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Hello and welcome to Noon Conference hosted by MRI Online

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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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We encourage you to ask questions

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and share ideas to help the community learn and grow.

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You can access the recording of today's conference

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and previous noom conferences

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by creating a free MRI online account.

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Today we are honored to welcome back

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to the noom Conference stage Dr.

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Samir Ranga for a lecture entitled

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Thora Columbar Spine Injury at ct,

0:37

A Systematic Search Pattern.

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Dr. Ranga serves

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as a staff radiologist at University Hospital in Muscat,

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Oman, and is a dedicated faculty member in the radiology

0:47

residency training program

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with an interest in various subspecialties.

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He blends his clinical skills

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with a strong interest in medical education.

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He's involved in teaching medical students, residents,

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fell fellows, and practicing radiologists in India and Oman,

1:01

and participating in international educational programs.

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He's a member of the annual meeting program planning

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committee for RSNA for the Emergency Radiology Subspecialty

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and a reviewer of the educational exhibits for RSNA.

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We're glad he's here today to share his expertise.

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At the end of this lecture, please join him in a q

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and a session while he will address questions you may

1:22

have on today's topic.

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Please remember to use the q

1:26

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

1:28

as many as we can before our time is up.

1:30

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

1:34

Ranga, please take it from here.

1:37

Thank you Ashley, for this invitation

1:39

and, uh, for the introduction.

1:40

Uh, I'm Sam Ranga.

1:42

I work, uh, at the University Hospital, mark Oman.

1:45

Uh, it's evening in Oman, 8:00 PM So good evening to all

1:48

of you from different time zones

1:51

and um, well, uh, the noon conference of MRI, um, is one

1:55

of the best, uh, online accessible, uh, uh,

1:59

resource available, uh, uh,

2:01

during the pandemic and after the pandemic.

2:03

And, uh, I would like to thank MRI online for stepping up

2:07

during the pandemic to make this radiologic

2:09

education accessible to all.

2:10

Uh, this is my second known conference, uh,

2:13

the first one I gave in 2021.

2:15

Uh, and, uh, uh, in next 45

2:19

or 50 minutes, we are going to learn about the role

2:21

of imaging in tho lumbar spine trauma assessment

2:24

with emphasis on CT and systematic search pattern.

2:28

Uh, I do not have any conflict of interest to disclose, um,

2:33

the, the, some of the amazing illustration,

2:36

which I'll be going to use in this presentation for prepared

2:39

by Matt Kki.

2:41

Uh, uh, Matt is a, is a, um, uh,

2:43

we collaborated on several projects,

2:45

but uh, the, the article which we published in 2016, uh,

2:49

radiographics, uh, Matt, uh, uh, prepared this uh, uh, some

2:54

of the illustrations and we're going to use it.

2:56

Uh, there'll be few abbreviations which I'll be using uh,

2:59

during my presentation.

3:01

So, uh, motor vehicle collision

3:03

and fall from height are some of the commonest mechanism

3:06

for the tural lumbar spine trauma and fractures

3:09

and almost two third

3:10

of the spine fractures occur in this region

3:14

among 32nd lumbar region.

3:16

The T two to T 10 is relatively uncommon fracture.

3:21

Majority of fractures occur between T 10 and L two

3:24

because this perico lumbar junction is biomechanically

3:28

transitional zone and preferable zone to fractures.

3:31

Lumbosacral spine is relatively less commonly involved.

3:35

This fractures are important

3:37

because up to one third

3:38

of these fractures result in neurologic injuries, some form

3:41

of at least 30% of the fractures that are associated

3:45

with some form of abdominal or other associated injuries.

3:48

15% of the fractures are non-contiguous fractures so

3:52

that when you see fracture in cervical

3:53

or lumbar spine, there is possibility

3:55

that the fracture other spine is also involved in at

3:58

least one in eight patients.

3:59

And quite often these fractures are delayed in diagnosis

4:02

or they're missed completely altogether.

4:07

So in this presentation what we are going to do is, uh,

4:11

my learning objective is to use the CT search pattern

4:15

to detect the fractures once fractures detected how

4:18

to describe it using the terms which are understandable

4:22

by our surgical team.

4:24

And we use the uniform same terms, we'll learn how

4:27

to discriminate different similar looking injuries on

4:30

imaging, particularly with the CT scan

4:32

and how not to miss this fractures on imaging at class.

4:36

We'll understand that how this information is useful

4:39

to our treating trauma surgeons

4:41

to decide which patient will go to operating room

4:45

vis-a-vis which patients will go

4:46

for non-operative management.

4:48

So this is the outline of my talk.

4:50

I'll start with some

4:51

of the concept important for spine trauma.

4:54

Then we'll understand how

4:55

to approach a CT using a systematic search pattern.

4:58

I'll show you plenty of cases and examples, some spot images

5:02

and some type of images to to, to show the pattern

5:06

recognition we are going to learn during this presentation.

5:09

And last but or not the least, throughout this presentation,

5:12

I'll to you

5:13

or I'll share a lot

5:14

of practical tips which will be

5:17

useful in day-to-day reporting.

5:19

So as far as concepts are concerned,

5:20

we'll learn about three important issues, the anatomy

5:23

and biomechanics, the imaging appropriateness in spine

5:26

trauma and fracture morphology and the classification.

5:30

So quickly understand uh, the biomechanics

5:34

and anatomy of the spine relevant to the spine trauma.

5:37

And this is what is described as the motion segment

5:42

of the spine, which is a basic motion unit of the spine

5:46

and it's a smallest functional unit.

5:48

The spinal column can be divided into

5:51

anterior and posterior column.

5:52

Anterior column is ral body, A LL, the disc and the PLL.

5:57

The posterior column is neural arch

5:59

and all the ligaments which connects the neural arch,

6:01

which is called posterior ligament as complex.

6:06

The posterior tension bend is important to understand

6:09

and posterior tension bend consist of neural arch,

6:11

which are the bony structures, which includes Pele superior

6:15

and inferior articular facet, the laina,

6:19

the spinous process, the facet joints

6:21

and the transverse processes.

6:23

The ligament which connects these different structures from

6:26

cranial to quarterly in constitute what is known

6:29

as posterior ligament as complex or TLC,

6:31

and they include the facet joints into spinous ligament,

6:35

supraspinous ligament, and ligamentum flavor.

6:37

So all of this four ligament together are called are are

6:41

called the posterior ligament complex.

6:43

As we can see, the supra spinous ligament connects the tip

6:46

of the spinous processes.

6:48

The interspinous ligament connects the

6:50

adjacent spin processor.

6:51

The ligamentum flavor connects the lamina to the upper

6:55

and the lower vertebral body contiguously

6:58

and they are seen in continuation

6:59

with the interspinous ligament

7:01

and facet joint capsules strength under facet joint.

7:05

All of these ligaments are very critical in restraining the

7:09

translation rotation and flexion movement.

7:12

And this is the main component of the tension bend,

7:15

working like a cable in a lifting crane.

7:19

When it comes to imaging appropriateness, CT is often used

7:23

as a first line imaging in all high velocity trauma.

7:26

Radiographs are used

7:27

as a screening modality in low low risk patients.

7:30

However, any abnormality you see on radiographs

7:33

or even suspicious abnormality on radiographs CT should be

7:36

done as the next imaging

7:39

and even when radiographs is normal.

7:40

If clinical suspicion is high for spine trauma,

7:43

the CT should be done in this patient as well.

7:46

MRI is complementary to CT in high risk patients.

7:50

MRI is the imaging modality of choice.

7:52

If X-rays are normal

7:53

or X-ray shows osteoporotic compression factor

7:56

and any patient who has a neurologically positive trial find

8:00

trauma MRI is something which is done in all the patients.

8:04

As far as the classification

8:06

of the spine trauma is concerned, the whole idea

8:09

of classifying the spine trauma is to unify the description

8:14

of the injury between the radiologist

8:16

and the referring team to decide whether the spine trauma is

8:20

stable or unstable based on the degree

8:23

of the injury that happens.

8:25

And last but not the least is the any spine trauma

8:28

classification should guide the treatment

8:30

and it should improve the outcome if it's

8:32

appropriately used.

8:34

So all the fine trauma classifications which are used

8:38

historically, all of them are imaging based.

8:40

Earlier it was based on radiographs

8:42

and later on they're based on the CT scan.

8:46

So early classification system were more qualitative

8:49

and me mechanistic,

8:51

that means they're pattern based which describes the

8:54

fracture, morphology and different patterns which we are

8:56

going to learn injury mechanisms like flexion,

8:58

like rotation, like uh, distraction, so and so forth.

9:02

And last is instability whether the fracture pattern which

9:05

is seen on the x-ray

9:06

or a CT scan will result in instability or not.

9:09

The recent classification system are more numeric.

9:12

They are based on the fracture pattern severity plus soft

9:15

tissue injuries as can be determined on CT

9:18

or MR along with the presence

9:20

or absence of the neurological symptom.

9:22

So if you start from the beginning, it started

9:24

with 1932 Ebola

9:26

and then the Watson then given 1938, Nicole in 1949,

9:30

but one of the most important classification was given in

9:33

1963 by Hallworth at that time only were available.

9:37

And he described the spine consist of a vertical two column.

9:40

The anterior column is vertical body dis

9:42

and the A LPL, the posterior column, both the neural arch

9:45

and the posterior ligamentus complex.

9:47

He was the first guy who came up with that.

9:49

Posterior ligaments are important tension Ben then Dennis in

9:53

1983 came up with the three column classification.

9:56

They divide the entry column into interior

9:57

and middle column, then McAfee in 83 came

10:00

up in another classification.

10:02

The mag classification was the original O eight

10:05

classification, which was, which came in 1995, which was one

10:08

of very difficult classification to use.

10:10

And so work in 20 2005 came up

10:14

with the still classification we,

10:15

which he himself updated the OA in 2030.

10:18

So let's understand the three column concept of deni,

10:21

which is very important to understand

10:22

and still makes a good portion

10:24

of many classifications system which we use.

10:26

So deni divided the anterior column of the into two parts.

10:31

So the anterior column can be divided into anterior

10:34

and the middle column, anterior column consists

10:37

of the anterior two third of the vertical body,

10:39

anterior two third of the disc

10:41

and the A LL the middle column consists

10:44

of the posterior one third of the vertebral body,

10:46

posterior one third of the disc and the PLL

10:49

and everything behind the PLL was the posterior column.

10:53

What Dennis believed

10:54

that the middle column is very important in the stability

10:58

and he, he proposed that fracture

11:01

or injury of any two contiguous column will result in

11:06

the instability of the spine.

11:08

So either anterior

11:09

and middle column fails that will result in unstable spine

11:12

or if middle or posterior column will fail,

11:14

it results in the unstable spine.

11:16

Of course, if all the three columns are injured,

11:18

it'll definitely result in unstable spine

11:21

and as we'll learn little bit later on, all of this unstable

11:25

or unstable spine needs some form

11:27

of surgical correction in order

11:30

to make the spine stable again.

11:33

McAfee, McAfee in 1983 came up

11:36

with this classification which was based on the pattern

11:39

and he used some of the descriptive terms like weg

11:41

compression, stable birth, unstable birth flexion,

11:44

traction chance translation and so forth.

11:47

However, in current time,

11:49

two most widely used classification system, both

11:52

of them were proposed by the vaccaro etal in 2005.

11:56

The spine trauma group came up with E-L-I-C-F,

11:59

which is a tho lumbar injury classification system,

12:03

which is based on the fracture,

12:05

morphology and the neurology.

12:07

And this classification was point based

12:09

and it determines what would with the treatment

12:12

of these fractures.

12:13

In 2013, the same group, uh, along with the OA,

12:18

modified the AO classification

12:21

and that is what is called the updated AO classification

12:24

or AO telex classification,

12:25

which again is based on the morphology,

12:28

which is simplified clinical behavior

12:29

and some of the modifier

12:31

as we'll learn detail in the next few slides.

12:34

So inte classification injury

12:36

morphology can be of four types.

12:38

Compression injury will get one point burst,

12:40

injury will get two points.

12:41

Rotational translation injuries will get three points

12:44

and destruction injuries will get four points.

12:47

Telex is the first group which comes up with the importance

12:50

of the posterior tension bent

12:52

and they say that if posterior ligament is complex is

12:55

injured, that will get an additional three points.

12:58

If the posterior ligament is complex is intact,

13:01

that will be zero point

13:02

and if it's indeterminate it'll get two points.

13:05

If you total the morphology points and the, and the

13:10

and the PPP integrity point, you will come up with a score.

13:14

So if the score is less than four, that means one to three.

13:17

These patients are operated non-operatively,

13:20

they're not operated, they are ERV treated.

13:23

If the score is more than four,

13:24

this patients are surgically treated

13:26

because those spines are unstable.

13:28

However, if the point score is exactly four, then the choice

13:32

to treat by surgery

13:34

or by non-operative is based on the surgeon per

13:38

surgeon's own choice.

13:40

In 2013,

13:41

the updated AO classification again has similar

13:44

morphology of injury.

13:46

So in compression injury it's called a type of injury.

13:49

It involves primarily the anterior column,

13:52

that means the the anterior plus middle column

13:55

and it has total five types, a zero to a four, a zero,

13:59

A one, and a two R compression practice.

14:02

A three and a four are different types of birth fractures.

14:05

So compression plus birth, all

14:07

of them comes under the group A, the distraction injuries

14:11

or the B injury, which primarily involve the flexion tension

14:16

bend or extension tension bed.

14:17

Most of the patients, their distraction injury occurs in the

14:21

flexion bend, which is the posterior ligament complex

14:24

or the posterior tension bend.

14:25

And there are three types. B one

14:27

and B two involves the posterior group

14:29

and B three involves the anterior group.

14:31

The anterior tension bend injuries are extremely rare in the

14:35

absence of the FUS or ankylos spine.

14:38

So we will not go into detail of the B three, however, B one

14:41

and B two are very, very important injuries which we learn.

14:43

And last but not the least is the translation injuries when

14:46

one vertebral body moves in relation to the other ral body

14:49

and that is called the type of injury.

14:51

And there is one C type.

14:52

So either translation is present or absent.

14:56

So A and B one

14:59

injuries are single level injury are called mono otic

15:02

injuries while B two and C are adjusted level injuries.

15:07

So what we'll do today is we'll try

15:12

to learn the basic principles

15:14

of systematic search pattern on CT without going into the

15:18

detail of this classification.

15:20

However, this morphology what we'll learn will help us

15:24

to use any of the classification system

15:27

your surgeons are using.

15:29

So based on the morphology,

15:30

the fracture morphology depends upon the failure mode

15:33

of the final column

15:35

and fracture morphology can be compression fracture,

15:38

which primarily involves the anterior columns burst

15:41

fracture, which involve anterior plus middle

15:43

column distraction injury.

15:45

It is a tension bend injury,

15:47

it can involve posterior tension bend

15:49

or anterior tension bend.

15:51

As I told you that the anterior tension bend injuries are

15:54

extremely rare, only seen in patients

15:56

who have OSE with a fuel spine.

15:58

So majority of the tension bend injury you will see in your

16:01

practice involve the posterior tension bend,

16:03

which is called distraction injury.

16:05

And last but not the least is the translation injuries

16:07

where all three columns, anterior, middle,

16:09

and posterior columns are involved.

16:11

So basically at the end of this presentation, you'll be able

16:14

to confidently decide the morphology

16:17

of the fracture into one of these four types based on

16:20

how they are seen on the seat side.

16:22

So let's see, four different types of uh, uh, fractures.

16:26

The most severe is the fracture dislocation as I told you

16:29

that in this one vertebral body moves

16:32

or the spinal column moves in front

16:35

of the vertebral body which is injured.

16:37

So this is translation injury.

16:38

And this translation injury can be vaginal plan,

16:41

can be in coronal plan or a plan.

16:43

So most severe type of injury the

16:47

the second most severe type of injury is

16:49

what is called flexion distraction.

16:51

It used to be called a chance type of fracture.

16:54

And this is the type of injury

16:56

where the posterior column failed due to the tension.

16:59

So it's called tension failure due to distraction

17:01

because the, the the,

17:03

the parts get separated from each

17:06

other vertically gets separated.

17:07

That is what distraction force is.

17:10

Compression forces will bring the part together

17:12

so it'll result in the collapse

17:14

of the vertical body while destruction forces will separate

17:17

the parts, uh,

17:18

either at the ligamentous level or bony level.

17:21

And that is what we are going to learn.

17:24

The third type of fracture, which is the least severe type

17:27

of fracture, which is called compression injury

17:29

and it primarily involved the anterior vertical body

17:32

and it only involves the anterior column

17:35

and the fourth type of injury, which is the birth fracture,

17:38

which is primarily due

17:39

to exhale load inflection injury which involves both

17:42

anterior and middle column of the tennis.

17:46

So the in terms of the the

17:48

translation injuries are more severe

17:51

then the posterior column that is a distraction injury.

17:53

Then the worst injuries

17:55

and the least severe injuries are the

17:57

we compression fractures.

17:59

So when you are looking at the ct, you can start

18:01

with the birth injury

18:02

and then go to the next worst injury, then the bad injury

18:06

and then the not the bad injuries, right?

18:08

So that way you can go ahead

18:10

or you can go the reverse where you start

18:12

with the best injuries

18:13

and then you go to the more severe injury,

18:15

more severe and the worst injuries.

18:17

So let's see how to look at it.

18:19

Okay, so first thing is when you have a ct, what I do is

18:22

that the coronal and sagittal reconstruction bone windowing

18:26

and uh, we look at the 2.5 millimeters section

18:29

and first we look for the alignment

18:32

and alignment is look for to diagnose type C injury,

18:35

which is the translation injury in the AO classification.

18:39

So how to look for the alignment on the,

18:41

by looking at this smooth code arc type

18:44

of lines which connects the anterior vertebral body,

18:47

which is called anterior vertebral line.

18:49

The green one is the posterior vertebral line,

18:51

the red one is the final laminar line

18:53

and the last one is the interspinous line.

18:56

So we look at this four lines very similar to

18:58

what we see in cervical spine in terms

19:01

of alignment on coronal images.

19:03

We look at this lateral vertebral line which connects the

19:06

lateral part of the vertebral bodies

19:08

and this will help you

19:09

to decide whether there is a translation in

19:11

the coronary plan or not.

19:12

So this is how we look at the translation injury in a

19:15

systematic such pattern on a cd.

19:17

How do we look at the distraction of the posterior column?

19:20

So distraction of the posterior column involve the posterior

19:25

vertebral arch and as you can see it here,

19:29

so it involves the neural arch.

19:30

So one is the pedicle, two is the past,

19:33

intraarticular three is the superior articular process.

19:36

Four is the inferior articular process, this is the lamina

19:40

and this is the spina process.

19:42

So any fracture involving any of this three thick structure

19:47

which has a orientation.

19:50

So if this fractures are horizontally oriented,

19:53

which can be seen on the sagittal CT

19:56

or can be seen on a coronal cd, those are the signs

19:59

of the distraction injury.

20:00

So distraction injury can be bony or ligamentous or mixed.

20:04

When it's a bony injury, any of the six structures

20:07

of the neural arch can fail

20:09

because of the transverse fracture

20:11

because there is a distraction forces.

20:14

What else can happen apart from this fracture?

20:17

The because of the ligamentous injury,

20:19

the facet joint capsule ligament when injured,

20:22

it'll result in the diastasis subluxation

20:25

or dislocation of the face joint

20:26

and faceted joints are seen best on the TAL

20:29

or the exile images.

20:32

The other ligament, when the intra spinous

20:34

or supra spinous ligament is disrupted,

20:37

that will result in the widening

20:39

of the interra finest distance.

20:41

How to look for interspinous distance widening.

20:43

So suppose this is the index level

20:45

where you are looking at the widening.

20:47

What you have to do is that you have

20:49

to measure the intraspinal distance above the level

20:52

of the index and you have to measure the index,

20:55

the interspinous distance below the level of the index

20:58

and then you have to average out

20:59

and suppose this is 10, this is 12, average will be 11.

21:03

So if at the index level, if this is more than 11,

21:06

that is a sign of a interspinous widening

21:09

and it is an indirect feature

21:11

of the posterior ligamentus complex.

21:16

The third type of injury,

21:18

which is the wedge compression injury,

21:19

which involves the anterior column, we look for five signs,

21:22

which is called sclerotic line parallel

21:25

to the vertebral end plate.

21:26

So those sclerotic line are seen somewhere here.

21:29

Then we look at the depression

21:30

or the veg of the vertebral body seen by the loss of height.

21:33

We look for the deformity of the vertical end plate

21:36

and I'll show you the example of it.

21:37

We look for discontinuity cortical how to look

21:41

for the birth fracture.

21:43

Fracture is compression fracture of the middle column.

21:46

Okay, so what you have to do, so

21:48

whenever there is a birth fracture,

21:50

the fracture line which was adjacent

21:52

to the vertebral end plate, extend to the posterior cortex.

21:55

So whenever fracture line extend to the posterior cortex,

21:58

that is the definition of the birth fracture.

22:02

So this posterior cortical line once extend,

22:05

you can see on the al image, you can see on the exile image

22:07

as you can see here, normally the posterior cortex is very

22:11

smooth and slightly concave.

22:13

So when you see loss of this smooth outline

22:15

or there is loss of this normal concavity sign

22:17

for birth factor, when birth factor is severe,

22:19

you can get two other signs

22:21

and that one sign is widening

22:23

of the inter particular distance.

22:25

How to measure inter particular distance.

22:27

Again the same rule it suppose this is the index level,

22:31

you have to measure the inter particular level above it

22:34

and inter particular distance below it, you average it out.

22:37

And if at the index level, same uh, example 10

22:40

and 12, so average is 11,

22:42

if at the index level your inter particular distance is more

22:46

than 11, it's a sign of inter particular distance widening.

22:50

That is one of the signs of a severe type

22:53

of birth fracture which you'll learn.

22:54

And last but not least,

22:56

birth fracture can also involve a neural arch.

22:59

However, unlike distraction injuries in birth fracture,

23:03

the injury which happens in the neural arch has more

23:07

vertical orientation, unlike in distraction injuries

23:10

where the orientation

23:12

of the neural arch fracture is more horizontal.

23:15

And we are going to see the examples of both

23:17

of them as we move ahead.

23:19

So this is about how to look for these injuries on a CT

23:23

and now we look at the details.

23:24

So four types of injuries either start from the most severe

23:28

and go to the list severe vice versa.

23:30

So let's start with the lead severe type of injury

23:32

and that injury is called compression injury In EO

23:36

classification, this can injury has been given grade A

23:40

one or a two.

23:42

So let's see how it looks like.

23:44

So what we see the several times we have to look

23:47

for is dense sclerotic line.

23:49

So you can see this nice dense sclerotic line.

23:51

There is a depression, how to look for the depression.

23:54

So again, same way if you look at the EB body height

23:57

below it and if you see that the vertical body index level

23:59

is lower than the variable body height

24:01

below it is probably depressed.

24:03

So that is a depression deformity.

24:05

As you can see, superior endplate is deformed

24:07

and you can see that there is a buckling of the cortex

24:10

and there is a discontinuity of the cortex

24:12

as you can see on the on the AAL images,

24:14

coronal images, andal images.

24:16

Now you have to remember that one

24:18

of the characteristic feature of burst fracture of

24:21

what are the characteristic feature

24:22

of the compression fracture is

24:24

that the fracture line does not extend

24:28

to the posterior cortex.

24:29

Okay? So the line stops somewhere

24:31

before the posterior cortex is reached.

24:33

And so use a smooth posterior cortical line on the axial

24:37

images is preserved.

24:40

Let's see an example on this video.

24:42

Okay, so look at this uh, video,

24:45

but what we are seeing here

24:51

is this nice sclerotic line.

24:53

There is loss of vertebral body height loss,

24:55

how many levels you see this sclerotic line.

24:57

So you can see multiple level,

24:58

this vertebral body is abnormal,

24:59

this veritable body is abnormal,

25:01

this veritable body is abnormal.

25:02

There is a step here, there is a deformity here,

25:05

there is a superior end plate compression is there.

25:08

However, none of these places this line is extending.

25:12

You can see that this line does not extend

25:15

to the posterior cortex

25:16

and that is the characteristic features

25:19

of this compression injury.

25:21

And this are described as a one slash a two.

25:24

The A two compression injuries will have a vertical split.

25:27

So if you see a vertical split, which is corona

25:32

oriented like this, that will call type of fracture

25:35

or a two type of fracture, again, a two type

25:37

of fracture is relatively rare.

25:39

So most of the injuries,

25:40

what you see is a one type of fracture.

25:44

The second type of injury, what we have

25:46

to describe is the birth fracture.

25:48

Birth fracture occur due toxi loading

25:51

and flexion in different uh, uh combination.

25:55

And what does it do is birth fracture will result in

25:58

compression of the anterior column

26:00

and quite often it can result in either compression

26:04

or distraction of the posterior column.

26:06

So everything in the spine,

26:08

the morphology depends upon three things.

26:10

One is the vector, the fourth vector.

26:13

So the fourth vector, how much magnitude

26:16

of the fourth vector cru of the fourth vector

26:19

and the direction of the fourth vector.

26:21

So if the po rim is in the vertebral body,

26:26

anteriorly rim is in the central part.

26:28

Pulm in the in the posterior part of Pulm is much anterior

26:31

to the ral body with the same magnitude,

26:34

different morphology of the injury happens.

26:38

But having said that, birth fracture is

26:40

where the exit loading injury predominance.

26:44

The burst fracture is a type of a compression fracture,

26:47

exhale load and and flexion.

26:49

90% of the burst fractures occur in T nine to L five

26:54

with more than 50% occur at the cortical lumbar junction.

26:58

What is the AO definition of burst fracture?

27:01

Birth fracture is when end plate is fractured plus posterior

27:06

cortex extension of the fracture is there.

27:08

Posterior cortex can buckle, can retro post

27:11

or just do nothing.

27:13

So let's see the example. Okay,

27:14

so in this example you can see that there is a

27:18

wedging compression.

27:19

So this is a normal vertical body

27:21

and this vertical body height is reduced.

27:23

There is a cortical step

27:24

and there is this fracture line which

27:26

is this sclerotic line.

27:27

So there is uh, a type of injury, compression injury

27:32

even at a two.

27:33

If this line does not extend to the posterior cortex.

27:36

However, in this patient that this line is extending

27:38

to the posterior cortex

27:40

and as I told you, normally the posterior vertebral body is

27:43

smooth or slightly concave.

27:46

However, here you can see

27:47

that the posterior vertebral cortex is conve button like a

27:52

pregnant belly appearance and this is very characteristic

27:54

feature of a birth fracture.

27:56

What does AO suggest?

27:58

AO suggest that you'll call something

28:00

as a birth fracture when endplate is involved.

28:03

So here in this case superior endplate is involved

28:06

plus posterior cortex.

28:08

So superior end place plus extension of the fracture

28:11

to the posterior cortex is enough to

28:14

classify it into a three A four.

28:17

However, once the fracture extend to the posterior cortex,

28:21

the posterior cortex may buckle posterior cortex,

28:24

may fragment posterior cortex, may retro pulse.

28:26

Lot of things will happen and that is where the severity

28:29

of fracture comes into place

28:31

where a three can be differentiated from a four.

28:35

When you look at the egg wheel,

28:36

the birth fracture is a characteristic feature

28:39

of the combination.

28:40

So you can see that multiple vertical body is not only

28:43

compressed, there is a combination

28:45

and this CD fragments are radially displayed

28:48

that another I showed you previously the normal

28:51

posterior vertical cortex.

28:52

Here you can see that the posterior cortex is irregular

28:55

and this is again a characteristic

28:57

feature of birth fracture.

28:58

On axial images, previous years when TAL images were not

29:01

available, people used to rely on the A images to diagnose.

29:04

Nowadays we hardly look at the axi images tally everything

29:07

what you need to uh know will tell you.

29:11

So birth fracture is the fracture involving vertical

29:14

and plate plus posterior cortex

29:15

and there is posterior cortex buckling

29:17

and loss of smooth uh, smooth posterior cortex.

29:20

So what are the spectrum of the burst injury?

29:23

So as per ao, as I told you, birth fracture is when either

29:27

superior or inferior

29:29

and plate is involved plus posterior cortex is involved.

29:32

However, there are other features of birth fracture

29:34

as well like a compression fracture which I showed you.

29:37

So vertebral body shows compression variable type level

29:40

of compression fracture extend to the posterior cortex,

29:42

which you already described.

29:44

Lots of posterior vertebral body height loss.

29:46

So as you can see in this example on your left,

29:49

the posterior vertebral body height is not

29:52

significantly lost.

29:53

However, in this example the posterior vertebral body height

29:57

is significantly lost.

29:58

So this is where the severity of birth is coming into place

30:02

and how we differentiate a three prong,

30:04

a four EEO classification.

30:06

Then what happens is that I told you that retropulsion

30:09

of the posterior cortex or posterior cortex buckles if it's

30:13

more severe, there is retropulsion commutative fracture

30:16

with centrifugal displacement.

30:18

I showed you all the centrifugal displacement.

30:20

So the best centrifugal displacement will be seen on

30:23

the exile images.

30:25

Neural arch can also fracture

30:27

however the neural arch is fractured.

30:29

It has a vertical orientation of the fracture.

30:31

Unlike the fracture injury which has more

30:34

of a horizontal orientation of the fracture

30:36

and vertebral body on coronal plant,

30:38

quite often split in sagittal plant.

30:42

So sagittal split is one of the characteristic features

30:46

of ex exhale loading, not necessary burst fracture

30:49

but burst fracture is a prototype of exel loading.

30:52

So whenever I see sagittal split in the vertical body,

30:56

I know that sagittal splitting is best seen

30:58

on coronal images.

30:59

So when we see the sagittal splitting of the vertical body,

31:03

you know that the exhale loading has happened.

31:05

So vertical body split into two parts right and left half

31:08

and last but not the least into a particular distance is

31:11

widened, which I already explained you how to look for.

31:14

It is inter particular distance about the level of the index

31:17

below the level of the index averages out and wider.

31:20

Just a practical tip, it's very difficult

31:22

to measure a two level and then

31:24

to average out a lot of hard work.

31:25

So what I do in lumbar spine as we know that

31:29

as we go from top to bottom,

31:31

inter particular distance normally widen.

31:34

So if the index level inter particular distance is wider,

31:39

then the vertical level below it, it is an indirect

31:44

or it is one of the signs

31:45

that inter particular distance is widen.

31:46

So you don't have to measure a two level

31:48

and then to average out because it's not possible in a busy

31:51

trauma center to go through all of this.

31:53

So just look at easily the inter particular distance at the

31:56

index level, the level below.

31:57

If it's wider than the level below, it's a sign of a

32:00

of a severe birth.

32:03

So what does birth cause?

32:04

The birth cause end plate fracture plus posterior coex

32:07

extension and plate fractures.

32:10

Now we come to how to differentiate a three from a four.

32:14

So if only one endplate is involved it's a three.

32:18

If both the end plates are involved, it's a four

32:21

and we'll see the example of course it goes

32:23

through the poster cortex, it goes through the combination

32:25

of the fracture with centrifugal uh, displacement.

32:28

Whenever you see inter particular distance widening

32:31

and the vertical lanar fracture which I showed you they

32:35

quite seen in

32:39

fracture can also have a posterior column

32:42

distraction which we're going to launch shortly.

32:44

So let's see an example of how burst fracture looks like.

32:48

So let's see the images

32:51

as I can show you here.

32:53

So you can see that in this patient there is a loss

32:57

of height of this vertebral body as you can see it here,

33:01

okay the anterior cortex has buckled here,

33:03

the fractures involving the superior plate

33:05

and the vertebral body and you can see that compared

33:07

to the vertical body about vertical body.

33:09

Uh uh below. Okay, now we'll go more corona.

33:13

And here you can see that this fracture line is not only

33:17

extending to the posterior cortex, there is a

33:26

so as I told you on on sagittal images,

33:29

your posterior cortex should be smooth straight line

33:33

or slightly concave line like this

33:36

whenever you see this pregnant belly like buckling of the,

33:39

so what I tell my resident,

33:41

if you see like distal radius tous fracture like fracture

33:44

of the posterior cortex of the vertebrae, that is the sign

33:47

of a burst fracture.

33:49

So this is one of the mild type

33:51

of birth fracture as you can see here.

33:52

The inferior plate is Ben.

33:54

So this fracture is only involving the superior end plate.

33:57

This is an example of a three type of a birth fracture.

34:02

Let's see how it looks on the coronal.

34:04

So as you can see on the coronal images,

34:06

the fracture is involving the superior endplate fracture is

34:09

involving the posterior cortex, which is not very wealthy.

34:12

The inter particular distance at the index level is not

34:14

wider than the inter particular distance below it

34:17

and there is no vertical laminar fracture.

34:19

So this is a very classic example of a mild type

34:22

of birth fracture on veal.

34:24

When you look at this, you will see this nice smooth

34:27

posterior cortex at non fracture level compared to the,

34:30

at the level of fracture where you see this posterior cortex

34:33

as the zaggy and irregular

34:35

with all the centrifugal displacement

34:36

of the combinated vertebral fractures.

34:40

This is another example of a more severe type

34:42

of a burst fracture.

34:43

You can see that there is a significant loss

34:46

of vertebral body height.

34:47

Superior end plate is involved, the fracture is extending

34:50

to the posterior cortex.

34:52

The posterior cortex is also broken

34:55

and there is this buckling

34:57

or the TAUs like deformity of the posterior cortex.

35:00

I'm going more vertically down

35:02

and now at this level you can see

35:03

that the fracture is also involving the inferior cortex

35:07

and the posterior vertebral body height is also lost.

35:10

So what are the characteristic feature of a four type

35:13

of burst frac in EO classification?

35:16

Few findings. First of all, it involve both the vertical

35:19

and plate, how to look

35:20

for both vertical and plate involvement.

35:22

The best is to look on the coronal.

35:24

So when you go coronal you will see that the both vertical

35:27

and plate, you'll see this

35:28

through and through fracture here.

35:29

So that is the involvement of both superior

35:32

and inferior vertical and plate.

35:33

You will see that the posterior vertical body height will be

35:37

lost compared to the A three vertebral, a three type of post

35:40

where the posterior vertebral height is reduced

35:43

or often normal or slightly reduced.

35:45

However, here you see significant loss

35:46

of posterior vertebral body height block.

35:48

There will be a significant retropulsion

35:51

and when you look at the posterior column you will see the

35:54

inter particular distance widening as well as the widening

35:57

as well as the vertical laminar fracture.

35:58

So let's see, what are the signs what you saw?

36:00

So this was a fracture which was

36:02

extending the posterior cortex.

36:03

So it's at least burst, at least a three.

36:06

There was retropulsion, there was this combination

36:09

and axial uh uh, plan with centrifugal distribution.

36:12

Posterior vertical height was lost,

36:14

then the fracture was extended, the posterior cortex

36:17

and then you can see the both superior,

36:19

inferior and plate wherein one.

36:21

So birth is not a single fracture though IC says birth has

36:24

two points and single fracture.

36:26

AO says that birth is a three and a four,

36:28

but even a three has a spectrum, even a four has a spectrum.

36:32

The birth can be can be said

36:33

as stable versus unstable in complete versus

36:36

complete mild versus severe.

36:37

In tix it'll just birth in ao it's a three and a four.

36:41

And in AO the birth has a third component which is called

36:44

birth with PLC plus,

36:45

which you'll learn little bit later how to locate it.

36:48

So in a three only single endplate is involved

36:52

with posterior wall in a four both endplate vertical laminar

36:55

fracture in particular widening though inter particular

36:58

whitening and particular laminar fractures are not uh,

37:01

the described findings in a four.

37:04

So AO says that if both end plates

37:06

are involved, you call it a four.

37:08

However, whenever there is a a four,

37:11

you will invariably see vertical LA

37:12

manufacture in the particular wideness.

37:14

So let's be an example. So the example on your left

37:17

shows a mild birth.

37:18

How do you know that? So because factories extending

37:20

to one endplate and posterior endplate,

37:22

as I see there is some posterior height lock

37:25

but not significant compared to compared

37:28

to that to the vertical bowel.

37:29

However, you can see the severe birth,

37:31

both hand plate are superior

37:32

and inferior end plates are involved.

37:34

There is a significant loss of posterior height.

37:36

There is a significant retropulsion.

37:39

When you do the coronal you will see the superior inferior

37:42

endplate extension.

37:43

When you look at it, you will see the widening of the

37:47

intra particular distance I told you is the inter particular

37:49

distance as index level is wider than the level below.

37:52

It is a sign of widening.

37:53

And then you see this vertical laminar fracture which is a

37:56

sign of an A four.

37:57

So now we are clear how

37:59

to differentiate a three from a four.

38:01

So burst again has multiple phases,

38:03

single versus both vertical and plate.

38:05

Uh, posterior variable high plus variable,

38:07

more retropulsion, more combination posterior column

38:09

involvement, a particular widening.

38:11

So this is what is described as vertical laminar fracture.

38:16

It's one of the characteristic features of the birth.

38:19

What does it signify?

38:20

It suggests that this birth fracture is severe.

38:23

There is a possibility of a dural tear

38:25

because this dura might pinch inside this, this uh,

38:29

uh uh, the fracture.

38:31

However, you have to remember that

38:33

whenever you see this vertical laminar fracture don't call

38:36

this birth fracture as a three column fracture.

38:38

It doesn't make it a three column.

38:40

Three column fractures are the more severe fracture in terms

38:44

of instability.

38:45

However, in this patient with vertical laminar fracture,

38:49

the posterior column has failed in compression when

38:53

posterior column fails in the distraction,

38:56

when the tenile failure occur,

38:58

that is the time you call it a three column fracture.

39:01

However, this becomes more of a three column injury,

39:04

but it is not as unstable injury

39:06

as we'll learn in the three column injury.

39:08

Okay, so this does not automatize a lot

39:10

of reports of radiology.

39:12

Different places where they say that birth fracture

39:15

with posterior column fracture.

39:17

So it's a three column, very highly unstable injury,

39:19

which is a wrong way of putting it.

39:21

In birth fractures are operated primarily not

39:24

because they are unstable, primarily

39:26

because they cough neurological instability And we'll learn

39:29

a little bit later on in our session.

39:31

Okay, so what to report when there is a burst fracture?

39:34

First of all, call it a burst fracture,

39:36

at least eight three, how to call it end

39:38

plate plaque posterior cortex.

39:39

Then you describe how ated the fracture is,

39:42

how retro pulses the posterior cortex is,

39:44

how much is the central canal compromised,

39:47

how much fragments are displaced,

39:49

whether the fragments are rotated or not.

39:50

And we'll just see an example of reverse particle sign

39:53

and what is happening to the posterior ligamentus complex.

39:56

So this is what is called reverse particle sign.

39:59

And what has happened is that this fragment has,

40:02

so this is an A four type of birth fracture

40:04

and this fragment has gone

40:06

inside the spinal canal called significant

40:09

spinal canal canop.

40:10

However, this fragment has rotated 180 degree.

40:15

So the cortex is in the front,

40:17

which should be on the posterior part

40:18

and the trabecular bone is behind.

40:20

So this is a sign of a reverse particle sign.

40:23

Extremely important sign

40:24

to mention in a burst fracture it suggests posterior

40:27

ligamentous disruption,

40:29

PLL posterior longitudinal ligament disruption.

40:31

This patient need to be approached

40:33

by the anterior approach decompression corpectomy needs

40:36

to be done and Cajun graft needs to be put in this patient,

40:39

unlike the other birth fracture which can potentially be

40:42

treated from the posterior approach as well.

40:45

Again, we'll leave this to the fine

40:46

trauma team, how to do that.

40:48

Okay, look at this.

40:50

This is how the frac fracture is retro pulse,

40:53

but the posterior cortex is still posterior so you can see

40:57

that the posterior cortex is still posterior.

40:59

This is normal. However, here you can see

41:02

that the posterior cortex, what you see this T margin

41:05

and the here is the cortex.

41:08

So this is called reverse. So it'll flip 180 degree.

41:11

A very important sign

41:13

to describe in your report about reverse cortical sign.

41:16

It is a lot of surgical implications.

41:19

Burst can also occur with posterior column distraction.

41:23

So, so far I showed you vertical lanar fracture,

41:25

which was a injury of the compression injury.

41:27

However, bur can also have a posterior ligament complex

41:31

injury as you can see here, anteriorly birth

41:33

but posterior, you can see that the facet joints are wide.

41:35

There's a transverse fracture through the spine of process.

41:38

So these are the hybrid type of birth

41:40

and that we'll learn more in the fracture, dislocation, uh,

41:43

in the, in the fracture, uh, distraction,

41:46

the chance type of fracture.

41:47

Okay, so what what,

41:49

what have we learned about birth burst is not a single type

41:53

of fracture at telex mentioned burst is a

41:55

heterogeneous group of injuries.

41:57

Even AO could not categorize into more than two types

42:01

because a three is a spectrum.

42:03

A four is a spectrum burst is commonly considered

42:07

as a mechanically unstable.

42:08

However, it's not always the case

42:11

Burst is birth is treated not because it's unstable

42:14

but primarily because it causes the neural

42:16

spinal penal compromise.

42:18

And there is another classification

42:19

for burst fracture, which is important.

42:21

If you are seeing a lot of, if you're working with lot

42:23

of spine trauma people, you should be learning about this

42:25

load sharing score, which you are not going to dis

42:28

and central co compromise canal compromise is a dynamic

42:32

process, um, and not aesthetic process.

42:36

Our births are managed, okay?

42:37

So the birth can be divided basically into two types.

42:39

Births with neurology, they are by

42:41

and large surgically treated our birth without neurology.

42:45

A four severe A four are treated surgically quite often

42:49

A three are often treated non-surgically.

42:51

A four with reverse particle time is invariably treated

42:54

surgically with the anterior approach.

42:56

When there is a significant spinal canal compromise,

42:59

some surgeons treat uh, this even without neurology, A four

43:04

with B injury.

43:05

Any posterior command complex distraction are unstable spine

43:08

and those patients are treated uh, uh, with the surgically

43:12

and kyphosis or progressive kyphosis

43:14

on on follow-up imaging.

43:15

These patients are treated. So these are the,

43:17

the signs which I described by this signs are the signs

43:20

of mechanical instability, uh, while neurological,

43:24

whenever it's present they need to be.

43:26

So what is the, what is the important thing to learn

43:29

that each injury morphology is not black and white.

43:32

It's a spectrum of injury and spectrum of severity.

43:35

A three is a spectrum, A four is a spectrum.

43:38

Describe them rather than just giving them a name.

43:41

Okay, so give them a name at the end

43:44

but describe them well in the body of your report.

43:46

The third type of injury which is now we are moving

43:48

to the more unstable injury,

43:50

which is called the flexion distraction injury,

43:52

which are given B one and B two in the EO classification.

43:56

So basically distraction injury will separate the

44:00

final column vertically so bones

44:03

or ligaments will move away from each other

44:05

tearing them apart.

44:08

As I told you, because of the biomechanic, most

44:10

of the time the tension failure occurs in the posterior

44:13

compartment and quite often this posterior compartment

44:16

tension failure is associated with the compression injury

44:20

of the anterior compartment.

44:21

So what you will see is anterior compartment has a type

44:24

of injury and posterior compartment is B type

44:26

of injury and we're gonna see it.

44:28

So flexion destruction are called chance

44:30

or chance like fractures.

44:32

Seatbelt fracture postal column fails in distraction

44:34

anterior middle column fail inflection 50% of chance

44:37

or chance like fracture iCal lumbar junction

44:39

and almost one third to one half

44:41

of the fractures have associated intrabdominal injuries.

44:44

Now you have to remember that the chance

44:46

describe this fracture in 1948 much before the CT

44:50

and his paper in British Journal of Radiology it consists

44:53

of one and a half page only three injuries

44:55

and he said that this are the pure bony injuries.

44:57

However, there were no CT scan

45:00

or MRI available to say that

45:01

what he told was actually bony injury or ligamentous injury

45:04

because quite often in real life we see very rarely pure

45:09

bony chance which are B one injuries.

45:11

So majority of real life chance injuries are B two injuries

45:15

which are ligamentous injury or mixed injuries

45:17

and that is why they're called chance like S

45:20

or chance variance.

45:22

So posterior tension bed failure,

45:24

which is the AO type B can occur through the bone,

45:28

which is a transverse fracture of the posterior element,

45:30

which is called B one

45:32

or it happens through the ligament, which is called B two

45:35

or it involves both bones

45:36

and ligament in which case it's also called B two.

45:39

So either pure ligament tests

45:40

or boney plus ligament test is called B two.

45:43

While pure osseous injuries are called B one which are

45:46

extremely rare or relatively rare, there is one

45:50

M1 modifier in AO classification

45:53

and same where there is a modifier in telex as well

45:55

where we are not sure even

45:57

after doing a ct, even after doing an mr.

45:59

If you are not sure whether the PLC is injured

46:02

or not, you call it indeterminate P PLC or M1 modify.

46:05

So just put M1, we'll learn how to do that.

46:08

Anterior injury can be veg

46:10

or bus, any type of a one A to a three or a four.

46:14

The posterior tension bend injury when there is a bony

46:17

chance CT is better than MR for ligamentus chance.

46:20

My personal preference, I prefer to look at the CT

46:23

for ligamentus injury

46:25

and we will see how to look on the CT for ligamentus injury.

46:28

MRI you can directly see the ligament

46:30

however, quite often you see edema which

46:32

makes it indeterminate.

46:34

So my personal preference is CT is better than MRI.

46:37

In describing the ligamentus injury

46:39

of the posterior ligamentus complex

46:41

MRI will overestimate the ligamentous injury.

46:44

So the edema is not equivalent to ligamentous disruption.

46:49

So B one the bony is mono segmental injury,

46:52

it involves single segment B two is mixed

46:54

or ligamentous injury is involved.

46:56

Two adjacent segment and anterior posterior injury can

46:59

at a different levels.

47:02

So how to look for this?

47:03

So on fractures you have to look for horizontal fractures

47:06

of the neural arch for ligament.

47:08

What are the signs of the posterior

47:10

ligament of complex injury?

47:12

If you see a local kyphosis more than 40,

47:14

if you see regional kyphosis more than 25 joint DIA sub

47:19

location increase intraspinal distance

47:21

or if you see MRI edema fluid

47:23

and dispen, let's see all of this one by one.

47:26

So first of all how to measure the the

47:28

the regional hypothesis.

47:29

The regional hypothesis is measured if this is the index

47:32

vertebrae, you go to the one vertebral level

47:34

above superior endplate

47:36

and one vertebral level below inferior endplate

47:38

and you measure the angle between these two,

47:41

which is called cobs angle.

47:42

If this cob angle is more than 25,

47:45

it is an indirect evidence

47:47

that this can happen only if the posterior

47:50

ligaments are distracted.

47:52

Let's see the example. So you can see

47:54

that there is a significant,

47:57

the the regional photic angle is more than 25 degree.

48:00

So even if this looks like a burst, this happens

48:04

only when the posterior ligaments are distracted

48:07

and there is a PLC injury.

48:09

Same way you can see that there is a vertebral body high

48:12

loss or vertebral body high loss

48:13

of more than 40% in a patient with normal bone density.

48:17

So I think this is very, very important thing to know

48:20

that all of the signs are useful when the

48:23

bone density is normal.

48:24

So these rules do not apply

48:26

to osteoporotic compression fractures in which you can have

48:30

a much worse photic angle with preserved posterior complex

48:34

or much worse lock of height

48:35

with preserved posterior complex.

48:37

However, in young patient with MVC,

48:40

if you will see the local photic angle, uh,

48:43

regional photic angle of more than 25

48:45

or if you see the vertical body height loss

48:47

of more than 40 degrees, that is a sign

48:50

of a severe posterior ligamentous complex indirect injury.

48:54

This is a local photic angle, how

48:56

to measure it from the superior vertical

48:58

and plate to inferior vertical and plate.

49:00

If this angle is more than 40 degree, that is a sign

49:03

of uh uh, uh, uh uh posterior ligamentus complex.

49:07

Look at some of the signs.

49:08

What are the other signs when you look at

49:10

for the interspinous distance widening, again,

49:13

interspinous distance at the index level is wider than the

49:16

average of the above and below.

49:17

And same way if you see any horizontal

49:20

fracture of the neural arch.

49:21

As you can see in this patient, horizontal fracture

49:24

of the par intraarticular horizontal fracture

49:26

through the lamina horizontal fracture,

49:28

inter the the spins process

49:30

and widening of the interspinous ligament passage joints

49:34

as you can see in this patient, uh, is a sign

49:36

of joint position is a sign such the joint dislocation is a

49:39

sign of this and any horizontal fracture

49:42

to the posterior column is a sign

49:43

of a posterior ligament of injury.

49:45

So when you're reporting what to report, first

49:47

of all mention whether it's a boney with a single level

49:51

or B two mixed with adjacent level ct.

49:53

The fracture you look for the fracture and the displacement.

49:56

MRI you look for edema fluid discontinuity.

49:58

If you're not sure at M1

50:00

and always describe the vertical body wedging

50:03

or birth, describe separately in AO eight one to a four

50:05

and we'll see some the example.

50:07

So let's see two examples, uh uh uh, in this patient.

50:10

So what's happening in this patient, as you can see here,

50:12

this patient has a significant loss of EB body height.

50:16

Anterior vertebral body height loss is more than 40%.

50:19

If I measure a photic angle, it'll be more than 25 degree.

50:23

That is a sign of a posterior column destruction.

50:25

You can see the superior vertical endplate has a fracture

50:28

which is extended to the posterior protex.

50:30

So that will make it a three, which is this vertebral body.

50:32

This vertical body is L one.

50:34

So you describe L one then a three.

50:37

So that means L one EB body has a three type of a fracture.

50:41

You go behind what you see here, you can see

50:42

that there is a significant widening

50:44

of the inter interspinous distance.

50:47

What you do next you go

50:48

and you can see that there is a transverse fracture

50:50

through the pedicle and the posterior element.

50:53

So there is a B one component, bony component,

50:55

there is a ligamentous component.

50:56

So it's a mixed component. If we go to B two,

50:58

let's look at the coronal what's happening in the coronal

51:00

anteriorly, you will see that there is a a three type of a

51:04

fracture of the of the uh, uh, of the vertebral body.

51:07

And as you go behind you can see transverse to fracture

51:10

through the pedicle laina and there is a distraction

51:13

and there is an interspinous wide.

51:15

So this level is called the E 12 L one.

51:19

So what you write in AO classification, you write T 12,

51:22

L one, P two and then you say L one A three.

51:26

So this is how the final report of

51:29

you will look like if you are losing a AO classification.

51:33

Otherwise you'll just say

51:34

that there is a detraction injury at T 12 L one with bony

51:38

and leg aus component

51:39

and there is a burst fracture predominantly involving the

51:43

superior end plate without significant retropulsion

51:46

suggestive for bile burst fracture.

51:48

Whatever way it works with your fine surgeon,

51:50

if they're using EO classification, this is what you write.

51:54

So B two fracture is always adjacent level B one fracture

51:58

or a fracture is mono single level.

52:01

I hope this is clear. So again, look at the same example.

52:04

Interspinous widening transverse fracture

52:06

to the posterior column, transverse fracture

52:08

to the posterior column anterior there is a wide uh,

52:11

significant loss of height.

52:13

Photic angle is more than 25 again transverse fracture,

52:15

the posterior column on the coronal transverse fracture

52:18

to the posterior column, transverse fracture

52:19

and wide spinal system.

52:21

So that is what you'll hear.

52:22

So if injury morphology has a spectrum of the B RT

52:26

and goal is to describe them rather than to name them

52:29

and remember that you can have more than my one

52:31

type of injury present.

52:32

So reporting tips is

52:34

that injury morphology are often mixed more than one injury.

52:37

Morphology is quite frequent.

52:39

When there are combined mechanisms,

52:41

each injury should be classified separately

52:43

with more severe injury return first.

52:45

So in the previous case, B is more severe than the A.

52:48

So right about the B first

52:50

and then the A, if multiple level of injuries are involved,

52:53

different level, each level injury is assessed independently

52:56

and separately and telex.

53:00

So telex, if more than one injury is present,

53:02

the single injury with the largest score is used

53:04

for in previous patient what you will say

53:07

distraction injury and PLC plus.

53:09

Okay, so three point per distraction injury

53:12

and three points four uh uh PL plus.

53:15

So six points in AO you will write exactly what we say T 12,

53:19

L one B2 and then T and L one A three.

53:23

So that is what you do in the ao.

53:25

So this is another example probably will not go through it

53:27

but it's a very similar example what I showed you.

53:35

Last type of fracture pattern is fracture, dislocation

53:38

or the translation type of injury,

53:39

which is the most severe injury.

53:42

It is described as AO type P

53:45

and in in tix also it is the type is

53:47

one of the worst injuries.

53:49

What happens the one vertebral level vertebrae entirely

53:53

as a column move in front of the other.

53:55

So you can see that there is a translation

53:58

of this vertebral body over the anterior translation

54:00

of more than 50% here.

54:02

So this is the fracture dislocation, the type

54:04

of fracture on plant.

54:06

Here there is a coronal plan translation

54:09

and here there is an veal plan translation.

54:11

So these are the different type of translation injury, some

54:13

of the most severe type of injury.

54:15

What are the other features which will always be

54:17

there in fracture dislocation.

54:19

So you will have either a facet joint dislocation

54:21

or fracture or facet articular facet fracture.

54:25

Posterior column quite often extracted and A LL

54:28

and PLL have quite often a stripping type of injury.

54:31

So all of these are one of those severe most type

54:34

of injury you will see in your day to life.

54:35

So there is a pass fracture

54:37

or uh, all the superior radicular facet fracture and A LL

54:41

and PLL stripping or the injuries are there.

54:43

Multi-ligament multis segmental, it's a very severe injury.

54:47

Most of these patients have a severe neurologic as well.

54:49

Now my residents quite often, like I tell them

54:52

that translation pitfall is not

54:54

so don't mistake the retropulsion with the translation.

54:58

So you can see in this example this vertebral body is

55:01

fractured and it is moving backside.

55:03

So it looks like this vertebral body has moved in

55:06

front of this vertebral body.

55:07

So quite often when you start interpreting you call it enter

55:10

assistive of five, four, three, two, one LT 12 over L one.

55:15

However, if you ignore the injured vertebra

55:19

and draw the smooth curve, you can see that the T 12

55:22

and L two vertebral body are normally aligned

55:25

and only the L one vertebral body has retropulsion.

55:29

So this is retropulsion,

55:31

which is not equivalent to translation.

55:33

Retropulsion is less severe injury compared to translation.

55:36

In translation what should happen,

55:39

ignore the vertebral body which is injured, draw a line

55:43

below the ver vertebral injured vertebral body

55:46

and draw a line above the injured vertebral body

55:48

and see whether the final column above the injured

55:51

and below the injured ignoring the injured vertebral body

55:54

are aligned or not.

55:56

Then that is the sign of a translation injury.

55:58

So retropulsion is not retro.

56:01

Quite often when retropulsion is there,

56:03

it looks like this vertebral body has mood in front

56:06

of others, but that is not the case.

56:10

So when to do an M-R-I-M-R-I is done with any spine trauma.

56:13

Who has a positive neurology in the absence of neurology?

56:17

When do we do MRI Translation injuries,

56:20

which is very unlikely

56:21

because translation injuries will

56:22

invariably have a neurology.

56:24

If you see any distraction injury on ct,

56:27

we invariably do M mri, so both B one and B two.

56:29

When you see severe compression injury A four, we,

56:33

we usually do the MRI to upgrade it to the PLC,

56:37

uh, which will be B grade.

56:38

And all patients who are going for surgery,

56:40

we invariably do p invariably do the MRI.

56:44

What we look for an MRI, we look for the spinal canal.

56:47

The spinal canal should have the nose

56:49

and the CSF, anything other than that.

56:52

So if you see the bone inside the spinal canal,

56:54

if you see blood in that inside the spinal canal,

56:56

that's abnormal product cord

56:59

or now root compress is abnormal.

57:01

If chord is compressed

57:02

and it shows abnormal signal, that's also abnormal.

57:05

We look for the ligaments on the spine.

57:07

Uh, uh, MRI

57:09

and ligaments can have edema discontinued to fluid.

57:11

And as I told you that the CT is far better than MR

57:14

looking for the bony injury.

57:16

It is quite good for ligamentous injury as well,

57:20

and presence of edema is not equivalent to ligament injury.

57:24

So MRI quite often does not contribute that much,

57:27

or MRI quite overestimates the injury.

57:31

And so, uh, uh, uh, you have

57:33

to take the RI finding the pinch.

57:35

So, and MRI can show you that this injury.

57:37

So look at the example. So this is a nice example

57:39

of normal posterior ligament complex.

57:41

So this is very useful.

57:43

MRI, if you are not sure on the CT or PLC

57:45

and you do an M-R-I-M-R-I shows this jet black type

57:49

of posterior ligament is complex.

57:50

I'm very sure that this ligaments are normal.

57:52

If I see edema of the posterior ligament,

57:55

it doesn't take me anywhere.

57:56

It goes to the indeterminate inte, I save 0.2, two points.

58:00

That's indeterminate in ao. I say M1 modified indeterminate.

58:04

If I see fluid, that is a sign

58:06

that this ligament is injured.

58:08

If I don't see a ligament

58:09

where I should be seeing it's a sign of a injury

58:11

that makes it a ligament as injury.

58:14

You can see that multi-ligament injury in this translation

58:17

type of fracture with this injury as well.

58:20

So I think approach

58:22

to MRI in a spine injury is a different topic altogether,

58:26

and probably, hopefully sometime later we'll do a,

58:28

a separate session on how to approach

58:31

a systematic search pattern of MRI in spine trauma.

58:35

Uh, but today my main concern was the CT

58:38

scan and that is what we did.

58:39

So what we do at the end of, uh, the, uh, your, uh, uh,

58:42

presentation, my presentation ct look for it.

58:45

First look for the sagittal coronal axial plan for ssis.

58:48

If the SSIS is present,

58:49

if the type C factor fracture dislocation,

58:52

if alignment is normal, look

58:53

for the posterior column distraction present,

58:55

then it's B type of fracture.

58:57

Decide whether B one or B two, no distraction.

58:59

Look for the look for the retropulsion

59:01

or the involvement of the posterior cortex.

59:03

If it's present, it'll make it burst,

59:04

which is a three A four,

59:06

and if it absent, makes it a one A two.

59:09

The take home points are systematic search pattern

59:11

and checklist based approach to detect, differentiate

59:21

that which CT features will predict PLC injuries,

59:24

including kyphosis, including body height loss,

59:27

including the, the posterior neur large fractures

59:30

and the widening of the distances.

59:32

Understand when to use ct.

59:33

So CT is used pretty much in every high velocity injury

59:36

patient, um, as a first line imaging MRI used when there is

59:40

a neurologic, uh,

59:41

neurologically patient is unstable when the ligaments are

59:45

expected to be injured or as a problem solver.

59:47

Radiographs are used as a screening in low risk patient,

59:50

low velocity injury,

59:51

and they're used quite often as a post-op follow-up to look

59:54

for the worsening of the kyphosis.

59:56

Uh, I recommend all of you to go through my paper, um, um,

59:59

um, our paper in 2016, um, uh,

60:02

about tho lumbar spine injury.

60:04

And all of this, uh, principles are described as well,

60:07

and I would be happy to take the questions.

60:09

Yeah, thank you so much.

60:11

Thank you so much Dr. Ranga for that awesome lecture.

60:14

Appreciate it so much. Thank you.

60:17

We will open the floor to questions now,

60:19

so if you've got those, please place them in

60:22

that q and A feature. Okay.

60:24

Uh, do you have c Okay,

60:26

do you have CT examples of fractures?

60:29

I think, uh, I have already shown the examples of fractures.

60:33

Right. Okay. Excellent. Thank you. Okay, thank you.

60:38

Thank you. So well, I don't see much of the presenta. Yeah,

60:42

There's a lot of compliments.

60:44

Okay. Yeah, they're just compliments. Okay.

60:47

Uh, okay, so there's one question,

60:48

no history or prior images.

60:50

Can you share features to differentiate acute versus

60:52

chronic compression fractures?

60:53

No. MRI available, uh, uh, well, this was honestly not, uh,

60:58

the, the, uh, goal of my presentation,

61:01

so I did not describe it so well.

61:03

But, uh, there are well described features

61:06

to differentiate acute for chronic compression fractures,

61:09

but most of those fractures occur in osteoporotic, uh, uh,

61:13

setting low velocity, low risk type of patients.

61:17

So, uh, we start with x-rays,

61:19

and then on x-ray, we look for, um, uh, the,

61:22

the sharp definition of the vertical end plates.

61:25

If I see all the vertical end plates really clearly, um, uh,

61:30

uh, usually those are the chronic factors.

61:32

If you're not sure MRI is something which is a problem

61:35

solver in this type of patient.

61:36

So quite often if patients have acute pain, uh, and fall,

61:40

and if I'm not sure, so when I look at the radiographs,

61:43

I describe my findings in three ways.

61:44

Sometimes I'm quite sure this is an remote or old fracture.

61:48

Sometimes I'm quite sure this is an acute fracture.

61:50

Sometimes I'm not sure. I'll just call it in a minute.

61:53

And we do an MRI. Yeah. Uh, thank you. Uh, oop.

61:57

Uh, yeah. Okay. Uh, no history, no priors.

62:01

Okay, fine. So I think I'm just looking at, um, okay,

62:06

a disc, uh, spondylitis, uh, how can we diagnose it?

62:09

Well, again, um, uh, this was not spondylitis, uh,

62:13

or the disc, uh, uh, infection.

62:16

So probably, we'll, we'll keep it some other day.

62:20

Um, I Why Tix gives three points

62:22

to translation if it's more severe than the Yeah,

62:25

I think they, they're a little bit, uh, I, I,

62:28

I completely agree.

62:29

So Helix has added that, uh, additional, uh,

62:33

injury morphology, which they call it rotation.

62:36

And this translation

62:37

and rotations are not very easy

62:40

to differentiate on morphology,

62:41

and that is where telex has poor inter

62:44

and intra observer reliability.

62:47

So telex has this problem, particularly in this 0.3

62:50

and 0.4, the which

62:52

to call translation in which to call rotation.

62:54

And they say rotation is worth in translation.

62:57

However, the AO has removed that part completely,

63:01

and as we now know that most

63:03

of the translation have rotation component.

63:06

So quite often you have compression injuries,

63:08

which are a type of injury, distraction injuries,

63:10

which are B type of injury,

63:11

and then you have translation rotation.

63:13

So that's where AO made it a little simplified

63:16

to make it slightly better reliable classification.

63:20

But I completely agree with, I struggle to

63:23

put three versus four, when to call it rotation

63:25

and when to call it a, a translation.

63:27

I, I I I'm with you, like, so, uh, so that, that,

63:30

that's the problem with the helix.

63:32

Would Kai four, Platy ver osteoplasty be advised in patients

63:35

having such injuries or crew of uh, well,

63:38

that's a very good question,

63:40

and the people have tried using kyphoplasty

63:44

and vertebroplasty in some of the mild birth fracture

63:47

with pain and some of even severe birth fracture also.

63:50

But as far as, uh, it is still more of an experimental,

63:54

majority of the centers still do some form

63:58

of spinal instrumentation, if at all,

64:01

surgical intervention needs to be done.

64:03

And majority of the center still uses the posterior

64:05

instrumentation with or without fusion.

64:07

Um, uh, and some,

64:09

sometimes they use anterior mix type of it.

64:12

But I agree with you, people have started doing kyphoplasty

64:15

for even traumatic, uh, uh, compression fractures as well.

64:19

Yes, but it's still not, the, the literature is not, uh, uh,

64:23

uh, uh, in a, in a huge quantity.

64:25

Um, or, or probably, uh, I haven't come across,

64:28

but, uh, I agree with, uh, you that, uh,

64:30

the people have started doing that.

64:32

Causes of stir hyperintensity. Okay.

64:34

How to differentiate causes

64:36

of stir hyperintensity endplate due

64:38

to modic changes of fracture?

64:41

Uh, uh, well, uh, that is, uh, so

64:45

quite often the interior endplate practice,

64:49

I'm very sure on the CT scan,

64:51

and it will be a bit of a challenge, uh, to differentiate

64:55

if the patient had modic type one changes, um, um,

64:59

and at the same time trauma

65:00

to differentiate it confidently all the time.

65:03

Having said that, the modic type changes occur more, uh,

65:07

in the central end plate with the anterior cortex

65:11

and the superior end plate anteriorly posterior intact.

65:14

So if the cts can show the fracture,

65:17

which involves the anterior corner

65:20

or entero superior corner, uh, those are more likely

65:23

to be related to the fracture.

65:25

So I told you density dis uh, depression, uh,

65:29

discontinuity, all those five d if those five Ds are there,

65:33

probably that is the sign

65:35

that this was a compression factor.

65:37

And, uh, uh, uh,

65:38

but, uh, honestly, I haven't come across a patient

65:41

who had a modic type one change

65:43

and fracture at the same level.

65:45

And, and, and we, we, we had this issue to differentiate

65:49

posterior tension bend.

65:51

Can you please repeat the component anatomy wise

65:53

and where it's relevant?

65:55

So the tension bend has two component.

65:58

One is called posterior tension bend, which is everything

66:01

behind the posterior ligamentous injury,

66:03

posterior tension posterior ligamentous complex posterior

66:06

liga longitudal ligament.

66:08

The posterior tension bend has two component,

66:09

the bony component, which is a neural arch,

66:12

which includes pedicle par articular,

66:15

superior articular facet, inferior articular facet lamina

66:18

and spinal processes and transverse processes.

66:21

Neural arch plus posterior longitudinal posterior ligament

66:25

complex PLP together makes the posterior tension bend.

66:28

So this ligaments include facet joint capsule,

66:31

interspinous ligament, supraspinous ligament,

66:34

and the, uh, the ligamentum flavum.

66:37

So this four ligament

66:38

and this seven neural arch component together,

66:41

11 things together makes the posterior tension bend.

66:45

The posterior tension bend is important because

66:48

because of the spine biomechanics, quite often it happens

66:51

that the anterior column

66:53

fails in compression while the posterior column

66:55

opens up in distraction.

66:57

And so when posterior tension bend is injured,

66:59

they are described as type B injuries in ao,

67:03

and those are the severe unstable injuries.

67:05

And quite often this patient undergoes the surgical

67:07

intervention, whether you call it retros

67:12

or lysis.

67:14

That's a good question. So spine is the only place

67:16

where we describe the moment of the

67:21

proximal spine in relation to the distal spine.

67:24

I don't call soap. So if, if, if a spine has,

67:28

if L three has more in front of L four, I call it ssis

67:33

of L three over L four, rather than retro

67:36

of L four over L five, L four over L three.

67:39

So unlike rest of the extremities, so in extremity practice

67:42

and dislocation, the displacement

67:45

of the distal part is described in relation

67:48

to the proximal part.

67:49

However, traditionally in fine the displacement

67:52

of the proximal part is described in relation

67:55

to the, the distal part.

67:57

That's number one. When a single vertical body is collapsed

68:01

and moves inside the spinal conal, I don't call it,

68:06

I call it retropulsion, so that's just the word

68:09

to describe it, but when I say retropulsion, I know

68:12

that I'm describing just the moment of the injured

68:16

vertical body rather than the moment of the entire spine.

68:19

So retro andis,

68:21

when the entire final column move in relation

68:25

to the final column below,

68:27

while if only injured level is moving,

68:30

we call it retropulsion, that makes it easier.

68:33

And at the end of the day, you have to talk

68:36

with your spine surgeons and what their understanding is

68:39

and try to tailor or report based on that

68:42

and their understanding,

68:43

and you try to make sure that what you understand is exactly

68:48

what you understand, uh, when you call it.

68:51

Okay. Where, uh, okay. Thank you. Oh, uh, thank you. Yeah.

68:56

Uh, uh, do you mention the percentage

68:58

of variable body height loss in compression factor?

69:00

Yes, we do. So, so how do, how do we do it?

69:04

So anterior vertebral height loss, what I do is

69:06

that vertebral height loss at the index level compared

69:11

to the vertebral height level above, below an average.

69:15

So for example, if the level above is, is, is 20

69:20

level, below is 30, average of both of them is 25.

69:24

And if my index level is supposed 10, so

69:28

10 in a percentage of 25, it's whatever percentage loss

69:32

of height I just calculated, sometimes it's eyeballing.

69:36

As I told you, in a busy trauma center,

69:38

you may not have time to look at this, so you basically know

69:41

what comes to around 40%.

69:43

So basically anything you describe about 40%

69:45

doesn't make a big sense.

69:47

So two things to look

69:48

for first is whether the bone density is normal or not.

69:52

A bone density is normal.

69:53

Any vertical body high loss more than 40%

69:56

is slightly less than half, like slightly less than half.

69:59

More than 40% is a time

70:02

that the posterior column must be distracted.

70:05

So that means that when interior vertebral body compressed,

70:09

you'll imply

70:10

that most likely the posterior ligament complex is

70:15

distracted or injured and there is a potential failure.

70:18

So yes, we do that, uh, in, in our report

70:22

with continuity to above question list.

70:24

This is always described vertebra above with,

70:27

but if the index fracture body is considered,

70:29

the nomenclature would change.

70:31

So yes, as I told you, we say retropulsion not

70:34

to create confusion with retrolisthesis or lysis

70:39

and how to differentiate between PLL dis disruption versus

70:43

PLL lifting no, uh, came.

70:45

So that's the very good question.

70:47

Uh, uh, in other than fractured dislocation,

70:51

PLLs are very uncommonly disrupted ligaments.

70:55

Uh, they're one of the very strong ligaments, uh,

71:00

most of the time PLL

71:03

as a stripping from the vertebral body.

71:06

So as I told you that

71:09

MRI search pattern is a different topic altogether,

71:11

and today I did not have enough time to concentrate on what

71:14

to look for an MRI, but, uh,

71:16

hopefully we'll do it sometime later.

71:18

However, having said that, majority of the patient

71:22

with anterior compression injury, you will see

71:25

that the PLL view will see in continuity,

71:28

but that is stripped off from the posterior vertebral cortex

71:33

except for the translation injuries, where you will see

71:36

that there is a discontinuity of the PLL.

71:39

Uh, the second thing is I told you about the reverse

71:42

cortical spine, which I described in the,

71:44

in the birth factor.

71:45

And they say that when you see that reverse cortical sign,

71:49

that's an indirect evidence of PLL discontinuity.

71:53

So that's a very important, uh, sign to describe.

71:55

Uh, and quite often

71:58

you will not see this PLL discontinuity even on MRI

72:01

for reverse cortical sign is the only sign which will be

72:05

present, which will tell you

72:06

that there is possible PLL disruption, okay?

72:10

In system, the gold standard for classification, uh, uh, uh,

72:15

well, that's a very good question.

72:17

Uh, unfortunately no, um, none of the classification is,

72:22

is, is is better than the other classification system.

72:25

It all depends upon how you

72:30

unify your language

72:32

and communicate your finding to your surgeon.

72:35

So at the end of the day, you have to understand

72:38

how much your surgeons understand this, this classification.

72:43

So if your surgeon is using a particular classification,

72:47

for example, TEIG

72:48

or ao, then you try to use those classification system.

72:53

Having said that, more

72:55

and more people are moving towards using AO teig.

72:58

So as I told you, 2013, uh, modification of ao,

73:03

which is given by the same group,

73:05

which gave the telex in 2005, so this 20 2013,

73:10

it is called AO telex classification,

73:12

and I think that is probably currently

73:14

available classification system.

73:16

It's the best available system.

73:18

However, it all depends upon, uh,

73:21

so many places in North America,

73:22

they have started using AO system.

73:25

The hospital where I work, they don't use AO classification.

73:28

So I, I try

73:30

to describe my findings based on if this was an AO

73:34

classification, how I would've described

73:36

that without ultimately giving that numbers like P 12,

73:40

L one, B two, and then TL one B three

73:42

and a three and things like that.

73:44

I don't give those numbers, but then I put in description

73:47

what exactly that mean.

73:49

Uh, by putting it so places

73:51

where they use the EO classification system in structured

73:54

report and impression at the impression they just put like

73:57

this T 12, L one, B two, L one, A three, and that's it.

74:01

Everyone understand. And then if there is a modify,

74:03

they put M1, so the, the, the spine surgeons understand,

74:07

but if your trauma surgeons do not use it, uh,

74:10

they're not using it, then probably better not to, uh,

74:14

give them this, uh, uh, numbers.

74:16

Uh, and don't confuse them then in that case,

74:18

give them more description, sit with them and,

74:21

and tell them what they are looking for

74:22

and try to answer this question.

74:24

Yeah, and um,

74:27

putting it simply injury of PLC is a distraction.

74:31

Absolutely. This is exactly the simplest way of putting it,

74:34

is that injury of PLC detraction injury.

74:37

Our distraction injury has three component.

74:40

One is pure bony, which used to be called chance

74:43

bony plus ligament test, which is mixed

74:46

or pure ligament test, which is B two.

74:49

So pure ligamentous B two

74:50

and bone plus ligamentous B two are called the

74:55

distraction injury or the PLC injury or the tensional

74:58

or the tension band failure.

75:01

All of this are synonym.

75:02

Having said that, I must tell you

75:04

that B one injuries were chance described,

75:06

which we are not sure whether he actually described B one

75:09

or not, but we are presuming

75:10

that he described B one based on the X-rays available at

75:13

that time and only three patients.

75:14

So we say that in our real life,

75:17

I hardly ever hear B one fracture.

75:19

All of my B one fractures are actually B two fractures.

75:22

So they, they have always have ligamentous component,

75:25

very rarely pure B one fracture.

75:27

So, uh, but what you are understanding is correct,

75:31

but it can have a bony component also.

75:34

Okay, thank you Yasser. Thank you.

75:37

Uh, retropulsion on cranial epidural set.

75:40

How you assess the prognosis?

75:42

Well, again, as I told you, uh, that retropulsion, you have

75:47

to say how much is the retropulsion

75:49

and what this retropulsion is causing to the spinal canal.

75:53

So what you have to say that while moderate figure,

75:56

if you can, if you can arbitrarily divide that retropulsion

76:00

or you say that with retropulsion

76:02

with spinal canal compromise less than 50%

76:06

or more than 50%,

76:08

or you say that minimum spinal canal AP

76:10

diameter is this much.

76:13

So either you put it,

76:14

either you put it at percentage based on the spinal canal

76:16

diameter level above and level below,

76:18

or you say that final canal diameter is reduced

76:21

by approximately this much percentage,

76:23

or you say that the minimum spinal canal diameter at the

76:26

level of the worst retropulsion death m Now at this point,

76:30

I must tell you that retropulsion,

76:32

what you see in image is not the actual retropulsion which

76:36

happened at the time of trauma, right?

76:37

The actual retropulsion, which happened at the time

76:39

of trauma, is quite often much worse

76:42

than what you see on images.

76:43