 So we got a patient RS who was 29 years old who is 39 now who fell from the roof two days before he came for admission to AIMS. He did not become unconscious he fell somewhere in the hills that wall or somewhere and his complaint was inability to move both lower limbs and loss of sensation below the nipple levels on the chest and when he came to us he was on a foley's catheter so somebody attended to him on the casualty one of our residents and he noted down all these things that the patient is alert he's oriented there is some tachycardia mild so the BP is a little less maybe 90 or 100 he looks a little bit pale there is no head injury there is no external laceration or anything any bleeding or sutures no apparent cranial nerve deficits the power in the lower limbs is 0 by 5 and the upper limbs are normal 5 by 5 the sensory loss below D3 the reflexes are 2 plus in the upper limbs and absent in the lower limbs the planters are mute and there is no other injury so what mental picture does this is it enough for you want some more information can you reach a diagnosis with this history there is a sensory level there's a clear-cut sensory level so there's something happening at D3 the segment D3 and he's got zero power in the lower limbs so there seems to be something severe happening at D3 remember it's two days it happened two days ago he's been the same since two days so what do you do x-rays so I've cropped this x-ray but this x-ray was done in the casualty and the resident told me sir I can't make head or tail of this x-ray but something seems horribly wrong in this x-ray why don't you try can you see something cervical thoracic this is T2 so this is cervical thoracic should be somewhere here what's the most obvious thing which you can see okay let me point out what's the axis of the spine this is the axis of the spine and what's the axis of the spine here do you see what is happening it's completely dislocated this is a spine which is dislocated at this level the rest of the spine is following here down and the upper spine is here so what is this what has happened the spine is completely dislocated and lying so there's some rotation as well it's lying by the side so what do you do so I said okay show me the x-ray so he showed me the x-ray so what I did will come later but what will you do well this was a chest x-ray it showed some contusion in the lung I've just cropped it there were no other fractures CT scan CT scan off head neck thorax believe me MRI is the last thing you want in this patient look at other places also I mean such a massive injury this is a massive injury and whenever there is a massive injury you must look everywhere and that's what we did so this is all the questions which are already asked you and we actually did a cervical spine x-ray and well anything wrong in this patient fracture and dislocation what is fractured and what is dislocated odontoid fracture so there is an odontoid fracture here you can see that and it's got displaced posteriorly so now you have an intact patient upper limb wise neurology does not show this complete paraplegia zero power in the lower limbs with a horribly dislocated thoracic spine the x-ray showed this so what do you do now he's come traveling from there are doing for 600 kilometers in bullock cart I don't know tractor bus train nobody even knew he had an odontoid fracture nothing happened to him and now you're panicking nothing is going to happen to him believe me if he has traveled all the way here without knowing nothing is going to happen to him you want to reduce his story you can fix it that is a better answer so we put him on traction and this is what happened after traction so now you have a patient with traction very well reduced in fact it's good in line with a horrible thoracic spine injury now what do you do that's we did this before because we didn't know the x-rays were not seen before how many times it happens you patient goes for x-ray comes out of x-ray the CT is next door so he goes for CT before anybody sees the x-ray he's got a CT done so we had a CT so it just confirmed whatever it was so let me just complete the picture for you this is the before the traction after the traction and this is a CT complete CT of the thoracic spine okay so you here you have the other cuts as well anything interesting here this seems to be display anything anyway this was done before the reduction so once it is got in position I don't know what happened to this but this is a red flag there's not a simple odontoid fracture there is this thing is also shifted because you could see on the x-ray the whole thing was shifted anteriorly so the C1 C2 joint or I don't know with joint this C2 C3 so it is shifted so what do you do how do you manage this patient I've given the choices posterior for dorsal spine you will go and fix the dorsal spine posteriorly and the cervical spine and the same sitting posterior you won't attempt an odontoid screw or you'll do an anterior for the odontoid fracture and a posterior for the thoracic spine I've had all kinds of answers I've got these answers from the audience responses they're not my own these are all experts who have a point so all these choices are there first choice you'll do posterior for both you will do anterior odontoid screw why so do you need to actually do anything for the dorsal spine that is what you're saying yeah I've had people arguing that as well what do you think should we do anything for the dorsal spine yeah some people believe that it should be stabilized some people believe there's no point but what the literature says is if you leave it without stabilizing then the pain is horrible the post of injury pain post-traumatic pain that incidence is definitely reduced with reducing this dorsal and fixing it so if not for anything else then for that reason one can attempt posterior surgery but anterior I'm more interested in the anterior part so one person said I'll do everything from the back he said he'll do it from the front and not think about the dorsal spine in the first instance but is there any other reason why you would like to do anterior there is a reason which I thought of I thought that I don't have to turn the patient for an odontoid he's lying supine I don't have to do anything I just have to put him on the table and fix the odontoid so at least one part is taken care of because for thoracic spine I'll have to turn the patient and turning a patient who's on traction with an odontoid fracture can be tricky sometimes you can dislodge it then getting it back in position under x-ray under anesthesia sometimes can be difficult so I thought the simplest thing for me to do is while he's reduced and he's lying supine let me put an odontoid screw I thought the x-ray looks fine so I suppose it did move a little bit but it's come back so I'll show you all the pictures but this is how we reduce the dorsal part and I had to take the help of my orthopedic colleagues for this is an instrument which is found in old spine theaters nowadays I I mean the orthopedics people have it this kind of distracts the spine it pulls it apart like that which you don't see it it's not there in our theater so once you hitch it here and you hitch it here and then you just jack it like that rotate the screws and it pulls it apart they jacked it anyway the cord was injured horribly we had to we tried to repair the dura I don't think we were able to repair the dura we placed some fascia whatever we could lay I don't think we had glue no we had that German remedies glue that metallic thing like quick fix it used to be two things which you mix together and it hardens that one was available I think you use that somehow managed to control but the cord was completely transected you were right so there was no hope for this so we finally managed to get in the screws and get it at least in alignment properly and ultimately this was the result this is the pre-op and this is the post-op so it is 2005 so it's 10 years ago almost nine years ago and this is the x-ray and this is the x-ray now do you think something funny here I had to do that I had to do that that's my bad now why did I have to do it because I didn't pay attention or I thought oh it's come back in position and everything is fine after I put this I realized that what if it doesn't work there was no time to put a CT no time to get a CT no time to get an MRI we didn't vision was on the table we were operating and I said if the ligament is fractured because of this massive translation if the ligament is torn I'm in for trouble so before we went ahead with this part I told them okay you wait for another couple of hours let me get this thing done just to be on the safe side because what you know I was a bit slow at that time not fast enough reflexes so then I thought that maybe what you're saying is right I should have done that in the first place and not gone for the anterior screw at all maybe I could have just done everything from the back done this or maybe put in screws here and then gone ahead with the posterior surgery that would have also worked and then we looked at the more important thing or the lesson to be learned over here is of multiple injuries and then I looked at all the data we looked at 255 patients but we did not concentrate only on spinal injuries we also took head injuries because the patient is unconscious here this patient was conscious we knew that his neurology is here but in an unconscious patient it is even more difficult to assess so we looked at the moderate and severe head injuries in just one year and most of them were traffic accidents 26% of them were falls and the x-rays simple x-rays showed us spinal injury in 7.6% and a CT spine revealed 26.7% incidence of spinal injury which was undetected because the patient was unconscious so remember that this is a very important point in an unconscious patient look at everything because you may miss and then from then on it became a protocol in the trauma center with every moderate and severe head injury you have to scan the spine it's a protocol so that you don't miss anything the head injury may recover the extra dural may go away the patient may wake up and by the time you realize oh God it's horribly dislocated spinal injury that's why he's not moving is so take home message look before you leap in any patient with massive trauma and this is a very good example of massive trauma something which can dislocate the thoracic spine which is the most stable part of the spine because of the rib cage and the sternum and this and that if that can get dislocated that trauma was massive and there must be some other injury somewhere even if there is no neurology you must look at everything from the head to foot very carefully that's the most important and the simplest message you can have from this but this case is beautiful you can learn about anterior approach you can learn about posterior approach when to do what very nice learning case and that's why I always like to show this case because it can branch off into many things you can have the discussion go anywhere thank you very much