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Hello and welcome to Noon Conference, hosted by modality

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Noon Conference connects the global radiology community

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through free live educational webinars that are accessible

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for all and is an opportunity

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to learn alongside top radiologists from around the world.

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and previous noon conferences by creating a free account.

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Today we are honored to welcome Dr.

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Samir Ranga for a case review entitled Spine Trauma Imaging,

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cranio Cervical Junction Injuries Case-Based Review.

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Dr. Ranga is a radiologist at University Hospital in Moscot

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Oman with subspecialty interest in emergency radiology

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neuroimaging and MSK imaging.

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In 2018, he received the prestigious Lee Rogers Fellowship

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in radiology journalism from the A RRS.

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Dr. Ranga is a reviewer on the RSNA Educational Exhibit

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Review panel and serves on the social media

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and Digital Innovation Committee for Radiographics Journal.

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He has authored over 40 peer reviewed articles,

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six book chapters, and over 30 educational exhibits

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and scientific presentations for R-S-N-A-A-R-R-S and ESR

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and has delivered more than 100 lectures at national

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and international conferences.

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At the end of the lecture, please join Dr.

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Ranga in a q and a session

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where he will address questions you may

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have on today's topic.

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Please remember to use the q

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and a feature to submit your questions so we can get to

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as many as we can before our time is up.

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With that, we are ready to begin today's lecture. Dr.

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Ranga, please take it from here.

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So yeah, good evening from Musca Oman,

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where it's 9:00 PM currently at present.

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And, uh, a warm welcome to all

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of you joining from different time zones.

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Good morning and good afternoon, different where you are.

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Um, my association with modality is now almost like, uh,

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since last five years

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and it's been my pleasure to contribute

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to the known conference all this year.

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Uh, the known conferences have become an invaluable result

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of, uh, pre radiology education since onset of covid

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and, uh, it has provided training fellows

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and practicing radiologists with the high quality content.

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Uh, uh, and I'm really grateful, um, uh,

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to be part of this journey.

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Uh, today we will be discussing an important topic, uh,

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which is not so uncommon, frequently missed, um, uh,

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by trainee fellows and even attending on call time.

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Um, and so, uh,

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this is a topic I'm quite, uh, passionate about.

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Uh, so we will be discussing about cranio cervical

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junction injuries in this case based review.

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Uh, no disclosure.

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So the cranio cervical junction, also known

2:42

as occipital cervical junction, also known

2:45

as cranial vertebral junction.

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So it's the same thing. What we are trying

2:48

to look at is the part where the skull base joint,

2:53

the upper cervical region.

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So it consist of occipital condyle P one,

2:57

which is also known as Atlas

2:59

and t2, which is known as the actus ver.

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So this three bones in the joint

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between them constitute the cranial vertebral junction, uh,

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almost up to one third

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of all C-spine injuries occur in this region,

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and so it's very important region to look at carefully.

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Majority of these injuries are high velocity injuries,

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particularly the distraction type of injuries,

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and quite a good number

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of these injuries have high morbidity and even mortality.

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Uh, there has been improved survival in recent years

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and, uh, uh, due to improved in pre uh, uh,

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hospital care, uh, there has been increase in detection due

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to recent, like increased use of CT

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and Mr uh, in last, uh, few years.

3:45

And these injuries can be easily overlooked

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and they remain one of the critical blind spot when we

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interpret the images.

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And quite a good number of these injuries occur in extreme

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of the age group, pediatrics

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and elderly, while majority of them, uh, involve the,

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the young people, uh, with motor vehicle collision.

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So with that, my learning objectives

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for today's talk will be we'll understand the concepts,

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the important part of the imaging anatomy of this region,

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what is the appropriateness of imaging when it comes

4:16

to cranial cervical junction injury

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and how the normal alignment

4:20

of this part can be evaluated on imaging.

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Then we'll look at the search pattern

4:25

and checklist on PT and r.

4:27

And last, we'll look at some of the cases

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with reporting tips and management implications of

4:33

what your report will be translated, uh, in, in which way.

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Uh, I have been fortunate to work at two

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of the largest trauma centers in Oman in last, uh, 15 years

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or so, and I worked with some

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of the most amazing spine surgeons in lot

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of my understanding of spine trauma is thanks

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to our regular interaction

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with those trauma and defined surgeon.

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So what we'll cover today is occipital condylar fractures,

4:59

atlan occipital dissociation,

5:00

or cranial ERV distraction injuries

5:03

and we'll talk about C one ring injuries.

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What we'll not discuss today is atlanto axi rotator fixation

5:09

or C one C two rotator fixation.

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We'll not discuss today about the P two fractures,

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which includes odontoid and hangman fracture

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and we'll keep it for some time later, uh,

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where we'll talk about the fracture.

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So let's start with the anatomy of uh, cranio vital region.

5:26

So the vital spine can be divided into two parts.

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Upper cervical part which cervical spine,

5:31

which is also known as cranial cervical junction,

5:34

which includes occipital condyle, C1

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and c2, lower cervical spine, also known as al spine,

5:40

which includes C3 to C seven.

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So cervical spine consists of several of the bones,

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which I told you occipital condyle.

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There are two in number right

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and left, one vertical body which is known as etla

5:53

and two body which is, which is body, the joints

5:57

between the occipital condyle

5:59

and C one is also called atlanto occipital joint joint

6:03

between the C one and C two is called atlanto axial joint.

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And then there is a joint between C2 and C3 as well.

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There are several ligaments which are capsular

6:12

and non capsular, which provides inherent stability

6:16

to this relatively unstable region.

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So as you can see that the skull-based occipital bone has

6:23

two bony rounded oblong projection on either side of foram

6:27

and magnum, which is colored with Greek

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and this other occipital condyle.

6:32

This occipital condyle connects to the top

6:35

of the C one vertebra, which is known as the atlas vertebra.

6:38

And atlas vertebrae is an atypical vertebrae

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and as you can see here, it does not have a body

6:43

but it has an anterior arch, it has a posterior arch

6:46

and which is connected at the lateral mass.

6:48

So there is a anterior arch lateral mass

6:49

and the posterior arch there is a transfer process and foram

6:53

and trans or there is a foram

6:54

and per package of the vertebral RT

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P two vertebral body is also atypical vertical body apart

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from it's a body it has with elongated cran uh, cranial uh,

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projection, which is called dense or odontoid process.

7:09

And it's a superior article of facet

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and inferior articular facets are not located at the same

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level and that's why it has this past interarticularis

7:17

unlike any other cervical ver.

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So you can see that on coronal ct,

7:23

the cranial cervical junction consists

7:25

of two occipital bones, which projects outward

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and downward from the either side of the foram and magnum.

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So this is foram and magnum

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and two occipital condyles, two occipital condyle joints

7:37

with the superior articular surface

7:40

of the C one forming atlanto occipital joints.

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C one lateral masses have the superior articular facet which

7:47

joins with occipital condyle

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and C has an inferior articular effect with joints

7:51

with the superior articular effect

7:52

of the c2 which is the ver.

7:57

On the on the there are five joints which constitute uh,

8:01

the cranial cervical junction, which includes two

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facet joints between OC and Steven.

8:07

That is occi condyle

8:09

and anti the atlas,

8:10

which is called Atlanto occipital joint two joints which are

8:14

the the Atlanto xal joint

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and the fifth joint, which is a central joint

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between the C one and C two,

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which is the mid median atlanto xal joints.

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So there are five joints and the four bones.

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The cranial cervical junction is quite a mobile part.

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The OCC one is responsible for almost 50% of the flexion

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and extension of the entire cervical spine.

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The C one C two is responsible for almost 50%

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of the rotation occurs in the neck and C3 to C seven.

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His rest of the 50% of the rotation

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and rest of the 50% of the lateral fraction

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or majority of the lateral fraction occurs in

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the C3 C seven region.

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As the region is quite mobile, it is inherently unstable

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and this instability has been taken care by this sum

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of the ligaments which trended this

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inherently unstable region.

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So cranial erv junction ligament can be categorized

9:10

or classified into three categories, intrinsic ligament.

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There are three number in which are located within the

9:16

spinal canal and they're some of the strongest ligament

9:18

of the cranial cervical junction.

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Extensive ligament along the outer surface

9:22

of the vertebrae And I we, we will we'll know the which

9:26

of this ligament constitute the extrinsic ligament

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and there are capital ligament which form the facet joints.

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So there are three intrinsic ligament within

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the final canal.

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Tial membrane or territorial ligament,

9:38

which is best seen on images or oid

9:41

or the ligament which is best thin on coronal images

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and cruciform of transverse ligament,

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which is best seen on the axi images

9:48

ligament along the outer surface

9:50

of the vertebrae anteriorly.

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It is a LL which is anterior longitudinal ligament.

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There is anterior atlanto axial

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membrane which is anterior located

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and there is anterior atlanto

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occipital membrane which is also located in

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anterior part posterior.

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There is posterior atlan occipital membrane

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and posterior atlanto axial membrane.

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So let's see how these ligaments are seen in the sagittal CT

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or bore importantly sagittal mr.

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So you can see that anterior longitudinal ligament extend

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from C one all the way till the sacrum,

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the superior continuation

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of the anterior longitudinal ligament between the

10:27

superior aspect of the atlas and the skull base

10:30

or the cliver.

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It is called anterior atlanto occipital membrane.

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There is a similar but smaller membrane between the atlass

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and the axis, which is called anterior atlanto ex membrane.

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And there is a little left uh, strong ligament

10:44

between the tip of the dense

10:46

and the cl, which is called aal ligament.

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All of these four ligaments together are known

10:51

as anterior brno ligamentous complex

10:56

posteriorly along the posterior surface of the dense

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to the base of the cls.

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There is a vertical segment of the cruciform

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or the cruciate ligament is there.

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It is relatively difficult to see

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and this ligament gets completely merged

11:10

with the tial membrane, which is a continuation

11:12

of the posterior longitudinal ligament.

11:14

So on imaging you cannot separate the tial membrane from the

11:18

vertical segment of the cruciform ligament,

11:20

posteriorly ligament and fla located between the lamina ERUs

11:23

and vertebrae between C one and C two

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and between C zero occipital yl

11:28

and three one, the ligament flavor is replaced

11:32

by posterior atlanto occipital

11:34

and posterior atlanto membrane.

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Both of them together are known

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as collectively posterior membrane ligamentus complex.

11:43

So we have anterior membrane, ligament is complex,

11:45

we have posterior membrane ligament is complex

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and we have those three intrinsic ligament outta three we

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have seen one ligament which is the tial ligament.

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So on CT you don't see the ligament

11:57

but somehow a cranial vertebral junction

11:58

because this ligaments are surrounded

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by fat, you can see them well.

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So the first ligament,

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what you see is anterior atlantic occipital membrane.

12:05

Then there is a fat, there is a bial ligament,

12:07

then there is a fat and then there is a tial membrane.

12:09

As you can see here posteriorly,

12:11

you can see this both the posterior leg uh,

12:13

ligament is complex, uh uh uh, between the occipital condyle

12:17

and C one and C one and C two.

12:20

On the MRI ligaments are seen as black thin line.

12:23

As you can see, anterior longitudal ligament

12:25

around the anterior surface of the vertical bodies,

12:28

anterior atlanta occipital membrane between the top of the

12:32

C one to the to the cli.

12:34

To the cliver. Then there is a smaller ligament on

12:36

either side of the fat.

12:38

So this is from the tip of the dense to the to the uh ion

12:42

and then posteriorly, as I told you, the vertical segment

12:44

of the crucet ligament is not very wealthy.

12:47

It merges with the tial membrane,

12:49

which is the direct continuation

12:52

of the posterior longin ligament above the level

12:54

of the C one two posteriorly.

12:58

We have this posterior ligament

13:00

or the membrane ligamentous complex which is

13:02

between the occipital conal and C one and C one

13:04

and C two, the three intrinsic ligament.

13:08

We talk about uh,

13:09

the most strongest ligament transverse lan ligament which is

13:13

best seen on axial images Alan ligament,

13:15

which is best seen on coronal images

13:17

and pictorial ligament best seen on sagittal images.

13:19

So if you have to look at the three important ligament on

13:23

MRI, I will look at this three ligament

13:25

and each of them is seen on different plans.

13:28

So let's try to see that.

13:29

Transverse atlan ligament connects the inner aspect

13:33

of the lateral mass of one side to the inner aspect

13:36

of the lateral mass of the other side of the atlas.

13:39

And this part where it attaches

13:41

to the lateral mass is called the medial tubercle.

13:44

So between two medial tubercle is a transverse atlan

13:47

ligament and transverse atlan ligament is responsible

13:50

for the stability of the dense.

13:52

It does not allow dents to move front

13:55

and back, so it provides the anterior

13:57

and posterior translational stability tolan axial joint.

14:03

So let's see, on ex you can see

14:05

that the dent is located centrally within the atlas

14:08

and the distance between the dense

14:10

and the atlass is less than two millimeter thanks

14:13

to this ligament which extend from the medial tubercle

14:16

of the lateral MAs on one side

14:17

to the medial tubercle lateral mass on the other side,

14:19

ligament is best seen on mr

14:21

and as you can see that attachment on either side

14:23

and the middle part, which looks like symmetrical black line

14:27

without any edema, thickening or discontinuity.

14:31

The second most important

14:33

or strongest ligament,

14:34

what you see is the all ligament allar ligament is best

14:37

seen on coronal images.

14:38

It extend from the ro superior aspects so

14:43

that the somewhere

14:44

around if you see this is the dense from the tip rises the

14:48

AAL ligament just next

14:49

to the tip from the lateral margin arises the,

14:52

the ligament andal ligament superiorly attaches

14:56

to the medial aspect of the occipital condyle

14:59

so extend from the dense to the occipital condyle

15:02

and they are best seen on the coronal images

15:04

and they are seen like as if someone has just put their

15:07

arm slightly upward.

15:08

And this is how I I I visualize the all ligament, which

15:12

with the face of the man is formed by the dense uh ligament.

15:15

So this is how the dense, this is

15:17

how ligament looks like best seen on coronal images

15:20

and uh, this is how you have to see it.

15:23

All ligament can be seen on CT also on soft tissue window

15:26

and what they look identical to as we see on the MRI

15:30

Tial membrane is the third most important ligament

15:34

among pre ligament transverse atlan ligament and

15:37

and the other ligament and the tial ligament.

15:39

Pectoral ligament is the weakest.

15:41

However, this is the third strongest ligament when it comes

15:43

to overall stability of the uh, cranial cervical junction.

15:48

So you can see that it is best seen on sagittal image.

15:50

It's a direct continuation of the uh, uh,

15:53

posterior longin ligament and it resists the hyperextension.

15:56

So in many of the hyperextension injury you can have the

15:59

stripping of the ligament or the tear of the ligament,

16:01

which happens, happens in many

16:03

of the cranial cervical destruction injuries.

16:06

Tial uh, membrane is seen

16:08

as a black line extending from the posterior aspect

16:10

of the dense all the way to the base of the cliver.

16:15

So three ligaments, intrinsic ligament, um,

16:17

and uh, three plans to look at pectoral and tatal al coronal

16:21

and trans ligament on axi.

16:23

Apart from that,

16:25

the capsular ligaments are extremely important

16:27

and they provide significant stability uh,

16:30

to the cradio cervical junction.

16:32

So vertical stability is

16:33

provided by the ligaments which are vertically oriented.

16:35

So all ligament is vertical oly oriented so

16:38

that provides vertical stability.

16:39

Al membrane is located, is vertically oriented

16:42

and the capital ligament provides all sort of stability.

16:46

Rotational stability is provided

16:47

by the ELLA ligament primarily

16:48

and inter posterior translation stability is

16:52

provided by trans lan ligament.

16:54

So this is about the anatomy, how we see on imaging,

16:57

what is when a patient

16:59

with suspected cranial ERV junction injuries presented

17:02

to the er, how to proceed with the imaging.

17:05

So CT and MRR complementary PT is often the first line

17:08

of investigation and quite often the only imaging modality

17:11

required the fractures are seen best on the CT including

17:15

the ligamentus aversion.

17:17

LIGAMENTUS injury can result in translation

17:20

or mal alignment of the of Theranos vital junction,

17:24

which is again best seen on the ct.

17:27

When do we do the mr?

17:29

So MR will show the best the ligamentous injury

17:32

or the tension bandage retention bend consists of ligaments

17:35

and the disc, normal ligament, EDUs ligament

17:38

and continuous ligament are the three categories

17:41

of the ligaments and the disc we see on MRI.

17:43

Soft tissue injuries include edema

17:45

and hematoma is against on three

17:49

again fractures are seen best on CT MA alignment seen is

17:52

best on CT and when it's a fine fracture we end up doing

17:56

both CT and M-R-I-M-R-I is

17:59

inable when it comes to six teeth.

18:02

Final cord injuries, spinal cord compression,

18:04

spinal canal based occupying lesion like hematoma

18:08

cables which is now nerve injuries.

18:10

Brachial plexus injury cushion which is disc disc injuries

18:14

coupler which is ligamentous injury

18:15

and all the connective issues around.

18:17

So a we tell of a resident that six

18:19

where we see the MRI rest

18:21

of the things PT is very, very, very good.

18:23

Okay, um, all of this area is very close proximity

18:28

to the vertebral artery.

18:29

So whenever there is any cranial cervical junction injury,

18:32

there is likelihood that vertebral artery also gets injured

18:35

and that is why the modified den criteria suggests

18:38

that any cranial cervical junction injury,

18:41

whether it's an octoPal condylar fracture,

18:43

whether there is ablation or dislocation

18:45

or any fracture from C1 C two

18:47

and C3 veritable artery should be considered as injured

18:52

until proven otherwise and how to prove that it's injured

18:55

or not injured by doing CT angiography.

18:57

So we do CT A in all of the patients

19:00

whenever there is any suspicion

19:01

of cranial horal junction injury.

19:04

So this is about UH, appropriateness.

19:06

Now we'll quickly learn about the

19:08

search pattern in the checklist.

19:09

So when it comes to search pattern, we look at the bones,

19:12

which are the bones to look for two occipital condyle, C one

19:16

atlas and C two axis and CT and MR both.

19:20

But CT is better than MR joints.

19:22

We have to look for OCC one complex

19:24

that is occipital condyle and the atlas leg joint.

19:28

Then the atlanto re joint t1, c2 and then the C2 C3 joint.

19:32

Again, joints can be evaluated both on CT and MR uh

19:35

and both of them are their own strength and weaknesses.

19:37

CT is extremely good. Ligament is injury.

19:40

MR is quite good in looking at the direct signs

19:43

of ligamentous injury.

19:44

However, most of this ligamentous injury when severe causes

19:47

MA alignment, which is better seen on CT than MRI

19:51

and soft signs can be seen on both CT and MRI.

19:56

So my search pattern includes first I look at the fractures,

19:59

occipital condyle is best fractured are best seen on coronal

20:03

and that's what we tell a resident.

20:04

Three Cs tech condyles on coronal even

20:09

fracture is can be seen in all three plans.

20:11

The best seen on ideal plan P two fracture it can is seen on

20:15

all the plans best seen on plus coronal when it comes

20:20

to alignment OCC when alignment is best seen on sagittal

20:23

plus coronal c1, C2 is best on sagittal p2,

20:26

C3 is best on sagittal

20:28

and soft times are seen best on sagittal pt.

20:31

Let's try to see what uh, what we, what we see here.

20:33

So there are three uh plans where we look at the uh uh,

20:39

our search pattern goes.

20:40

So first is we look atag, then we

20:46

look at the atlanto occipital joint

20:49

and the atlanto axial joint

20:51

and then we look on the coronal

20:53

where we look at Atlanta occipital occipital, uh,

20:56

and thelan axial joint as well.

20:58

So mid sagal extreme are the, are the para sagittal

21:02

and the coronary images and on axial images as I say

21:05

that even practice are best seen on axi images.

21:10

So when to suspect cranial vertebral junction

21:13

injury on imaging.

21:14

So there are hard signs when you see fracture,

21:16

which is pretty obvious whenever there is loss of alignment.

21:19

And we will learn how to look for the loss of alignment.

21:21

And then when there are soft signs,

21:23

so which are the soft signs which you have to look for, uh,

21:27

which will help you

21:28

to detect potentially unstable cranial

21:31

cervical junction injury.

21:32

So let's try to look at which signs to look for.

21:34

First we look for the retro clival hematoma, which is due

21:38

to stripping of the territorial membrane.

21:40

Then we look at the posterior

21:43

membrane ligamentous complex edema, P AO M-P-A-A-M edema.

21:47

So any edema anywhere from the posterior aspect

21:50

of the occipital bone to the C two, that's one of the sign

21:54

of the cranial cerv junction injury.

21:56

Then we look at the denal space and any hematoma

22:00

or any loss of fat is suspicious for presence

22:03

of potentially unstable cranial cervical junction injury.

22:07

Then we look at the final canal

22:09

and within the spinal canal hematoma.

22:11

Then we look at the prevertebral soft tissue at C one it

22:14

should be less than 10 millimeter at C two it should be less

22:16

than seven millimeter.

22:18

And then we look at the uh, the, the rest

22:21

of the findings like posterior FOSS, subdural hematoma,

22:24

posterior FOSS subarachnoid bleed,

22:26

final canal hematoma, so on and so forth.

22:28

Let's see, a couple of examples look at these images.

22:30

Firstly what you see here is the retro lyal hematoma due

22:34

to stripping of the pectoral membrane loss of fat,

22:36

which supra dental hematoma on the mr.

22:40

You can see that posterior membrane

22:42

ligamentous complex edema.

22:43

You can see this retro clival hematoma due

22:46

to tial membrane stripping.

22:48

You can see the prevertebral soft tissue edema

22:51

at C one and C two.

22:52

You can see this large retro clival soft tissue edema

22:55

or retro clival hematoma due to pictorial membrane stripping

22:59

commonly seen in children.

23:01

Whenever you see this on head ct you have to look at the

23:04

MRI CT of the cervical spine

23:06

and potentially how to do MRI of the cervical spine as well

23:09

because this are the soft sign

23:10

that potentially there is a cranial

23:12

cervical junction injuries.

23:14

Some other examples of soft signs on you can see

23:17

that retro uh uh, clival hematoma, there is loss

23:21

of normal fat, presence of fluid in the raden space.

23:24

There is a large prevertebral hematoma or fluid collection

23:28

and same way on the posteriorly also you can see

23:30

that a posterior complex also shows presence of hematoma.

23:33

The similar signs can also be seen on the CT

23:36

and these signs are more important on CT to look for

23:38

because then you look at this region more carefully

23:40

and not miss the s.

23:43

Let's try to understand how, look at the alignment on ct.

23:47

So alignment today we'll align the alignment of occipital

23:52

joint and atlanta xdl joint.

23:54

We'll keep the C2 C3 alignment

23:56

for some other known conference.

23:58

So let's start with the OCC one alignment

24:00

or Atlanta occipital dissociation

24:03

or cranio vital destruction injury.

24:06

So there are indirect signs.

24:07

So when CT was not there, people used to look at the x-ray

24:11

for potential injury of the atlanta occipital joint.

24:15

And so we had lot of indirect

24:18

uh measurements like basion dental interval like anterior

24:23

Atlanta dental interval powers ratio based on axial uh,

24:27

interval and suns interspinous ratio.

24:30

This were important where multi slice CT was not available.

24:34

When CT is available, we directly look at the OCC one joint

24:39

and so we look at the alignment of the

24:43

atlanta occipital joint directly.

24:45

So let's try to see how to look at the signs.

24:48

So landmarks, which we have

24:49

to look at is on the first the medial or the median.

24:52

The midal plant based of the CL is called the ion.

24:58

Top of the dense is called top of the dense.

25:00

And the distance between the ion

25:02

and the dense on the midsagittal images is called ion dense

25:06

interval or BDI In on CT.

25:10

In adults it is normal is less than 8.5

25:14

and on radiographs is around 12 millimeter

25:17

because radiograph will magnify the things in

25:19

pediatric patients.

25:21

The ion dense interval is slightly wider.

25:24

It depends upon how young the child is.

25:26

Younger child children will have more wider

25:29

ion 10 interval up to 11 to 12 millimeter.

25:32

Older children will have more similar

25:34

to adults like nine millimeter, 9.5 millimeter.

25:38

Anywhere where you see more than 12 millimeter is abnormal.

25:42

In pediatric on um, uh,

25:45

x-rays also 12 millimeter is a good point to consider.

25:48

So adults age you have to consider around eight

25:52

to 10 millimeter anything more than if we are learning more

25:56

and more about this injuries, we are realizing

25:58

that the distances on the ct,

26:00

the the normal values are smaller than

26:02

what we used to believe it.

26:04

So uh, uh, the, the latest is 8.5,

26:08

anything more than 8.5 on CT.

26:09

In adults you think about

26:12

the the the cranial cerv destruction injury

26:15

and pediatric patient anything more than 11

26:17

to 12 millimeter.

26:19

But as the child becomes more towards the teenage,

26:21

you start giving the lower values like you give

26:24

it in the adult patient.

26:26

So this is how you count the basal danger.

26:28

Uh, BDI you can see the normal patient

26:30

and you can see the market widening

26:32

of the BDI in this patient

26:34

with cranio cerv distraction injury.

26:38

This injury has become a translation or distraction injury.

26:41

In EO classification they are given the worst type

26:44

of injury, which is type C injuries

26:47

and type C injuries suggest

26:48

that this are grossly unstable injury.

26:51

Majority of them will need surgical fixation.

26:56

The second criteria of second thing to look for is the

27:01

raspin ratio, which is basically the interspinous distance

27:05

between C one C2 and C two C3.

27:07

And when you divide this two distance

27:10

and if your answer is more than 2.5 times,

27:13

so when C1 C2 distance becomes more than 2.5 times to C2 C3,

27:17

that is one of the times

27:18

of cranial cervical junction detraction injury.

27:21

And when they did some studies

27:23

and they they they found that on CT omit the TAL plan,

27:27

only two indirect signs have the highest correlation

27:31

with potential distraction injury.

27:33

One was BDI second was intraspinal ratio,

27:37

all other powers ratio the BAI was found not to be

27:42

that reliable in differentiating the distraction of uh,

27:46

positive patient from the negative patients.

27:48

As I say this, this indirect signs were extremely important

27:52

where multipl CT was not available.

27:55

Since now we have multiple slice ct,

27:57

we can directly look at the OCC one joint

28:00

and so we directly look at those alignments.

28:02

So let's see how to look for the OCC one joint.

28:06

So we look for four things, distant symmetry,

28:09

congruency and coverage.

28:11

This are seen on mid coronal plan

28:13

and they are seen on the mid the lateral sagittal plan

28:17

midpoint between the uh OCC one joint.

28:21

So let's try to see what to look for.

28:23

So these are the area which we have to look for

28:25

and we look for four things.

28:27

So this distance is called P-C-I-P-C-I-A,

28:31

Condi C one interval, PCI distance.

28:35

Okay, how to look for it.

28:37

So you look for it on coronal, you look

28:39

for it on the sagittal and then you average out.

28:43

So there are some research protocols.

28:45

So they measure it several points on coronal,

28:48

several points on sagittal,

28:49

which is not possible in day-to-day practice.

28:51

So we have to be more practical.

28:52

So what we do,

28:54

so on sagittal you measure the widest distance don't

28:58

include the notch.

28:59

So you will see this notch along the under surface

29:02

of the occipital condyle which is seen in children

29:04

and you sometimes see knot along the superior surface

29:07

of the sea one which is usually seen in adult.

29:10

So when you measure it you have

29:11

to measure from the widest part somewhere in the mid portion

29:15

on the al image and mid portion on the coronal image

29:18

and avoid this,

29:20

this notches on the occipital condyle or C one.

29:23

And this distance is is what we have to measure.

29:26

So you can see the normal distance

29:27

and this is the abnormal distance.

29:30

So what is the normal distance in In adult current standard

29:35

for normal distance is 1.5 millimeters.

29:38

So we started with 2.5, then we came with little bit lower.

29:41

The current standard is 1.5.

29:43

So anything 1.5 in adult, the CCI is suspicious for injury

29:48

and anything more than 2.5 will definitely be abnormal.

29:52

Anything between 1.5 to two to 2.5 is borderline.

29:56

All of this borderline patient will undergo MRI.

29:59

So less than 1.5, normal 1.5

30:03

to 2.5 is borderline more than 2.5 is definite.

30:07

In children it is more variable, it is age specific.

30:11

The largest distance you will see is

30:13

between two to four years.

30:14

And it also depends upon which method you use.

30:17

So there is single plan which is used

30:19

by some author on coronal only.

30:21

There are some authors use the plan

30:23

and some people use multiple

30:25

and then they, so you can see

30:26

that this mid coronal plan midlevel

30:29

where you bo measure one on each side

30:31

and then you give it that as a CPI.

30:34

There are people who do it on midsagittal uh uh uh uh image,

30:38

uh, sorry the lateral sagittal from the mid OCC one joint

30:42

and then they major this and that is the CPI

30:44

and there are people who do more

30:46

rigorous matter which is not possible in daily practice.

30:50

So what are the cutoff?

30:51

So if you keep the cutoff higher

30:54

than the sensitivity will reduce,

30:56

but specificity is hundred percent.

30:57

So time get all says

30:59

that four millimeter cutoff which is a hundred percent

31:02

specific but then you lose the sensitivity

31:04

the some other authors give a lower cutoff like 2.5 which

31:07

increases the sensitivity

31:08

but then specificity reduces significantly.

31:10

So you have to decide which way you want to go.

31:14

Basically anything like if the patient is younger probably

31:17

will go more towards four ms.

31:20

As the patient become older, like 10 years

31:22

and above we go more towards 2.5.

31:25

So look at this, what we look for.

31:27

So we look for this distance on coronal

31:29

and tle, we look

31:30

for bilateral asymmetry in this patient you can see

31:33

that right sided is more than the left uh, left side.

31:36

So we look for again asymmetry,

31:38

it should be bilateral symmetrical

31:39

as seen on AL and Corona images.

31:41

And look at this patient

31:43

where right-sided OCC one distance is much

31:45

wider compared to the left side.

31:47

Any asymmetry is sufficient.

31:49

Whether you measure, you don't measure it.

31:52

Again we look for the congruency.

31:53

The entire articular surface

31:55

of OC should have a symmetrical articular

31:58

surface with the c1.

32:00

Any loss of congruency is one of the signs

32:02

that there is potentially uh uh, uh,

32:05

dislocation or subluxation.

32:07

And last thing we look for is coverage.

32:09

It should like cover completely,

32:11

but that depends a little bit on the position

32:13

of the head flexion and extension

32:14

and that varies little bit.

32:15

So outta all four probably distance symmetry

32:18

and congruency are very important.

32:20

Coverage is not that important

32:21

and can have its own pitfalls.

32:23

Okay? So you can see that there is lots of coverage

32:24

but apart from coverage you can see that

32:27

as you go from front to back there is more widening behind

32:30

that is always abnormal, okay?

32:32

So you can have little bit of front

32:33

to back motion is possible,

32:35

but this type of widening behind in one point

32:38

and narrowing other point is always very, very suspicious.

32:42

If there are gray zones do an MRI have a very low threshold

32:46

to ask for the MRI.

32:48

Again, you can see that there is a loss of normal alignment

32:51

but look at the asymmetry as you go from front to back.

32:54

Look at this, how much widen the joint is behind

32:57

and that's a grossly abnormal joint.

33:01

So that is about OCC one alignment.

33:04

As far as C one C two alignment is concerned.

33:06

We look for three basic, uh, distances.

33:09

Anterior atlanto dental interval,

33:12

posterior atlanto dental interval in lateral atlanto dental

33:15

interval, most importantly anterior A DI which

33:18

is also known as adi.

33:20

So this is normal is less than two millimeter in

33:24

adults and 2.5 millimeter in children.

33:27

Again, as I told you, we started with PMM in adults,

33:30

then we went to 2.5.

33:32

In current standard is two mm

33:34

and in children we started with three

33:37

and currently it's 2.5 mm.

33:39

This is on the PT on x-rays.

33:42

In adult it's 3M

33:43

and in children it's five less than 30 millimeter.

33:47

Is is uh, no is is narrowing

33:50

and paddy is primary indicator

33:53

of potential spinal cord compression.

33:56

Lower the paddy, more likely that this patient have

33:59

spinal cord compression

34:00

and lateral a DI we look for the symmetry.

34:02

We'll we'll see how to do that.

34:04

Okay, and then we on the coronal we look at the plant ideal

34:07

uh, uh, uh, distance of the face joint

34:09

and which is quite variable and this is not very reliable.

34:13

We look at the lateral offset on the coronal plan

34:15

and anything more than seven is time of uh, instability.

34:19

We look when we look at the, uh,

34:20

when we look at the Jefferson fracture.

34:23

So let's see how to do that.

34:25

So mix sagittal image,

34:26

draw a line along the posterior cortex of the C one,

34:29

draw the line along the anterior cortex of the dense

34:32

and do how to measure this distance.

34:34

Two criteria should be met. One is this.

34:36

Two lines should be parallel

34:38

and this distance should be less than two millimeter in

34:41

adults, less than 2.5 millimeter in children

34:43

or less than three millimeter in children.

34:45

So two and three are good numbers to remember,

34:47

but they should be parallel to each other.

34:49

In, in red radiographs it's three and five millimeter.

34:52

When this distance increases then more than two millimeter

34:56

but less than five millimeter, it suggests

34:58

that transverse atlan injury ligament is interrupted.

35:02

When this distance is more than five millimeter, it suggests

35:05

that all the three ments which keeps the dense to position,

35:08

which is transverse ligament,

35:10

a pi ligament and all ligament.

35:11

So more than five millimeters suggests multi ligamentous

35:14

injury less than five millimeter, two

35:16

to five millimeters suggest potentially TL injury only.

35:20

So look at this example, you can see

35:21

that there is widening plus loss of parallelism

35:24

and this is a sign of uh, at least transverse

35:28

ligamentous injury if it's more than five millimeter aga.

35:32

So loss of parallel plus distance, which is

35:35

which is more than two millimeters.

35:37

What you look for the coronal corona look

35:39

for the lateral atlanto dental interval.

35:41

This should be symmetrical.

35:43

However majority of the patient, this is asymmetry

35:45

and that is primarily due to rotation of the neck

35:48

during the CT positioning.

35:50

So that is what we look for

35:52

and this is the graph asymmetry

35:54

of the lateral dental interval.

35:56

When there is a growth asymetry

35:58

of the lateral atlanta dental interval,

36:01

think about Atlanta axial rotational fixation

36:04

or rotational instability in trauma setting.

36:07

So when there is a growth asymmetry

36:09

of the Atlanta dental interval, I put in my report

36:12

that there is market asymmetry between the right

36:15

and left atlanto dental interval.

36:17

This is most likely due to rotation.

36:19

However, if the patient has fixed tic,

36:23

this can also suggest atlanto axial rotational instability.

36:28

And that is where I leave my report.

36:31

So the second thing on coronal to look

36:33

for is lateral mass offset, how to look for it.

36:36

So draw a line along the lateral cortex of the C2

36:39

and draw the line along the lateral cortex of the C one

36:42

and both the line should coincide with each other

36:45

and normal condition.

36:47

The lateral mass of the C one is at the level

36:51

of the lateral mass of the c2.

36:56

So let's start with cases and reporting tips

36:59

and how what, how that will impact the management.

37:02

Okay, so let's start with the case number one.

37:04

Eight years old with motor vehicle collision.

37:07

This is the mid image of the patient ct. What does it show?

37:12

It shows that the bayden interval has been significantly

37:17

increased in this patient it was 17 millimeter in children.

37:21

I told you younger children should have

37:23

around 12 millimeter older children should have

37:26

around 10 millimeters.

37:28

So 9.5

37:29

and 11.5 is been given as younger children and the older children.

37:33

However, anything more than 12 is almost always abnormal.

37:37

So that is something what you look

37:38

for on the midsagittal plan.

37:41

When you look at the mid coronal plan, you can see

37:43

that the con dialer C one interval has increased more than

37:47

four millimeter on right side

37:49

and more than four millimeter on the left side.

37:52

I told you that CCI is wide in the younger children two

37:56

to four years of age

37:57

as a child becomes more towards the double digit number.

38:01

This CCI start getting lower and lower.

38:03

So if you keep four millimeter

38:05

as your threshold then it's possible that you will miss some

38:09

of these injuries but you will increase the specificity.

38:11

So just depends where your threshold is.

38:14

It's always a good idea that in polytrauma patients,

38:16

whenever you are not comfortable with any CCI interval,

38:20

think about getting that in MRI.

38:22

So we have a very low threshold for MRI

38:25

and particularly for the patient who have other signs

38:28

of a DI like increase in the BDI as well.

38:32

So and the midsagittal image, you can see

38:34

that we look for the distance.

38:36

So there is widening of the distance, there is symmetry,

38:39

loss of symmetry, you can see there is loss of congruency

38:41

as you come from front to back.

38:43

There is more widening

38:44

and there is loss of coverage as well.

38:45

So you can see that here the interior aspect of the c uh,

38:49

occipital condyle has moved in front compared

38:52

to the anterior aspect of the c1.

38:55

So this is called because of the widening, it's called

38:58

atlan, it's called the occipital dissociation

39:03

or atlanta occipital dissociation A OD.

39:06

It's also called PCD cranial ERV distraction injury.

39:12

And since the occipital condyle are more anteriorly in

39:16

relation to the C one, it's called anterior stabilization of

39:21

thelan XI joint.

39:25

So look at the MR what we see on mr For mr, you can see

39:28

that there is tripping of

39:29

of the territorial membrane from the base of the cliver.

39:33

The territorial membrane should be attached

39:35

to the posterior cortex.

39:36

You can see there is a space between that

39:38

and there is this retro clival hematoma.

39:41

What you see here is retro clival hematoma.

39:43

There is a large prevertebral soft tissue uh,

39:46

and then you can see that the anterior

39:49

ligamentous complex is disrupted completely

39:52

and the posterior ligamentous complex also has the edema.

39:57

When you look at the coronal, you can see

39:59

that the guy which we, I told you that uh,

40:01

the L ligament is disrupted

40:04

or evolves from both the side ligament avulsion

40:07

without bony avulsion.

40:08

As we saw on the Corona, we could not see any bone avulsion.

40:11

However, the transverse LAN ligament is still normal.

40:15

So transverse LAN ligament is not disrupted.

40:17

However, the ligament is disrupted, membrane is disrupted.

40:21

The cap ligament that disrupted, what does it mean?

40:23

It is the anterior occipital dissociation.

40:27

It's the part or spectrum of the severe

40:30

cranio cervical distraction spectrum injury.

40:33

So this is what I put in my report.

40:35

Severe cranio cervical uh, uh, dissociation spectrum injury

40:39

and there is an interior occipital dislocation

40:43

publication or dissociation.

40:45

So this is the case two 34-year-old with MVC and neck pain

40:50

and what you see here, so you can see

40:52

that there is this tiny fragment

40:53

of the bone arising from the oc separated from the inner

40:57

aspect of the occipital condyle.

40:59

And this is a occipital condyle aversion injury.

41:03

It is best seen on coronal. That's what I see, three Cs.

41:07

Check your coronals for the condyle.

41:09

So condyle is a best scene on the uh, coronal

41:12

and uh, the this UL injury is best seen

41:15

on this coronal images.

41:16

When you look at carefully you see on this axi as well.

41:19

But this can be easily overlooked when you are going

41:22

through 4,000 images which are routine when, when we,

41:26

when we interpret a panc trauma in the patient.

41:31

The same patient al uh, image from the uh, uh, from the

41:36

Atlantic occipital joint shows the normal joint

41:38

and the midsagittal image shows the normal BDI

41:41

and the sun interspinous ratio.

41:43

What does it mean? It says that.

41:45

So this impression

41:46

of this patient is occipital condylar type pre-injury which

41:50

is an A wellsian fracture at the attachment

41:52

of the al ligament.

41:55

No CT features of atlanto occipital dissociation

41:58

or cranial cervical destruction injury.

42:02

So the teaching point is

42:03

that always check condyles on the coronal.

42:05

You can easily overlook this.

42:08

This uh uh AULs injuries on TAL and exhale plan.

42:12

So what are what you have to report?

42:14

So occipital condylar fractures are three types.

42:17

Type one is when you see com fracture,

42:19

it is a compression fracture, it's usually stable.

42:22

Type two fracture is the skull-based fracture which extend

42:25

to the occipital condyle usually stable.

42:28

And type three is this AULs injury which used

42:32

to be called an unstable fracture.

42:34

However we call it a potentially unstable

42:37

but majority of them are table fracture until and

42:41

unless there is associated other signs

42:43

of atlanta occipital dissociation.

42:45

So what I put in my report,

42:47

whether the occipital condylar fracture is present or not.

42:51

If it's fracture is present, what type of fracture is there?

42:54

Communicate with type one linear fracture extending from the

42:57

skull base, occipital condyle type two

42:59

or a injury which is type three.

43:01

Then I say whether the fracture is unilateral

43:03

or bilateral, then I say whether

43:04

the fracture is in place or under.

43:06

And then I see whether it's an isolated fracture

43:08

of the occipital condyle or occipital condyle

43:11

or UL fracture with lan oxide dissociated.

43:14

So let's see, one more case.

43:15

So you can see that there is an ulg injury on the right side

43:17

there is a very subtle UL injury on the left side.

43:20

On the right side there is hardly any displacement.

43:23

On the left side there is eight

43:24

to four millimeter of the displacement.

43:26

What you look for, you look carefully

43:28

for the atlanta al dissociation on coronal

43:31

sagittal images as well.

43:34

This is a case three young adult

43:36

with motor vehicle collision coronal image.

43:38

What you see here, there is an alion injury occipital

43:41

condylar type three injury

43:43

but this time it's unilateral on left side

43:45

however there is a significant displacement

43:48

of the occipital condylar fracture on this coronal image.

43:51

What you do next look at the statal

43:53

and you can see that on tatal image there is a graph

43:57

subluxation of the occipital condyle over the C one loss

44:01

of symmetry, increase in the distance loss

44:04

of bilateral symmetry congruency.

44:06

All the features suggest that there is Atlanta axial

44:09

occipital depreciation injury on the coronal you can see

44:12

that there is a widening of the distance, uh um, uh,

44:15

between on the right side as well as

44:17

of the distance on the left side.

44:19

What does it say? So this patient has occipital three

44:25

there, but injury,

44:31

uh, spectrum of the CCD injury.

44:33

So in this patient in my impression I put

44:36

that severe cranial cervical distraction spectrum injury

44:39

and then I say that occipital caused condylar type three

44:42

uls fracture pain.

44:43

But that fracture here doesn't make a big difference

44:46

because more severe injury is the CCD which is there rather

44:50

than occipital conal fracture.

44:53

So this is case four 44-year-old with MVC.

44:56

What you see here, as I told you,

44:57

the atlas vertere is a ring shaped vertebrae best seen on

45:01

axial and uh, you have to look

45:04

for just like anywhere else in the body like pelvis

45:06

where you have a ring ring always gets

45:09

disrupted at two places.

45:11

So when ring is broken one place you have

45:13

to look at the ring broken at fourth in one place.

45:16

So let's see what are the fractures,

45:17

what you see in this patient.

45:18

So you can see there is a fracture occurring

45:21

through the lateral mass on the left side.

45:23

So this is fracture number one.

45:24

There is a fracture through the posterior arch

45:27

of the atlas on left side with fracture number two.

45:30

This is, there is a fracture of the posterior arch

45:32

of the atlas on right side fracture number three

45:35

and there is a fracture occurring

45:37

through the anterior arch of the atlas.

45:39

So how many fractures you saw?

45:41

You saw four fractures, one through the anterior arch, one

45:44

through the lateral mass and two through the posterior arch.

45:48

So how many parts fracture this is?

45:51

So when one fracture occur it causes two parts.

45:54

So when four fractures occur it causes five part.

45:57

So you decide

45:58

how many fracture lines we see in particular case.

46:01

So in this patient we saw four fracture lines.

46:03

So total parts are five.

46:05

Jefferson fracture is

46:07

whenever you see three fracture lines occurring in the atlas

46:12

that will make it classic Jefferson though

46:15

by convention we call all C one ring fracture as Jefferson.

46:19

However, technically

46:21

what Jefferson described was the fracture

46:24

where there were at least four parts

46:26

with three fracture lines.

46:28

Now you have to remember that most of these fractures

46:31

and their classifications were described in seventies

46:34

and eighties and nineties before CT scan was there.

46:38

So many of these classifications are actually outdated

46:42

and there is a time for newer CT based classification,

46:46

easier classification and that is what AO is trying to do.

46:50

The AO is trying to standardize the term,

46:52

how we describe the fractures

46:54

and basically rather than describing it Jefferson

46:56

or giving them the name, you try to describe

46:59

how many parts are there and whether it's a table

47:01

or unstable fraction.

47:03

So how to decide whether it's a table or unstable.

47:06

So first of all decide whether the ring is,

47:09

is fractured anteriorly or posteriorly and which side right

47:12

or left, what is the offset and what is the total offset?

47:15

We'll learn how to say that.

47:16

And most important part in deciding the atlas fracture

47:20

management is whether the transverse atlan ligament is

47:23

injured or not, which is seen on mr.

47:26

But CT can potentially show the aversion injury

47:29

of the medial tubercle

47:30

where the trans lateral ligament attaches.

47:32

MRI has its own role

47:33

and many people believe

47:34

that MRI should be done in all the patient

47:36

with Jefferson fracture.

47:38

Uh uh, but still the experts uh, um, uh,

47:41

uh, have different opinion.

47:42

Quite a good number of Jefferson fracture are treated

47:46

without surgical intervention, non-operatively

47:49

and only unstable fractures, uh,

47:51

after putting them immobilization.

47:53

And the hello, uh, the pain fractures which remain unstable

47:57

or does not heal,

47:58

they are the only one which goes for surgery.

48:00

So till there is a lot of gray zone, which patients

48:02

to operate and which patients not to operate, but more

48:05

and more patients are being not operated, uh,

48:08

with Jefferson fracture.

48:10

So let's try to see what our patient showed.

48:12

So we, our patient had four fracture lines,

48:14

so it's the five parts.

48:16

So anything more than four part can be called Jefferson.

48:18

But again, don't try to name it, just say that multi-part

48:22

is at less ring fracture.

48:24

However, many times our surgeons still use the old term.

48:27

So putting Jefferson will give them an idea that okay,

48:30

we are talking about jefferson fractures.

48:32

I always put Jefferson in the bracket of my impression,

48:35

but I'm not thinking about Jefferson,

48:37

I'm just thinking about how the, how

48:39

how many parts fracture it is.

48:40

And then we look at this, this thing,

48:43

something called rule of Spence.

48:44

Rule of Spence is when lateral offset is more than seven

48:48

millimeters, it suggests

48:49

that transverse lateral ligament is above on ct.

48:51

Let's try to see how to do that.

48:53

So this is a normal patient

48:54

and you can see that lateral mass of C

48:56

and lateral mass of C two are aligned to each other on ct.

49:00

This was originally described on x-ray

49:02

and what we try to do is we try to take the thick section

49:06

of thick, uh, uh, MultiPlan reconstruction, try

49:09

to make it like a radiograph and then we do it

49:11

and then look at the lateral mass of the C1 lateral mass

49:14

of the c2, same way on the other side.

49:16

And then we measure each of this distance.

49:19

Like for the example, this is four millimeter here,

49:21

this is four millimeter here,

49:22

so four plus four is equal to eight.

49:24

So this is called lateral mass offset distance.

49:28

Anything where some

49:29

of two sided lateral mass offset is more

49:32

than seven millimeter.

49:34

It means that this patients transverse atlan ligament is a

49:38

worse whether you see it or don't see it on imaging.

49:41

However, as I told you,

49:43

CT will show you the aversion fracture coming from the inner

49:46

surface of the, of the, of the uh, atlas, which is one

49:50

of the indirect sign of a uh,

49:52

transatlantic ligament aversion.

49:54

This is another patient

49:56

where we see the lateral mass fracture, uh,

49:59

which is seen predominantly on the left side on the coronal.

50:02

And let's try to see what you see in the exile.

50:04

So exile, you can see the compression fracture

50:07

of the C one lateral mark.

50:09

You can see that this lateral mark fracture is extended

50:11

to the vertebral artery, which is one

50:12

of the high risk factor for vertical artery injury.

50:15

Always do CT angiography

50:17

before you, uh, do any other surgical intervention

50:20

or or anything else.

50:22

So there is a lateral fracture

50:24

and other than that there is an anterior ring fracture,

50:27

which is tally oriented.

50:29

There is a posterior ring fracture which is sagittal

50:31

to coronary oriented.

50:33

What does it mean? So these two fractures are separating the

50:36

lateral mark, which is called isolation of the lateral mark.

50:40

How many fracture lines you see?

50:41

So you see one fracture line, two fracture lines,

50:44

three fracture line and four fracture line.

50:46

So this is jefferson fracture, how this is considered

50:48

to be one of the unstable fractures

50:50

because this lateral mass is now completely separate

50:53

to move more laterally.

50:54

And if you can see here this bony fragment coming from the

50:58

medial aspect of the medial tubercle, this is

51:01

where the transverse lateral ligament attaches

51:03

and this is one of the sign

51:05

of transverse atlan ligament avulsion.

51:08

Let's see. So this is uh, when MRI was done,

51:11

what you should be looking at.

51:12

So you should be looking at the medial tubercle here

51:16

and the transverse atlan ligament attaches

51:18

to the cortex of the bone.

51:20

Here you can see that the ligament still attaches

51:23

to the bone but this bone is fractured.

51:25

So there is an aul of the bone

51:26

with the ligament evolves from the medial tubercle.

51:31

So this patient, you can see

51:32

that initially when we do the first x-ray,

51:35

when it was done pt there was no lateral mass offset on the

51:39

right side and on the left side there was four

51:42

millimeter of the offset.

51:43

So this patient was put on a immobilization hard collar.

51:47

Hello. After six weeks we did another ct

51:50

and now you can see that there is increased instability

51:53

with lateral mass offset now seen on both the sides,

51:56

which when you total it's more than eight millimeters.

52:00

So this itself says

52:01

that seven millimeter rule doesn't make a big sense, like

52:04

what you have to tell is whether there is offset or not

52:07

and whether the offset is unilateral or bilateral.

52:10

And quite a good number

52:11

of these patients were offset was

52:13

initially not seven millimeter.

52:14

Later on when you do a CT

52:17

or upright x-ray you will see that the offset is

52:19

so these people are called potentially unstable,

52:22

where first CT does not show you the instability.

52:26

However, when you do a repeat CT with without uh, uh, after,

52:30

after six to 12 weeks of immobilization

52:33

or when you do an upright radiograph,

52:36

you will see this instability at t place.

52:39

We also do dynamic X-rays, uh, inflection

52:42

and extension, which will show you the atlanto exile

52:45

uh, instability.

52:47

And you can see that the, the the uh, upright X-ray shows

52:50

that the normal atlanto dental interval

52:53

less than three millimeter.

52:54

However on the flexion you can see

52:57

that this distance has increased to five millimeters

52:59

with such as dynamic atlanto T stability.

53:02

Any patient with Jefferson factor who develops

53:05

anterior atlanto real instability needs surgical fixation

53:10

that now becomes types C fracture in in um, uh,

53:15

uh, AO classification.

53:16

If there is only lateral mass offset, uh,

53:19

that is still considered

53:21

as type B fracture in a in AO classification.

53:24

The moment moment the A i the NT A DI type increasing on

53:28

dynamic authentic imaging,

53:30

that is the time when it's upgraded

53:33

to type C which is a translational injury which is unstable

53:37

injury which needs surgical fixation.

53:39

So what you have to report when it comes to atlas fracture,

53:41

how many factor parts you see?

53:43

So count fracture lines and add one

53:46

or when jefferson is technically four part fracture,

53:50

then you say anterior ring,

53:52

how many places it is broken posterior ring,

53:55

how many places it is broken,

53:56

whether it's broken on left side or right side

53:58

or both the sides you look

53:59

for lateral mask is isolated or not.

54:02

When you see ly oriented factor in the anterior

54:04

and posterior ring on the same side

54:07

as the I showed you the case,

54:08

then you look at the offset total

54:10

and bilateral, then you look at the transport atlan ligament

54:13

tear on CT by AULs

54:15

and also look at the MRI

54:16

for transverse atlanta ligament injury.

54:19

Always after immobilization to the dynamic, uh, radiographs

54:24

examination and anesthesia can be done to

54:27

demonstrate clinically uh, uh, uh,

54:30

radiographically undetected instability.

54:34

So what further needs to be done?

54:36

So once you have done the ct, if is normal, you stop.

54:40

If neurology is negative, you do mr.

54:43

If neurology is positive, borderline abnormal ct,

54:46

which I told you like 8.5 is normal, 8.5

54:50

to 10 is borderline.

54:51

Same with children like up to 10, 11 is normal,

54:54

then up abnormal when there is a borderline,

54:56

then suppose your a DI is between two to three millimeters.

54:59

That's the bottom line. Do an MRI to look

55:02

for ligamentous edema, disunity grossly abnormal.

55:07

C you always do an MRI

55:09

because this patient needs surgical fixation somewhere

55:11

to look for those six cord and cable and pusher and, and

55:14

and, and so and so forth.

55:17

MRI uh, shows only ligamentous edema, borderline ct

55:22

what needs to be done immobilize the patients.

55:24

Most of the surgeons would like to immobilize.

55:27

Very rarely surgeons are more aggressive

55:29

to do surgical fixation.

55:31

Most of the surgeons will immobilize it and then

55:33

after six to 12 weeks they will do examination anesthesia

55:37

or traction fluoroscopy or, or uh, upright radiographs.

55:41

Um, one of those dynamic examination.

55:43

And if this segment is moveable,

55:46

if segment shows dynamic instability,

55:48

then they need surgical fix succession.

55:50

It is upgraded to type C,

55:53

all potentially unstable are type B.

55:55

They can go to non-surgical management

55:58

or they can go towards the surgical management.

56:01

So MRI we do when there is a borderline alignment

56:04

abnormality, MRI we do when there is definite alignment

56:07

abnormality to look at the ligament more carefully

56:09

whenever you see the, those red flex

56:11

or soft tissue signs on CT without alignment abnormality

56:15

whenever we see fractures.

56:16

But that does not match the neurology.

56:18

And whenever the patient cannot be reliably examined, even

56:23

with the normal ct, we'll do the MRI.

56:25

So the take home message is

56:26

that the cranial cervical junction injuries are not

56:29

so, um, uncommon.

56:32

It's a critical blind spot.

56:33

As I told you that when we are interpreting a hand ct,

56:37

which is 4,000 images, it's very easy to

56:40

overlook this cranial cervical junction,

56:42

which is a small part and until,

56:44

unless you have some search pattern.

56:46

So I take around couple

56:48

of minutes at the cranial cervical junction, Corona, I know

56:50

what to look for, decon al I know what to look for, midal,

56:54

lateral and so forth.

56:56

Systemic search pattern and checklists are, are, are,

56:59

are really important

57:01

and you must know what your surgeons want to know.

57:05

Try to put those things in your report.

57:08

And with that, uh, I would like to take any questions.

57:11

Um, if you have, thank you so much. Thank you.

57:13

Thank you medal. Thank you Ashley.

57:16

Thank you so much for sharing your

57:17

lecture with us today, Dr.

57:19

Ika. At this time we will open the floor

57:21

for any questions from our audience.

57:23

You may submit your questions through the q

57:25

and A feature and Dr.

57:29

Ika, if you see there's about six questions. Yeah, now.

57:33

Hmm. Okay, fine. So yeah, there are six questions.

57:36

So first is how best

57:38

to evaluate Atlanta axial rotation in stability versus

57:42

physiological head turning during imaging?

57:45

Yes. Um, so, uh, it's not easy.

57:48

Like most of my patients have some form

57:51

of rotation at Atlanta, axial joint on coronal ct.

57:54

It is seen as asymmetry of thelan axial joint.

57:58

And on axial we see some, um, uh, rotation as well.

58:02

As I said, if the, if the rotational, uh, difference

58:06

between the both the side a DI is like one

58:09

or two millimeter, I just ignore them.

58:12

If I see a gross rotational abnormality, like for example,

58:16

on one side I see one

58:17

or two millimeter, a DI lateral a DI coronal other side,

58:20

I see five or six millimeter.

58:22

In those patients, I will put in my report

58:25

that there is a growth asymmetry

58:27

and rotational morphology at thelan XXI joint

58:32

rotational deformity if this patient has fixed tic.

58:36

So it's very important that clinically they should know

58:39

that if this patient have a pre neck moment, right to left,

58:43

left, nothing to be done.

58:44

Second important thing that we are presuming that all

58:48

of these patients have normal a DI.

58:50

If your anter atlanto dental interval is increased more than

58:55

two millimeter, they become automatically type two

58:58

to type four atlanto axial rotational instability.

59:02

So our most difficult part to differentiate

59:05

normal rotation from a A RI is type one building.

59:09

Type one building in hawking type one is the most difficult

59:12

1, 2, 3,

59:14

and four has anterior atlanta

59:16

dental interval is also widened.

59:17

So if anterior atlanta d distance, uh,

59:20

the dental distance is wide, that victim,

59:23

that cannot be rotation, that has to be, uh, uh, uh, uh,

59:27

rotational, uh, fixation or stabilization.

59:30

It's only when you have the anterior a DI is normal

59:33

and only lateral as symmetry seen.

59:35

Is is more trick your part? Is it clear Vishal?

59:42

Okay. Uh, can AI help to make diagnosis? I wish it can.

59:46

Uh, it's a bit too complex.

59:47

Uh, uh, there's a lot of, uh, that's

59:50

what exactly we want to do, right?

59:52

So we want AI to do a little more simpler stuff

59:54

where the pattern, uh, happens like, uh,

59:57

more frequently like bleed, like in fact like large things

60:01

so that we can use our grade scale to gray cells to, uh,

60:05

use it at more complex things like vertical junctions

60:08

where a lot of variables are involved.

60:10

But yeah, uh, uh, uh, the future looks promising

60:13

and probably someday AI should be

60:16

able to do some of the things.

60:17

What we do, particularly some of this measurements,

60:19

AI can do it, uh, really well, uh, in a consistent way so

60:24

that, uh, that is being taken care of.

60:26

So when you are, when you are interpreting this image, they,

60:28

they already have the measurements, uh,

60:30

on different imaging where it's required.

60:33

Uh, what will be the slice thickness

60:35

and performing MRI CV junction on exile Corona.

60:38

So what we do is that we do a three millimeter section.

60:43

Our best imaging is done T two without fat.

60:47

So we do, uh, T two, uh,

60:50

coronal without FactSet

60:52

and T two coronal with FactSet axi, uh, uh, T two

60:57

with set and axial T two without fat.

60:59

So axial and coronal T two with

61:03

and without fat set,

61:04

particularly the T two without fat set is three millimeter.

61:07

Is what is like a, a reasonable size on sagittal.

61:10

It's just the normal spine.

61:12

Uh, what we do in a normal cervical spine, uh, is lot

61:15

of normal cervical lordosis with normal alignment of time.

61:18

No, it is not, usually not loss of cervical lordosis

61:21

or even uh, uh, kyphosis is not a sign of, uh,

61:25

ligamentous injury even on the Corona plan.

61:28

Also, rotation is not sign of ligamentous injury.

61:30

No, just severe

61:31

of arthritis protect against bon spine injury.

61:35

My 17 reporting trauma ct,

61:37

I've never seen spine trauma in the

61:38

presence of severe of arthritis.

61:39

That's an interesting question.

61:41

Uh, well, uh, uh, I don't have the correct answer, uh,

61:45

but, um, uh, uh, most of these patients like, uh, the,

61:49

the injuries occur in younger population,

61:53

probably the reason is

61:54

that young people have slightly bigger head size, uh,

61:57

and their biomechanics are slightly different.

62:00

So quite a good number of these patients we see in children

62:03

as people become older.

62:05

Like, uh, the other, uh, fractures start showing up like

62:08

through the rigid spine, like through the, OR process like,

62:12

uh, hangman fracture, those fractures will start coming up.

62:15

Uh, uh, I also don't remember seeing many old people

62:19

with the choroidal junction, so probably the biomechanic,

62:23

uh, and the body, uh, weight distribution from the head

62:26

to the rest of the body with changes, uh,

62:28

which might be the reason.

62:30

I, I agree with you. Uh, thank you. Thank you.

62:33

Thank you, Williams. Thank you. Uh, thank you. Okay.

62:37

And how to diagnose sports person's finger

62:40

pain if he feels pain.

62:41

Only if vendor is making a strong punch,

62:44

otherwise it doesn't feel pain.

62:46

Well, I'm not very sure what to finger pain. I'm not sure.

62:52

Can I use the alignment of lateral mass of C one

62:55

to the C two joints in the coronal images

62:57

to know whether this is instability or rotational?

63:00

Uh, well, alignment of the lateral mass on C1

63:04

and C2 in coronal, no, it doesn't help a lot.

63:08

So what I do is that, uh, when I look at the coronal,

63:11

I look at the lateral atlanto dental

63:13

interval for the asymmetric.

63:15

Now, when the la when the dent moves laterally,

63:18

the one side on the same side, even C2 also moves,

63:21

the facet joint also moves in the same direction

63:25

of the dent.

63:26

So what happens is that if the, the dent is moving

63:28

to the left side, the C two on the left side moves lateral

63:32

compared to that on the, uh, on the C one on the same side,

63:36

it doesn't help, uh, in axial also, it doesn't help it,

63:39

it doesn't help anyway.

63:41

The only way to do it is that it's a rotational abnormality.

63:44

So it'll be seen on aal,

63:45

it'll be seen on tal, it'll be seen on Corona.

63:48

Only way to know is whether it's a rotation

63:50

or rotatory fixation.

63:51

If the patient has a fixed tic collar or,

63:54

or the c**k robin position on clinical examination how to,

63:59

the next day we perform their patient

64:00

with ERV spine injury mobilize with a metal collar?

64:03

Well, I don't think so. We, we don't use the metal collar.

64:07

Uh, so most of our collar are even hard collars are not

64:10

made up of metal.

64:12

So I'm not sure anyone is using metal color or not.

64:14

So either, uh, uh, the,

64:16

the hello which is used has some metal component,

64:19

but again, it's not, uh, uh, the, the, the, the metal.

64:22

So the patient who comes to the er,

64:24

like they put the soft collar first before they,

64:27

before the spine is clear,

64:28

and if the fracture is sinned,

64:30

then sometimes they put the hard color,

64:31

but the hard color is also not complete metal.

64:34

It's still the deal, still the non-metal component only.

64:37

Yeah. Thank you. Uh, I suggested article

64:40

or there are plenty of good articles to read.

64:42

Uh, uh, I have many of them.

64:45

Uh, I think I'll put my email address, uh, uh,

64:47

with this, uh, talk up.

64:49

Uh, and, and probably at the bottom I'll answer this, uh, so

64:52

that all of you can um, uh, uh, uh, reply

64:54

and so just send me an email and I send you some article.

64:57

What is the appropriate to do dynamic flexion

64:59

extension when is appropriate?

65:00

So usually what we do is that, um, we do flex.

65:04

So most of this patients with fracture with, uh,

65:08

borderline abnormal alignment,

65:10

they're put on the hard collar or hello.

65:13

And after three to six weeks, uh, uh, uh, they do the,

65:17

they remove the collar and they try to do dynamic uh, tests.

65:20

So we don't decide that that's been done by, primarily

65:22

by our spine surgeons and spine team.

65:24

Uh, um, uh, but uh, uh, basically it's not done immediately

65:28

and uh, upright x-ray is also being done.

65:31

So, uh, uh, only time is that when you clear the spine, uh,

65:35

on PT or MR.

65:36

And the patient still has pain.

65:38

Sometimes we do flex and extension,

65:40

but uh, it's usually on the spine surgeons, uh, request.

65:43

Like we don't decide when we do.

65:45

Uh, yeah, surely we'll try to do it. Thank you.

65:51

I think you got 'em all. Dr. Ran, thank you so much for

65:54

Again sharing. Thanks. So

65:55

where can I put, uh, uh, my email address so

65:57

that they can, um, um, okay.

66:01

And so if, if I answer to someone,

66:03

like everyone will get it, um, uh, the email address or

66:06

You can drop your email address right

66:08

into the webinar chat.

66:11

Okay. So put in the chat and then can grab it. Yeah. Yeah.

66:15

So, uh, okay. Yeah.

66:17

So, okay, so my email address is

66:20

for mEq.

66:25

Okay. So that is my email address.

66:26

Send me an email and I'll send you whatever articles

66:30

or any questions you have later on

66:33

when you go through this presentation. Thank

66:35

You. Excellent. Thank

66:36

you so much Dr. rga. Thanks and thank you.

66:40

Thank you so much for everyone for participating in, um,

66:43

our lecture today and asking such great questions.

66:47

You can access the recording of today's conference

66:49

and all our previous noon conferences

66:51

by creating a free account.

66:53

We'll also email out a link to the replay later today.

66:57

Be sure to join us next week on Thursday,

67:00

November 14th at 12:00 PM Eastern, where Dr.

67:03

Ssh Mukerji will deliver part two

67:06

of his lecture entitled Anatomy

67:08

and Pathology of the Oral Pharynx.

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You can register for it@mrionline.com

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and follow us on social media

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for updates on future noon conferences.

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Thanks again, and have a great day.