is incredibly low and their heart rate is very low it could be that they have a functional sympathectomy remember the sympathetic nervous system is going to be responsible for your heart rate and your blood pressure and maintaining your vascular tone if you have a transection somewhere there or an injury to the sympathetic system which is running along the carotid right next to the cervical spine these are some other things that you should look into and keep in mind some patients might present with asymmetric pupils like a Horner syndrome so something really to look at again while we have wonderful imaging modalities being a clinician being a practitioner is still first and foremost here is somebody much like that egyptian case the second one here is just a translocation of and you can count with me c1 c2 c3 c4 c5 c6 c6 on c7 that means that their deltoid function probably works their biceps might be out their triceps will surely be out and very likely they have no leg function and they have a high sensory level again this is where we're electricians electricians and carpenters but we can really only fix the carpentry not necessarily the electric but by stabilizing the spine the mechanical elements of the spine this patient can at least be mobilized to whatever extent they might be able to here's an awful injury it happens if any of you are not aware of what's going on here this is a high cervical spine injury this is a bullet and it went from front to back and it caused not a transection of the spine but blast injury to the spine so you don't just necessarily need something to insult the spine directly but it's a blast injury effect that created quadriplegia in this patient unlike that earlier patient that i showed you where we use a kind of a different wiring system she was only nine this was an adult we have better tools for this we took what parts of the bullet out that we could and we basically reaffix their head to their neck but in this situation again it's not to necessarily reanimate them and give them spinal cord function back it's just to make sure that their head and their neck are together and that's what it looks like a little bit more in that kind of manner i think that's really uh it for me i know i only left about four minutes for questions i apologize for that but i'm absolutely happy to take any questions that anyone has now or later if you want to just email me um we do have a question um on the prior slide where you did the corpectomy um the question is is there a reason you did the corpectomy as opposed to a laminectomy and posterior decompression well because uh so yeah that gets a little bit technical um the problem is in the front uh the disruption is in the front uh and i felt that the uh the way to get the correction uh is by doing it in the front but it's and if there's one thing that if you ever talk to spine surgeons if you have one case and you ask three people you'll probably get five different opinions on how to fix it um yes i've seen that yes i just have a quick question of how you make um decision on timing of surgical intervention when somebody comes in with trauma yeah so i think that's a really uh good question i think uh in some cases what we would say if there's spinal cord injury if you're completely out if you have no neurological function then it doesn't matter and i don't mean that in a dismissive way but we're not going to be able to fix the electric but if you have some function like you have proprioception or you can sense or you can wiggle a toe or something like that then i think the safest quickest time to do the surgery is when you have to do it some of us are in centers that are level one trauma centers and the or is always available the hardware is always available the reps are available the monitoring folks are available so that's one thing and that's a real luxury at other places it might not be the best idea to start a case at two in the morning when you don't have all the resources so ideally if there's compromise on the spinal cord that could be reversed then i'd say as soon as you can but it all depends on the setting that you're in okay now we're um winding down and i want to thank you so much for um giving this lecture just a quick question for a standard workup if cervical spine trauma is considered than initial imaging to be obtained would you recommend ct cervical cta cervical or mri cervical yeah i think it just kind of depends usually in most cases what we're seeing uh way back when we used to think and fret whether we should get a ct scan or not or plain film x-rays these days it seems like even if you're in a community hospital setting which i actually practice at some of my settings that are community hospital based they'll get a head ct and a ct of the cervical spine just in one shot and i think that's not unreasonable um i don't think that there's much room for plain films anymore because there's so much ambiguity and the cts allow you to have all these various reconstructions i think mris are very reasonable but usually the ability to get an mri scan right away is limited and an mri scan i would say has more indication after the ct scan the cta you could say well why do a study twice just get them the ct and the cta if there is no spinal uh bony osseous injury then it might be something that you don't need and again it's probably again dealer's choice once again thank you so much for joining us okay everyone have a good rest of your conference thank you

cervical spine trauma

cranial trauma

vascular trauma

spinal cord injuries

ligamentous integrity

MRI assessment

surgical interventions

neural pathways