WEBVTT

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*This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.*

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the following is a medical media production from

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WRAMC-TV

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ladies and gentlemen,

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this session will deal with the

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upper cervical spine in childhood.

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It's actually a lot of the stuff will hold

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for adulthood and but I will

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concentrate primarily on the child.

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And uh one of the reasons I got

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interested in this area is because it was

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difficult for me to understand.

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And I think I find that

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after residents finished three or four years of

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training,

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if you could give him a diploma that says

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uh qualified and diagnostic run

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technology and will never have to read a cervical

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spine film for the rest of his life.

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He'll pay you double for that diploma

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and would be just as happy if they never had to look at another

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spine in their life.

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Isn't that right?

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I know I haven't seen 1/4 year resident yet that

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said that I really understand that cervical spine

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and that's one of the reasons I got interested

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because I was the same way.

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I mean I was hoping nobody would ask me anything like

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that on the boards.

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Uh it's not so difficult.

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The real big problem is that there are some normal

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variations that you might not be aware of in

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Children.

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But the real big problems are a bunch of weird

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anomalies that will work through slowly this

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morning.

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Now as I mentioned,

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some of this stuff will apply to an adult and I'll

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mentioned uh when the areas

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that this would pertain to.

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First thing our normal findings that cause

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problems.

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Now this is one of the first things That

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one ought to appreciate because I as a

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matter of fact,

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10 days ago had a telephone call from

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one of our former residents from a town

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city,

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small city in Texas.

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And he said,

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you know,

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we had a kid with a cervical

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C12 dens distance of

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four and I didn't know what to do about it.

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You know,

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the kid had stiff neck,

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he was in an accident.

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And The first thing you have to

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appreciate is this in an adult,

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the usual figure is if it's 2

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mm the space between anterior

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arch of C.

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One and the dens,

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you're probably okay.

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That doesn't mean you can't have a fracture.

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It just means it's not dislocated,

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it's not moved around.

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If it's 2.5,

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people will worry if it's three,

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everybody will agree that that ought to be abnormal.

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In 99% of cases that's in an adult.

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In a child,

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it's quite different.

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Obviously in infancy,

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it's going to be bigger because everything's under ossified.

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But in Children that are 78,

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10 years old.

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Very often this space is three

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millimeters and normal.

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I mean very often,

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I mean I can find you half a dozen of these a week

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in our institution Very often it will be three.

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Occasionally it can be four and occasionally it can be

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five and still be normal and this one is normal

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and this one will be about four.

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So you have to be careful you have to be careful.

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That's not to say that true.

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Dislocation like in this patient with

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rheumatoid arthritis of the spine and laxity

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of the joints between C.

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One and C.

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Two.

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You notice the space is much more than five there and

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on flexion here it opens up considerably.

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That's not to say that this doesn't occur and that's

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distinctly abnormal.

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But the thing is it can be

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Normal up to five.

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That's not gonna happen every day.

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But four is more common and three is

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really garden variety space.

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I can guarantee you that if you see a lot of

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pediatric films.

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So that's number one.

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Now here's another thing this

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will hardly ever come up

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unless you get an oblique spine.

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Or better still unless you have skull

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films for head trauma

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and you get a kind of an oblique cervical spine to go

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along with it.

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This is the sin condo sits sits anterior.

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It's the sin condos is between the arches and

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the body and dens of C.

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Two.

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You will see it only only on the

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oblique film and there it is there you can see the dents in the

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body and then there's the sink on grosses between The

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dense and body of c.

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two.

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But it's this thing right here,

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this oblique line that shows up on oblique

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views.

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Now this is what will happen.

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I don't know how the neurosurgeons are around your parts,

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but at our place,

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almost every place I've been,

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they don't come and see anybody unless he's got a

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skull and spine films.

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You know,

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whether he needs them or not.

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I'll tell you that right now he's got him.

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Part of it is because they're busy.

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Part of it is they don't want to miss anything for medical legal

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purposes.

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So you're gonna end up with skull and spine

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films and the kids probably going to be okay in the head

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and somebody's gonna notice this.

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And if you don't know that that's a normal simcon dross is

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seen only on a bleak view.

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You'll get sidetracked by that and you may end up actually

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polito ming and everything else.

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This is normal Silicon Drusus of C

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two.

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Now,

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very fortunately,

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I had a case like this,

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this is simcon Drusus and fracture and it makes a very good

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point.

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You see here we've got two arrows.

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Is that in focus there?

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Is that in focus for everybody.

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Okay?

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Now you've got a shouldn't give the

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secret away,

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but this is about 15 ft and I can't see too

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well just well enough at 15 ft

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to get my texas driver's license.

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That's all.

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But there are two cracks here up,

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interior is the simcon grosses and post

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your ear is the fracture through the arch,

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most of the times you're gonna get a fracture to the arch,

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it'll be poster to the sin Condra Asus,

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you know and you're not going to happen to come up with a film like this too often

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but there's the fracture and there's the sink and roses.

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But this is the point I want to make.

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If you see something on lateral view,

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do you see there's a crack here in the arch of

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C.

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Two.

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It's a fracture because you never see the normal

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simcon Drusus on lateral view because it's an

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anterior structure and you have two oblique the

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spine.

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So the important thing to remember there is if you see it

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on oblique and you don't see it on the lateral it ought to be

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the same condo sis you never see that sink.

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Andreas is on a good lateral film to

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normal findings so far the normal distances C.

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One to the dens and this Sin Condra Asus.

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Now posterior

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arch of C.

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One defects.

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Congenital defect versus fracture.

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How do you deal with this?

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Well,

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I have some of these diagrams which I've redrawn

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myself and modified after uh the

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diagrams as they appeared in the book by von

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torque lists and jelly.

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I think that's where you pronounce it is a good little book from

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europe and you can have a whole

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host of these arch defects very prone to

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it.

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How do you tell them apart from a fracture.

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Well first of all they look

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weird.

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That's a good way to approach it.

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They look strange.

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Here's a car accident or a motorcycle or

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something.

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I don't know what it was.

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It was a trauma case number one.

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There's nothing wrong here,

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right,

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because you can't have a normal curve to the cervical spine

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and have a whole lot wrong.

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You can't even have muscle spasm.

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Besides this girl could tell you if anything was wrong with her

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next,

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she'd say,

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uh huh.

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So you could have saved her all the trouble here.

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But we got some X rays and found this thing.

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And of course,

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if you don't realize that that's a big poster arch

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defect that's congenital,

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you'll get worried about it.

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First point then,

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weird.

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Second point,

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the bigger the defect,

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the more likely it's going to be a congenital

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defect.

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And the poster fragment is often bizarre

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appearing and very often triangular

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and tapering as you go up front here are two

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examples of poster arch defects,

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with the posterior fragment being

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triangular.

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Okay,

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now,

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if you're gonna have a fracture back there,

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it'll be an extension injury and it may be

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associated with other

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fractures of C.

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One usually is,

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but fractures if you will just remove this

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anterior line which is an artifact,

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there's a bilateral fracture here.

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Through the arch of C.

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One right here and right there fractures

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are narrow defects.

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They're straight,

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they may be unilateral or bilateral.

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There are there is no indication of any other

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anomaly.

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There's no peculiar looking C.

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one.

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There's no big gap.

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They're small,

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linear.

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Sometimes they're a little crooked like this over here,

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that's an extension injury with a fracture through

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the arch of C.

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One on frontal view.

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This patient also had a displaced lateral

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mass of C.

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One.

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This is an injury,

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they're fine,

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they're hardly ever Two or more than two

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in width.

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The gap just doesn't separate that much.

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So you're looking for a narrow,

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crooked or straight to defect as opposed

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to a big gap there with a triangular posture

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element.

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Now I'll show you how this becomes useful.

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This was a fortuitous case.

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And the next thing and these bright lights in

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front of me,

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if you really don't need them,

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you might dim them down because they're having trouble seeing

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these X rays.

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I can tell with these bright lights and so am I.

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Now,

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here's a patient is an adult with a

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car accident and a sore

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neck isn't that much better.

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Radiologists hate bright lights,

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don't they?

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I mean we were morning and evening

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people then we hide with our illuminator

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and so forth.

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And if the sun went out

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probably wouldn't bother us too much,

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you know?

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Um Thank

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you,

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that's much better.

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Now,

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here's a patient with a straight neck,

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okay?

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There's something wrong here,

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but you figure out what it is.

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And I was walking by the view box as well.

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The neurosurgeons were looking at this and

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this is a really interesting case because

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the neurosurgeon said,

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you know,

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I don't know there's pain but this,

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you know,

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just she didn't have that much trouble.

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This is a combination,

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a very good case to make our points here.

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# one,

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it does look triangular,

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doesn't it?

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It looks anomalous.

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What do we have here?

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Look closely at this next view,

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which is just slightly oblique.

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You have a fracture through a thin

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arch on one side,

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that's what's given her pain.

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And on the other side you have a congenital defect with

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a triangular components.

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So,

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you have here a hypoplastic

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C1 thin on one side,

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gap on the other side,

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the thin side fractured that's giving her pain,

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nothing else fractured.

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What does this mean?

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This means pain and spasm,

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but a stable spine.

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This requires minimal treatment.

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You know,

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you're not thinking of an unstable dislocating spine.

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We know why she's got pain,

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but we're not as worried as if we had a whole lot of

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fractures up there and instability.

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And I would tell you from the onset that your job in

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the cervical spine is not so much to do

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detect every little Snookie fracture in there,

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but to decide whether you got stable or

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unstable spine,

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that's the most important thing.

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So,

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don't forget,

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after you're finished looking at all the cracks and weird looking

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things and so forth.

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You have to say to yourself,

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is it stable or unstable because that's the only thing,

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the neurosurgeon or the Ortho pod,

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whoever usually looks after these things is

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interested in.

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This is a fracture,

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but it's perfectly stable.

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Nothing else with it had cuts in the frontal plane

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and nothing else associated with it.

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When you understand this,

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you can figure it out.

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And then the neurosurgery resident said,

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no,

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that makes sense.

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He was a senior,

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was a good man,

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he's a senior resident there were he was finishing up and

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and he said,

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now that makes sense.

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He said,

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I couldn't figure out,

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you know,

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the degree of clinical finding just didn't fit

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what we were seeing.

11:55.240 --> 11:58.240
This is just to round it out and to emphasize to

11:58.240 --> 12:00.920
you that C one comes off pretty

12:00.920 --> 12:03.910
funny looking a lot of times it is very prone to

12:03.910 --> 12:04.340
anomaly,

12:04.340 --> 12:07.030
hypoplastic and un united in the

12:07.030 --> 12:07.430
back.

12:07.430 --> 12:08.270
Very common.

12:08.270 --> 12:09.460
Nothing else wrong here?

12:09.940 --> 12:12.160
Very thin unilateral arch.

12:12.170 --> 12:14.980
It almost looks like some kind of aneurysm will bone cyst or

12:14.980 --> 12:15.580
something like that.

12:15.580 --> 12:17.990
That's just a thin unilateral arch.

12:18.000 --> 12:20.820
Incidental finding just found that I was going through a bunch of

12:20.820 --> 12:23.690
cervical spine films and three days ago,

12:23.690 --> 12:25.230
just before I came to Washington.

12:25.410 --> 12:28.060
This peculiar thing with an overgrown

12:28.070 --> 12:29.690
occipital condo here,

12:29.690 --> 12:32.290
see one fused to see to a most

12:32.290 --> 12:34.450
peculiar anomaly in a newborn.

12:34.460 --> 12:36.850
And I don't think this will lead to any difficulty.

12:36.960 --> 12:39.900
But it's just to emphasize that this area is

12:39.900 --> 12:42.660
really prone to anomalous formation and that's

12:42.840 --> 12:44.690
what's going to be our big problems.

12:44.690 --> 12:47.610
So we've covered some normal findings in the C.

12:47.610 --> 12:50.580
One area we've touched on anomaly and we would

12:50.590 --> 12:53.360
emphasize that this area is very prone to

12:53.370 --> 12:54.110
anomalies.

12:54.270 --> 12:56.810
Before I go onto anomalies of the dens.

12:57.440 --> 13:00.280
I would like to cover this which is kind of a pet

13:00.290 --> 13:03.060
topic of mine last year we had an

13:03.060 --> 13:05.990
exhibit on this at the at

13:05.990 --> 13:07.990
both the meetings Rank and Ray and R.

13:07.990 --> 13:08.150
S.

13:08.150 --> 13:08.280
N.

13:08.280 --> 13:08.430
A.

13:08.430 --> 13:11.290
And and I have a paper on this that should be coming up pretty soon

13:11.480 --> 13:12.730
in radiology.

13:12.740 --> 13:15.720
And the reason I mentioned that if you remember anything

13:15.730 --> 13:18.650
about this whole business about whether it's dislocated

13:18.650 --> 13:19.260
or not,

13:20.640 --> 13:23.170
Don't do anything until you make the

13:23.170 --> 13:24.540
observation that c.

13:24.540 --> 13:26.920
two is anterior early

13:26.920 --> 13:28.320
displaced on C.

13:28.320 --> 13:28.760
Three.

13:28.770 --> 13:31.750
Now don't forget that if it isn't don't bother with

13:31.750 --> 13:32.960
a line or anything else,

13:32.960 --> 13:33.750
I'm gonna tell you.

13:34.070 --> 13:36.890
It's designed to bail you out only

13:37.000 --> 13:37.750
when C.

13:37.750 --> 13:40.630
Two is anterior early offset displaced

13:40.640 --> 13:42.910
or dislocated on C.

13:42.910 --> 13:43.460
Three.

13:44.440 --> 13:47.070
Now that's I've found that since I presented this,

13:47.070 --> 13:49.480
people want to apply this line for everything.

13:49.600 --> 13:51.100
Don't do it unless C.

13:51.100 --> 13:53.130
Two is offset on C.

13:53.130 --> 13:53.590
Three.

13:54.240 --> 13:57.140
Now it's designed basically to tell you whether you've got

13:57.150 --> 13:59.940
true versus physiologic dislocation.

13:59.950 --> 14:02.860
Take this 14 year old motorcycle accident in the

14:02.860 --> 14:03.620
emergency room.

14:03.620 --> 14:04.870
See all this junk back here.

14:04.870 --> 14:06.580
He's laying down on the table.

14:06.580 --> 14:09.110
This is the film was taken cross table lateral.

14:09.250 --> 14:10.100
Now C.

14:10.100 --> 14:11.610
Two is offset on C.

14:11.610 --> 14:11.950
Three.

14:11.950 --> 14:12.330
Right?

14:13.040 --> 14:15.950
The question is should you move them and of

14:15.950 --> 14:18.890
course this is the one time when the neurosurgeon

14:19.440 --> 14:20.550
Ortho pod,

14:20.550 --> 14:22.460
whoever else would like your opinion.

14:22.940 --> 14:25.550
Not because he thinks it's so valuable

14:26.140 --> 14:28.950
because he wants to share the lawsuit with

14:28.950 --> 14:31.210
you don't get yourself.

14:31.210 --> 14:34.180
Not very often does he think your opinion is so valuable?

14:34.190 --> 14:37.080
I found that that it really doesn't make a deal read

14:37.080 --> 14:40.010
what they want out of the thing and I don't make any bones about it and

14:40.010 --> 14:42.570
what I say about him they deserve because

14:42.580 --> 14:43.760
whatever the you know,

14:43.760 --> 14:46.150
whatever the band plays they sing Stardust

14:46.410 --> 14:48.270
and that's true.

14:48.280 --> 14:51.150
Uh And uh I'm not gonna

14:51.150 --> 14:53.130
convince them but for our benefit,

14:53.130 --> 14:55.750
let me say you this that when you see this they're gonna

14:55.750 --> 14:56.350
ask you.

14:56.840 --> 14:59.790
So if you don't wanna up your premium you

14:59.790 --> 15:01.640
have to try to figure out whether they should move,

15:01.640 --> 15:01.850
you know,

15:01.850 --> 15:02.810
you can't tell them.

15:02.990 --> 15:05.390
Well how about move them just a little bit

15:05.400 --> 15:08.240
you know and uh they won't buy that

15:08.240 --> 15:08.830
stuff.

15:08.840 --> 15:10.910
So that's how I got interested in this.

15:10.910 --> 15:13.850
Well before we figure out how to bail us out out

15:13.850 --> 15:14.770
of this situation,

15:14.770 --> 15:17.640
let's look at something here in the in the childhood

15:17.640 --> 15:18.010
spine.

15:18.010 --> 15:20.480
This does not occur in adults for the most part this is

15:20.640 --> 15:23.160
Like 16 years and under for the most part

15:23.740 --> 15:26.470
if you extend there is no moral alignment

15:26.470 --> 15:26.800
right?

15:27.200 --> 15:29.310
If you flex very often you get C.

15:29.310 --> 15:30.470
To offset on C.

15:30.470 --> 15:33.430
Three like that sometimes three on four and four on

15:33.430 --> 15:34.750
five and then it peters out.

15:34.750 --> 15:35.710
So it may be step.

15:35.710 --> 15:37.810
Like now we've known this for a long time,

15:37.810 --> 15:40.700
it's been described and everybody is familiar with this.

15:41.340 --> 15:42.740
Where does the motion occur?

15:42.740 --> 15:44.240
It occurs through this joint here.

15:44.240 --> 15:46.460
Now compare it on this side and on this side

15:47.340 --> 15:50.320
with flexion there's a lot of motion occurs through the

15:50.320 --> 15:50.600
C.

15:50.600 --> 15:50.920
Two,

15:50.920 --> 15:52.740
C three above seal joint.

15:52.990 --> 15:54.360
And when this occurs,

15:55.300 --> 15:57.380
C two will slide forward on c.

15:57.380 --> 15:59.710
three and the body will look offset.

16:00.540 --> 16:01.730
That's how it happens.

16:01.830 --> 16:04.500
And that's how you create the thing number one,

16:04.500 --> 16:06.500
if you can get this much motion out of spine,

16:06.500 --> 16:07.280
nothing's wrong.

16:07.280 --> 16:07.640
Right.

16:07.640 --> 16:08.650
I mean it's gonna be hard,

16:08.650 --> 16:10.570
but I want to show you here,

16:10.730 --> 16:13.050
not that you have to flex the spine

16:14.240 --> 16:15.960
to use this line that I'm going to show.

16:15.960 --> 16:16.430
You know,

16:16.430 --> 16:17.220
that's not the thing.

16:17.330 --> 16:19.760
I'm only showing you how this occurs.

16:20.180 --> 16:22.860
This occurs inflection because of motion through C.

16:22.860 --> 16:23.550
23,

16:23.710 --> 16:25.320
A popsicle joint area.

16:25.540 --> 16:28.320
Now the thing that's important is look at the

16:28.320 --> 16:30.820
alignment of the posterior arches of C.

16:30.820 --> 16:33.430
12 and three in extension C

16:33.430 --> 16:36.150
two Is posterior to both one and

16:36.150 --> 16:39.020
3 in the neutral position.

16:39.030 --> 16:41.480
It maintains that configuration

16:42.940 --> 16:44.000
most important,

16:44.000 --> 16:44.610
however,

16:44.620 --> 16:45.740
with flexion,

16:46.020 --> 16:46.890
in other words,

16:47.140 --> 16:49.790
with the mechanism that produces C.

16:49.790 --> 16:50.840
Two and C.

16:50.840 --> 16:53.540
Three offsetting these three things come

16:53.540 --> 16:55.890
into almost a straight line

16:55.900 --> 16:56.680
alignment.

16:56.690 --> 16:57.950
Almost a straight line.

16:57.950 --> 16:58.430
In fact,

16:58.430 --> 17:00.850
most cases it'll be straight line in this one,

17:01.040 --> 17:03.830
it's just about a straight line And that's

17:03.830 --> 17:06.520
very important because I looked at a whole bunch of

17:06.520 --> 17:06.840
these,

17:06.850 --> 17:09.330
I mean it must have been like 500 or more.

17:09.340 --> 17:10.350
It's easy to do.

17:11.040 --> 17:13.960
Every chest film will have you a neck like this.

17:13.960 --> 17:14.270
You know,

17:14.280 --> 17:16.110
you can see it on 50% neck film,

17:16.740 --> 17:17.950
sinus skull,

17:17.950 --> 17:18.700
whatever you want.

17:18.700 --> 17:20.530
There's gonna be a little bit of cervical spine.

17:20.530 --> 17:23.130
So you don't have to have a cervical spine

17:23.130 --> 17:24.630
series to look at this,

17:24.630 --> 17:26.820
just look at anything with cervical spine on it

17:27.340 --> 17:30.060
and you'll find out that it is very difficult

17:30.440 --> 17:33.220
for a normal child to do anything else but a

17:33.220 --> 17:35.790
line that up into almost a

17:35.790 --> 17:36.710
straight line.

17:37.240 --> 17:38.560
Consequently,

17:39.840 --> 17:42.030
If you have C2,

17:42.370 --> 17:45.320
offsetting like in our friend in the motorcycle accident

17:45.740 --> 17:48.660
and you draw a line from the cortex of C

17:48.660 --> 17:51.050
one down to the cortex of C three,

17:51.640 --> 17:54.470
Take this line from here to here and watch what

17:54.470 --> 17:56.500
happens to it at Sea two.

17:56.670 --> 17:58.990
If it goes through C2 Cortex

17:59.540 --> 18:02.380
if it touches it or if it comes

18:02.380 --> 18:05.300
within one millimeter of the cortex of C.

18:05.300 --> 18:05.670
Two,

18:05.750 --> 18:08.520
I believe that the only thing you have is

18:08.520 --> 18:10.780
pseudo dislocation or in other words,

18:10.780 --> 18:13.270
you do not have an unstable spine.

18:14.540 --> 18:14.950
Now,

18:14.960 --> 18:17.890
once in a while I found that in a normal kid it

18:17.890 --> 18:20.870
would be a millimeter distance between the line

18:20.870 --> 18:21.390
and see too.

18:21.390 --> 18:24.100
And that's why I say a millimeter is probably

18:24.100 --> 18:26.880
still okay and I'm not a great measure,

18:26.880 --> 18:27.340
I'll tell you.

18:27.340 --> 18:30.180
But I would recommend to you that you do take the ruler out here

18:30.190 --> 18:32.900
and measure millimeters because it's going to become very

18:32.900 --> 18:33.460
important.

18:33.540 --> 18:35.590
As you'll see in just a few moments,

18:38.430 --> 18:39.680
I'll rephrase this.

18:39.940 --> 18:42.520
You must have C two C three offsetting

18:43.340 --> 18:44.220
in this case.

18:44.230 --> 18:46.910
It's pseudo dislocation or physiologic.

18:47.140 --> 18:50.120
It's physiologic because of the position

18:50.120 --> 18:50.890
of the spine.

18:50.920 --> 18:53.840
And this line confirms that it is physiologic

18:53.840 --> 18:56.770
because the line drawn from the cortex of C one anterior

18:56.770 --> 18:59.520
aspect of it to see three cuts through the

18:59.520 --> 19:00.630
cortex of C.

19:00.630 --> 19:01.020
Two.

19:01.240 --> 19:03.960
As long as it comes within one millimeter anterior

19:03.960 --> 19:04.480
surface,

19:04.740 --> 19:06.450
you're probably okay.

19:06.940 --> 19:08.320
Now let's look at another one.

19:09.540 --> 19:11.680
You don't have to flex the spine.

19:11.690 --> 19:13.720
People have asked me that and don't do it.

19:14.070 --> 19:15.770
Take the first film you get.

19:16.540 --> 19:19.260
And if this is offset like we have here,

19:19.260 --> 19:20.760
this is another trauma case.

19:21.530 --> 19:22.910
If this is offset,

19:23.250 --> 19:25.150
then you have to decide what to do with this.

19:25.150 --> 19:25.670
Now,

19:26.040 --> 19:29.010
here comes one little problem that I want to outline to you.

19:29.440 --> 19:32.070
This is hypoplastic and we know C1 is

19:32.070 --> 19:32.840
hypoplastic.

19:32.840 --> 19:34.000
So where are you going to measure?

19:34.000 --> 19:34.820
Be careful.

19:35.040 --> 19:37.630
This is not the posterior cortex here.

19:37.790 --> 19:40.310
This is the posterior cortex of c.

19:40.310 --> 19:40.730
one.

19:41.340 --> 19:44.080
Now I had a resident that measured it in the wrong place,

19:44.250 --> 19:45.190
it still came out.

19:45.190 --> 19:45.760
Okay,

19:45.770 --> 19:48.560
but you must know where to measure this thing and if you can't

19:48.560 --> 19:49.130
figure it out,

19:49.140 --> 19:50.860
don't put the line on it isn't worth it.

19:50.870 --> 19:52.270
You'll just make a mistake,

19:52.320 --> 19:54.270
you have to see the post your cortex.

19:54.270 --> 19:57.100
However we did find it and there it is right

19:57.110 --> 19:57.500
there.

19:57.930 --> 19:59.320
And if you draw it down here,

19:59.320 --> 20:00.960
this is just physiologic.

20:01.940 --> 20:02.160
Now,

20:02.160 --> 20:03.380
why is that important?

20:03.850 --> 20:04.790
I'll tell you why.

20:05.840 --> 20:06.370
Here's,

20:06.380 --> 20:09.210
here's the reason this kid has a

20:09.210 --> 20:09.860
stiff neck,

20:09.870 --> 20:12.840
it's a car accident And the neurosurgery resident,

20:12.840 --> 20:13.800
this is a different 1.

20:13.810 --> 20:15.350
1 I don't care so much about.

20:15.610 --> 20:18.390
And he said I

20:18.390 --> 20:21.360
wasn't worried about that dislocation until I

20:21.360 --> 20:22.820
saw the soft tissue swelling.

20:23.540 --> 20:24.230
Oh yeah,

20:24.510 --> 20:27.460
he saw it down here and

20:27.460 --> 20:30.210
when he saw this down here and he put it

20:30.210 --> 20:33.050
together with this and the kid had tongs slapped

20:33.050 --> 20:35.920
on for friday night and and he

20:35.920 --> 20:38.910
stayed with him until monday morning until they got laminate grams

20:39.240 --> 20:40.240
of the whole thing.

20:40.240 --> 20:40.730
You see.

20:40.820 --> 20:42.010
Well number one,

20:42.300 --> 20:43.440
this was normal.

20:43.730 --> 20:45.070
If you applied this line,

20:45.070 --> 20:46.660
the resident applied it incorrectly.

20:46.660 --> 20:49.660
So he wasn't sure how are you gonna get swelling down

20:49.660 --> 20:51.910
here and not up there if you have a

20:51.920 --> 20:53.360
dislocation up here.

20:53.380 --> 20:56.300
So his thinking is all screwed up and this kid

20:56.300 --> 20:59.300
got two tongues in his head and spent the whole

20:59.300 --> 21:00.170
weekend over there.

21:00.170 --> 21:02.970
Well actually it was a good reason because the kid

21:02.970 --> 21:05.850
had intra cranial contusions and so forth and

21:05.850 --> 21:08.830
was jumping around all over the place and they figured this was the

21:08.830 --> 21:09.380
best thing,

21:09.380 --> 21:11.220
but you see how mixed up the thinking.

21:11.220 --> 21:14.180
Get everybody with kids wouldn't mind having a couple of

21:14.180 --> 21:14.960
tongs at home,

21:14.960 --> 21:15.310
wouldn't you?

21:15.320 --> 21:17.350
Five o'clock?

21:17.350 --> 21:17.680
You know,

21:17.680 --> 21:20.090
just if we were born with two holes in their PJs,

21:20.090 --> 21:21.420
really at five o'clock in the afternoon,

21:21.420 --> 21:23.260
the mother just slap on the tongs over there,

21:23.260 --> 21:23.610
you know,

21:23.920 --> 21:25.940
and the best way to keep a two year old down,

21:25.940 --> 21:26.390
I'll tell you.

21:26.550 --> 21:28.930
And uh if you have any two year olds,

21:28.930 --> 21:29.770
you know what I mean?

21:29.810 --> 21:32.520
And uh see the thinking was all

21:32.520 --> 21:34.540
screwed up and there was nothing wrong over there.

21:34.630 --> 21:36.030
So one other thing,

21:36.030 --> 21:36.940
watch out for this.

21:36.940 --> 21:38.370
If you're not sure where to measure this,

21:38.370 --> 21:39.040
don't measure it,

21:39.040 --> 21:40.230
you'll just get into trouble.

21:40.420 --> 21:41.350
And the other thing,

21:41.360 --> 21:43.800
you do not have to don't flex the spine,

21:43.810 --> 21:44.720
take the first one,

21:44.720 --> 21:47.440
that you get to make the observation that

21:47.440 --> 21:49.860
C two is offset on C three.

21:49.860 --> 21:52.300
And if this line measures within normal range,

21:52.640 --> 21:55.000
it doesn't make any difference how bad that looks.

21:55.000 --> 21:55.600
You're okay.

21:55.600 --> 21:57.170
There is nothing wrong with this kid,

21:57.740 --> 21:59.230
It looks terrible in this infant.

21:59.230 --> 22:00.070
There is nothing wrong,

22:00.070 --> 22:01.760
this is pseudo dislocation.

22:02.140 --> 22:05.090
And I believe the line is helpful and it's worked for

22:05.090 --> 22:07.740
me and I'm gonna show you why it

22:07.740 --> 22:08.250
works,

22:08.250 --> 22:11.020
because if you have true dislocation,

22:11.020 --> 22:13.800
you're going to have a fracture

22:13.800 --> 22:14.690
through the pericles,

22:14.690 --> 22:16.750
or arches a so called Hangman's fracture,

22:16.750 --> 22:19.360
bilateral unstable spine.

22:19.940 --> 22:20.980
What's happened here,

22:21.220 --> 22:23.560
motion did not occur through the c.

22:23.560 --> 22:23.800
2,

22:23.800 --> 22:24.140
3,

22:24.140 --> 22:26.390
apophis seal joint Motion.

22:26.390 --> 22:29.300
Now instability is located through

22:29.300 --> 22:30.060
the arches,

22:30.520 --> 22:33.460
now see two moves forward to be offset

22:33.460 --> 22:34.160
on C3.

22:34.160 --> 22:36.800
You must make that observation here.

22:36.800 --> 22:39.780
You can obviously see the fracture so it's redundant to apply the

22:39.780 --> 22:40.040
line,

22:40.040 --> 22:42.160
but I want to show you why it works.

22:42.520 --> 22:44.290
See two now moves forward,

22:44.350 --> 22:47.000
so do the base at the base of the pericles,

22:47.040 --> 22:48.370
but it carries C.

22:48.370 --> 22:49.170
One with it.

22:49.310 --> 22:50.240
Do you see that?

22:51.240 --> 22:53.700
So when this now slides forward it carries c.

22:53.700 --> 22:54.080
one,

22:54.090 --> 22:56.220
but see to arch remains

22:56.220 --> 22:57.190
posterior.

22:57.400 --> 23:00.130
It remains in the extended or

23:00.130 --> 23:01.260
neutral position.

23:02.740 --> 23:03.760
And as a matter of fact,

23:03.770 --> 23:06.590
this line will now measure two or more.

23:06.700 --> 23:09.260
And if it measures the distance there measures two

23:09.930 --> 23:10.580
or more,

23:10.850 --> 23:13.300
you should assume that you have an unstable spine.

23:13.310 --> 23:15.770
And you ought to look for a hangman's

23:15.770 --> 23:16.320
fracture.

23:16.330 --> 23:19.210
Here's another case missed in the emergency

23:19.210 --> 23:19.510
room,

23:21.040 --> 23:23.590
missed in the emergency room because many of these

23:23.590 --> 23:25.910
fractures are difficult to see there is a fracture here.

23:25.910 --> 23:26.720
You may not see it.

23:26.730 --> 23:28.350
What's the most important thing.

23:28.360 --> 23:29.430
What caught their eye?

23:29.560 --> 23:31.290
It didn't catch their eye actually,

23:31.290 --> 23:33.920
a very good resident of ours picked this up the next

23:33.920 --> 23:36.050
morning and she looked at this and she said,

23:36.050 --> 23:38.930
that looks a little offset And then she

23:38.930 --> 23:40.970
looked at this and she said,

23:40.980 --> 23:41.380
Gosh,

23:41.390 --> 23:44.140
if you drew that that would look a little bit on the

23:44.140 --> 23:45.070
generous side.

23:45.070 --> 23:46.000
And as a matter of fact,

23:46.000 --> 23:47.350
if you do draw that line,

23:47.350 --> 23:48.900
look at from here to there.

23:49.050 --> 23:51.900
You notice that the gap is two from the

23:51.900 --> 23:52.590
Cortex.

23:53.040 --> 23:55.170
And here is the lamb in a gram

23:56.150 --> 23:57.810
with a definite fracture here.

23:58.310 --> 24:00.330
Now you see the first one had tongs in there.

24:00.330 --> 24:01.170
He didn't need them.

24:01.740 --> 24:04.580
This one didn't have tongs needed them,

24:04.940 --> 24:06.720
missed until the next morning.

24:07.010 --> 24:09.920
And the observation of C23 offsetting

24:09.930 --> 24:12.320
was not made by the people looking at this.

24:12.320 --> 24:13.320
You must make that.

24:13.470 --> 24:16.380
Then you can apply the line and it will be very helpful.

24:16.620 --> 24:19.580
I'll summarize and then I'll give you one case that smack

24:19.580 --> 24:22.490
down the middle and I was very pleased when they picked

24:22.490 --> 24:23.270
this other one up.

24:23.940 --> 24:26.910
This if it's abnormal it will almost always be with a

24:26.910 --> 24:27.860
Hangman's fracture.

24:27.870 --> 24:29.510
But it may be with other things.

24:29.510 --> 24:32.210
But I'm gonna say most of the time if it misses C.

24:32.210 --> 24:34.350
Two by two millimeters or more,

24:34.740 --> 24:35.730
it's abnormal.

24:35.730 --> 24:38.270
You can assume there's an unstable fracture over there.

24:39.540 --> 24:42.500
If it misses it by 1.5 mm,

24:42.630 --> 24:43.960
be suspicious.

24:45.840 --> 24:48.760
And use it only if C2 and

24:48.760 --> 24:50.190
C3 are offset,

24:50.200 --> 24:52.230
don't use it for anything else.

24:53.430 --> 24:56.350
Now here's a case that's right down the middle and also

24:56.350 --> 24:58.420
you don't have to flex the spine or do anything.

24:58.420 --> 25:01.050
Just take the first film you get here's a patient.

25:01.540 --> 25:02.740
These are a little dark.

25:02.750 --> 25:04.060
I'll tell you why they're dark.

25:04.400 --> 25:06.060
They're emergency room films.

25:06.640 --> 25:09.060
You only get very light or very dark films in the

25:09.060 --> 25:11.560
emergency room at least in ours.

25:11.940 --> 25:14.420
I thought first is because it was all done at night.

25:14.430 --> 25:16.380
But I don't think that's the that's the answer.

25:16.700 --> 25:19.400
But they are dark and I want

25:19.400 --> 25:21.870
and you ought to appreciate that because this is

25:21.870 --> 25:24.170
exactly the kind of film you're gonna be working with.

25:24.540 --> 25:25.370
Now here,

25:25.620 --> 25:27.360
is there anything going on here

25:27.940 --> 25:30.850
offset a little here and suspicious

25:30.960 --> 25:33.940
measure this line and this is I have to

25:33.940 --> 25:36.860
take a ruler and measure this because my eye is not good enough to

25:36.860 --> 25:39.210
tell one from 1.5,

25:39.340 --> 25:41.420
2 and over when you measure that,

25:41.420 --> 25:42.890
that's going to be to some people,

25:42.890 --> 25:44.510
one to other people,

25:44.510 --> 25:45.760
it will be 1.5.

25:46.140 --> 25:47.490
And my point is,

25:47.940 --> 25:49.350
if you're not sure,

25:49.620 --> 25:51.270
don't slough it off as normal.

25:51.600 --> 25:54.130
If you have any question that it's 1.5

25:54.230 --> 25:56.910
or beyond the normal limit of one millimeter,

25:57.010 --> 25:58.690
do something else about it.

25:58.700 --> 26:01.560
And the best thing to do is immobilize them

26:01.560 --> 26:04.430
and get yourself some cuts because here's a lamb instagram,

26:04.430 --> 26:05.270
it's offset.

26:05.280 --> 26:07.600
Now it's clearly two millimeters in here.

26:07.610 --> 26:10.460
You can always get a beautiful measurement in laminar graffiti

26:10.650 --> 26:13.350
and there's the fracture on one side and there's the fracture

26:13.360 --> 26:16.290
on the other side and this is another unstable

26:16.290 --> 26:19.080
spine that needs stability,

26:19.370 --> 26:19.830
you see.

26:19.830 --> 26:21.320
And this is right down the middle.

26:21.320 --> 26:24.170
This was 1.5 millimeters and that's exactly

26:24.170 --> 26:27.060
why I put that in a long time ago because I think

26:27.340 --> 26:29.330
that anything over a millimeter,

26:29.330 --> 26:30.560
you ought to be suspicious.

26:30.640 --> 26:33.470
Anything over 2 mm is

26:33.470 --> 26:34.220
abnormal.

26:34.230 --> 26:37.180
You'll you'll get screwed up on one case sooner or later.

26:37.180 --> 26:39.800
But it's not gonna be a big thing if you make the errors on the

26:39.810 --> 26:40.730
correct side.

26:40.730 --> 26:41.170
In other words,

26:41.170 --> 26:42.600
don't slough it off as normal.

26:42.850 --> 26:43.850
If you're not sure,

26:44.340 --> 26:47.040
you don't have to flex the spine and above all,

26:47.040 --> 26:48.670
don't apply the line unless C.

26:48.670 --> 26:50.810
Two and C three are offset.

26:50.820 --> 26:51.080
Well,

26:51.090 --> 26:52.100
that'll be enough of that.

26:52.100 --> 26:53.360
Except for one thing,

26:55.040 --> 26:56.400
When you have spasm,

26:56.540 --> 26:58.440
C2 will be angled on c.

26:58.440 --> 26:58.730
three.

26:58.730 --> 26:59.960
It is not dislocated.

26:59.960 --> 27:00.900
If you measured here,

27:00.910 --> 27:02.120
it still would be normal.

27:02.130 --> 27:04.940
How do you decide whether you have dislocation or

27:04.940 --> 27:06.090
just angular ation?

27:06.840 --> 27:07.050
Well,

27:07.050 --> 27:09.290
you draw a line down the poster aspect of C.

27:09.290 --> 27:11.080
Two and if it misses C.

27:11.080 --> 27:11.560
Three,

27:11.860 --> 27:13.520
it can't be offset right.

27:13.940 --> 27:15.220
It can't be dislocated.

27:15.220 --> 27:17.260
It would have to cut through c.

27:17.260 --> 27:19.160
3 to be anti really displaced.

27:19.370 --> 27:21.160
So if it's just angled,

27:21.290 --> 27:22.560
don't apply the line.

27:22.570 --> 27:25.270
And I mention this because this is very common in Children.

27:25.640 --> 27:28.640
They stand like this with the neck kind of straight for

27:28.640 --> 27:31.470
you or it's actually has spasm or somebody's got

27:31.470 --> 27:34.150
their hand on top of the head to keep them still

27:34.160 --> 27:37.070
and they're fighting it and they will have a spine like

27:37.070 --> 27:38.630
this all screwed up,

27:38.630 --> 27:39.690
look at the soft issues,

27:39.690 --> 27:40.760
this is all normal,

27:41.940 --> 27:43.860
but this is not offset.

27:44.280 --> 27:46.340
If you measure this line back there though,

27:46.340 --> 27:48.960
you'll be misled because it does miss it by 2

27:48.960 --> 27:51.870
mm because this spine is basically in the

27:51.870 --> 27:52.910
neutral position.

27:53.110 --> 27:56.080
And if you take the line

27:56.080 --> 27:57.940
along the poster aspect of C.

27:57.940 --> 27:59.020
Two and draw down,

27:59.020 --> 28:01.060
extend it down along C.

28:01.060 --> 28:01.340
Three,

28:01.340 --> 28:02.910
you'll notice that it mrs C.

28:02.910 --> 28:05.370
Three and if it misses C.

28:05.370 --> 28:05.680
Three,

28:05.680 --> 28:06.880
it is not offset.

28:07.020 --> 28:09.980
I mentioned that because that is the major pitfall in

28:09.980 --> 28:11.720
applying this line in Children.

28:11.900 --> 28:14.890
If you have angular ation without offsetting and

28:14.890 --> 28:17.660
you determine whether it's offset by aligning the

28:17.660 --> 28:18.990
poster aspect of C.

28:18.990 --> 28:19.680
Two with C.

28:19.680 --> 28:20.150
Three.

28:20.360 --> 28:21.420
If it's not offset,

28:21.420 --> 28:23.680
don't apply the line because it will lead you astray.

28:23.840 --> 28:25.360
You must have offsetting.

28:25.730 --> 28:28.460
This is angular ation only very

28:28.460 --> 28:28.870
common.

28:28.870 --> 28:29.410
You can do it.

28:29.410 --> 28:31.720
Just tell them to hold their neck nice and stiff like this

28:31.890 --> 28:33.350
angular ation only.

28:37.440 --> 28:37.890
Okay,

28:37.890 --> 28:40.670
I'll just let you think about that for a minute because that's tricky.

28:41.440 --> 28:44.230
You have to take the Poster aspect of the

28:44.230 --> 28:44.910
body of c.

28:44.910 --> 28:47.750
two and a dense and extend the line down here and once again,

28:47.750 --> 28:48.800
if you're not sure,

28:49.130 --> 28:52.060
proceed with another with lambda

28:52.060 --> 28:54.620
grams or whatever else you want to exclude a fracture

28:54.770 --> 28:57.480
only when you are sure that there is no

28:57.480 --> 28:58.070
offsetting.

28:58.070 --> 29:00.320
Should you say it's okay if there's any

29:00.330 --> 29:01.850
uncertainty in your mind,

29:02.180 --> 29:03.760
proceed with your work up.

29:04.540 --> 29:07.490
But you'll save yourself a lot of trouble if you appreciate that

29:07.500 --> 29:10.360
angular ation occurs like this without offsetting because

29:10.360 --> 29:11.790
this is very common.

29:12.340 --> 29:12.610
Well,

29:12.610 --> 29:15.040
I spent some time with that because if it's not used

29:15.050 --> 29:15.660
properly,

29:15.840 --> 29:18.260
it will lead you astray if that line is used

29:18.270 --> 29:18.850
properly,

29:20.340 --> 29:21.520
it is very helpful.

29:21.530 --> 29:24.440
And I think I've illustrated with two cases how helpful it

29:24.440 --> 29:24.730
can be.

29:24.730 --> 29:27.600
It could have saved tongs for one kid and two other

29:27.600 --> 29:30.580
ones that could have gotten him immobilized a little earlier.

29:31.040 --> 29:33.940
Now Ryan nik it's not too

29:33.940 --> 29:35.620
much exciting for us for Rinek.

29:35.620 --> 29:35.870
I mean,

29:35.870 --> 29:37.640
it has a classic history and so forth.

29:37.640 --> 29:40.460
The only thing that's important about Rinek is that

29:40.470 --> 29:42.430
if you can determine what's midline,

29:43.840 --> 29:46.090
are you gonna take the the thoracic spine is

29:46.090 --> 29:48.570
processes are you going to take the cervical ones?

29:48.790 --> 29:51.660
I finally decided I'd rather take the thoracic ones

29:51.660 --> 29:53.880
because that's the only part of the spine that's straight.

29:54.640 --> 29:57.520
But others will measure the spine ist processes of

29:57.520 --> 29:59.350
the cervical vertebra.

29:59.740 --> 30:00.030
Well,

30:00.040 --> 30:02.900
you figure out where midline is and you can

30:02.900 --> 30:04.970
decide for yourself which one you want to use.

30:04.970 --> 30:07.740
I use this one right here and then you decide two

30:07.740 --> 30:10.510
things If the mandible is rotated this

30:10.510 --> 30:12.740
way and the spine ist tip of C.

30:12.740 --> 30:15.330
Two is on the same side of the line as the

30:15.330 --> 30:16.600
mandible rotation,

30:16.830 --> 30:19.650
then you have what's called subluxation with the rye

30:19.650 --> 30:22.350
neck and they're still just gonna treat it conservatively.

30:22.740 --> 30:24.320
If this C.

30:24.320 --> 30:26.980
Two spineless processes on the opposite side to

30:26.980 --> 30:28.610
which the neck,

30:28.620 --> 30:31.130
the mandible is turned then you just have a

30:31.130 --> 30:32.350
positioning abnormality.

30:32.350 --> 30:34.070
The kid is just turned like this.

30:34.260 --> 30:36.990
But you have with wry neck a so called

30:36.990 --> 30:38.830
subluxation at this level C.

30:38.830 --> 30:39.230
One C.

30:39.230 --> 30:39.550
Two.

30:39.560 --> 30:42.440
And if when you have that The spine

30:42.440 --> 30:43.200
ist tip of C.

30:43.200 --> 30:46.030
two will end up on the same side of that midline

30:46.230 --> 30:47.890
as your mandible.

30:49.240 --> 30:49.650
Okay.

30:49.650 --> 30:51.550
And that's all I want to say about Rinek.

30:52.000 --> 30:55.000
Now now we're going to get into anomalies of the

30:55.000 --> 30:57.960
dense and it may be just

30:57.960 --> 31:00.860
as important here to sort of get an overall view

31:01.540 --> 31:03.670
as to look at each thing in detail.

31:03.670 --> 31:06.490
So I'm gonna go through a whole bunch of stuff here to

31:06.490 --> 31:07.200
give you an idea.

31:07.200 --> 31:10.110
Now don't don't don't don't vomit here

31:10.270 --> 31:13.130
with it says embryology and all

31:13.130 --> 31:14.450
kind of stuff and so forth.

31:14.450 --> 31:15.260
I hate it too.

31:15.490 --> 31:17.590
But these are scleral tomes,

31:17.590 --> 31:19.020
occipital four and C.

31:19.020 --> 31:19.610
One and C.

31:19.610 --> 31:20.050
Two.

31:20.240 --> 31:23.150
It so happens that in lower vertebrates there's a

31:23.150 --> 31:25.700
thing called the pro atlas in between

31:25.700 --> 31:27.240
occipital four and C.

31:27.240 --> 31:27.590
One.

31:27.590 --> 31:28.040
Okay.

31:28.360 --> 31:30.820
And it is a separate bone in a lot of lower

31:30.820 --> 31:32.230
vertebrates in men,

31:32.640 --> 31:35.270
it goes over and joins up with occipital four.

31:35.270 --> 31:35.730
Okay.

31:35.890 --> 31:38.700
But this pro atlas happens to give off the top

31:38.700 --> 31:39.360
part of C.

31:39.360 --> 31:39.640
One.

31:39.640 --> 31:42.410
The articular surface is a little bit of the spine ist tip

31:42.420 --> 31:45.360
and the ost terminally the little thing

31:45.360 --> 31:46.710
at the top of C.

31:46.710 --> 31:47.130
Two.

31:47.140 --> 31:47.660
Okay.

31:48.020 --> 31:48.830
That's important.

31:48.840 --> 31:51.780
Also it can give off a bunch of other little obstacles

31:51.780 --> 31:52.990
located in about here,

31:52.990 --> 31:54.270
just off of C.

31:54.270 --> 31:54.460
One,

31:54.460 --> 31:57.390
you can see if this thing doesn't get amalgamated properly with

31:57.390 --> 32:00.190
occipital for little bones could result.

32:00.490 --> 32:02.460
Now the body of C.

32:02.460 --> 32:04.660
One is actually the dens of C.

32:04.660 --> 32:05.040
Two.

32:05.050 --> 32:06.360
There is no body of C.

32:06.360 --> 32:06.620
One,

32:06.620 --> 32:06.900
right?

32:07.040 --> 32:07.600
So C.

32:07.600 --> 32:07.900
One,

32:07.900 --> 32:08.380
dens,

32:08.390 --> 32:08.930
I mean C.

32:08.930 --> 32:10.870
One body is actually the dens of C.

32:10.870 --> 32:11.240
Two,

32:11.380 --> 32:12.350
and the rest of C.

32:12.350 --> 32:14.320
Two comes from Clara tome C.

32:14.320 --> 32:14.600
Two.

32:14.600 --> 32:15.040
So you see,

32:15.040 --> 32:16.610
it's not as difficult as it looks.

32:17.140 --> 32:18.770
Remember the pro atlas,

32:18.780 --> 32:20.770
because I'm going to show you what we call,

32:20.950 --> 32:23.770
we've called the osce terminally then everybody

32:23.770 --> 32:26.670
calls it that and pro atlas obstacles and

32:26.670 --> 32:28.050
that's what we're going to deal with next.

32:28.060 --> 32:30.860
These are just a bunch of little obstacles that

32:30.860 --> 32:33.730
occur primarily Superior to

32:33.730 --> 32:35.020
the anterior arch of c.

32:35.020 --> 32:35.290
one.

32:35.290 --> 32:36.200
They're usually small,

32:36.200 --> 32:38.650
they may may maybe multiple or single

32:38.660 --> 32:40.880
have no particular significance,

32:40.890 --> 32:42.440
no particular significance.

32:42.440 --> 32:42.850
Okay,

32:44.140 --> 32:47.080
Little obstacles that you see above the anterior arch of c.

32:47.080 --> 32:47.390
one.

32:47.660 --> 32:49.810
Some of them look very big like this,

32:50.170 --> 32:51.670
still no significance.

32:52.140 --> 32:54.420
And we've just called those pro atlas

32:54.430 --> 32:55.230
obstacles.

32:55.240 --> 32:57.810
Others call them remnants of sort of an occipital

32:57.820 --> 32:58.730
vertebra,

32:58.740 --> 33:00.650
but you can expect them to occur.

33:00.650 --> 33:03.620
I mentioned them because they I think they must

33:03.630 --> 33:06.510
be differentiated from this thing which sits right at the

33:06.510 --> 33:09.320
top of the dens and

33:09.320 --> 33:11.960
that's the osce terminally normal.

33:12.440 --> 33:14.800
If you take a lot of polyrhythms for ear

33:14.800 --> 33:17.500
problems or just good old open mouth of non toys.

33:17.500 --> 33:18.680
You'll see it in kids.

33:18.900 --> 33:21.130
It stays there till late childhood.

33:21.130 --> 33:23.650
It goes by adolescents usually sometimes earlier,

33:23.650 --> 33:26.190
sometimes later and it sits on top.

33:26.230 --> 33:27.790
But why is this important?

33:27.800 --> 33:28.030
Well,

33:28.030 --> 33:30.940
I'll tell you why it's important because if

33:30.940 --> 33:32.270
you collect enough cases,

33:32.280 --> 33:34.420
here's one with a small mosque.

33:34.420 --> 33:36.090
Terminally normal,

33:36.090 --> 33:36.570
dense.

33:36.580 --> 33:38.900
Here's one in the second slide.

33:39.330 --> 33:40.260
A bigger office.

33:40.260 --> 33:42.880
Terminally with a dense that looks a little smaller.

33:44.040 --> 33:44.550
Now,

33:44.560 --> 33:46.980
I prefer to start calling it at this

33:46.980 --> 33:47.590
stage.

33:47.600 --> 33:49.350
And certainly by the third slide,

33:49.730 --> 33:52.460
the auditorium which we feel is an

33:52.470 --> 33:54.500
overgrown osk terminally

33:54.940 --> 33:57.780
almost always associated with some degree of

33:57.780 --> 33:58.760
hyperplasia.

33:58.980 --> 34:00.160
Of the dense.

34:00.600 --> 34:03.440
So we have the pro atlas obstacles up front

34:03.450 --> 34:04.260
which do nothing.

34:04.260 --> 34:07.110
I think then you have the ost terminally on

34:07.110 --> 34:09.860
top of the dens and then you have this

34:09.860 --> 34:12.490
thing perhaps getting bigger in some patients with the

34:12.490 --> 34:15.140
dens getting smaller and you will have

34:15.150 --> 34:17.160
then the old on toy.

34:17.160 --> 34:19.810
Um which I can you may want to think of it

34:19.810 --> 34:22.660
certainly I think of it as an overgrown osk

34:22.660 --> 34:25.560
terminally now this is the thing that gives you a lot of

34:25.570 --> 34:28.470
trouble here are four cases

34:28.480 --> 34:29.060
of us.

34:29.080 --> 34:29.790
Golden toity.

34:29.790 --> 34:32.130
Um Here's one that we looked at on the previous slide,

34:32.840 --> 34:34.480
right on top of the dens.

34:35.540 --> 34:37.360
Hypoplastic dense here,

34:38.220 --> 34:39.160
funny looking.

34:39.160 --> 34:40.620
These are funny looking bones,

34:40.620 --> 34:43.150
triangular hypoplastic dens,

34:43.150 --> 34:44.420
there's the body of C.

34:44.420 --> 34:46.850
Two weird

34:46.850 --> 34:47.430
looking.

34:47.520 --> 34:49.160
No dens at all.

34:49.170 --> 34:50.220
Weird looking.

34:50.940 --> 34:53.240
and here's one here that is anti really

34:53.240 --> 34:54.460
displaced with C.

34:54.460 --> 34:56.720
One hypoplastic dens.

34:56.980 --> 34:59.940
These are all sewed on toy idioms

35:00.020 --> 35:02.090
also hold on tightly I guess for latin,

35:02.090 --> 35:02.360
right?

35:02.740 --> 35:05.180
When it becomes for texas it's comes

35:05.570 --> 35:07.210
for for a lantern.

35:07.210 --> 35:08.140
It's I guess.

35:08.320 --> 35:10.080
And but you have

35:10.080 --> 35:13.020
hyperplasia hyperplasia of

35:13.020 --> 35:15.920
the dens and you have instability of the

35:15.920 --> 35:18.890
spine and this toronto medium takes

35:18.890 --> 35:21.600
up space in the spinal canal and especially

35:21.600 --> 35:23.880
with posterior dislocation,

35:23.880 --> 35:26.770
it will encroach upon the medulla

35:26.770 --> 35:27.890
and so forth.

35:27.980 --> 35:30.120
And this patient had a lot of serious

35:30.340 --> 35:31.720
neurological sequelae.

35:31.730 --> 35:33.080
Was a six year old child.

35:33.080 --> 35:35.910
So what do we want to remember from this series of slides?

35:36.090 --> 35:38.880
The also don't odium we feel and I

35:38.880 --> 35:41.550
find it at least convenient to think of it this way is an

35:41.560 --> 35:44.540
overgrown Osk terminally which is a normal part of

35:44.540 --> 35:44.800
C.

35:44.800 --> 35:46.650
Two If you see it.

35:47.000 --> 35:48.350
So that the bigger it is,

35:48.700 --> 35:51.510
the more hyperplasia of of the dens you

35:51.510 --> 35:51.920
have.

35:52.060 --> 35:54.980
It is often very bizarre in configuration

35:55.090 --> 35:58.040
and it's very frequently if not almost always

35:58.040 --> 36:00.830
associated with some instability at the

36:00.830 --> 36:03.250
C12 area often profound.

36:03.430 --> 36:06.370
And cord compression does occur and

36:06.370 --> 36:08.420
this thing has to be looked after.

36:08.550 --> 36:11.340
It's just as serious as an as instability

36:11.340 --> 36:13.400
with trauma but it's all anomaly.

36:13.410 --> 36:15.750
Okay and here's a bigger one

36:16.420 --> 36:18.100
and we'll come back to this one later on.

36:18.100 --> 36:19.500
This is poster and this kid,

36:19.930 --> 36:20.680
this kid,

36:20.850 --> 36:23.850
this kid came in for an accident and we

36:23.850 --> 36:26.700
discovered this and they spent all these politicians deciding

36:26.700 --> 36:28.330
whether this was a fracture or not.

36:28.630 --> 36:29.840
The tip off was this,

36:29.840 --> 36:31.190
and we'll come back to this later.

36:31.490 --> 36:31.920
Well,

36:31.930 --> 36:33.290
that's I don't have it in there.

36:33.290 --> 36:34.540
I think maybe I have it on the next one.

36:36.430 --> 36:36.660
Okay.

36:37.030 --> 36:39.310
The tip off was that he had other anomalies,

36:39.310 --> 36:41.380
but that was another episode on totem,

36:41.390 --> 36:43.860
and I'll come to it a little later in the slides.

36:43.860 --> 36:44.250
Now,

36:45.630 --> 36:46.480
the big question is,

36:46.480 --> 36:47.570
how do you tell the us?

36:47.580 --> 36:47.940
Hold on,

36:47.940 --> 36:49.650
Tony um from a fracture.

36:50.230 --> 36:50.500
Well,

36:50.500 --> 36:51.980
we'll go back to this diagram,

36:51.980 --> 36:52.890
but it's much simpler.

36:52.890 --> 36:53.350
Now,

36:54.530 --> 36:55.290
basically,

36:55.290 --> 36:57.160
if you have a high defect,

36:58.330 --> 36:58.870
in other words,

36:58.870 --> 36:59.980
high up in the dens,

36:59.980 --> 37:02.070
you don't have to worry that's going to be an anomaly.

37:02.070 --> 37:03.240
It may be unstable,

37:03.240 --> 37:04.230
but it's an anomaly.

37:04.510 --> 37:07.090
If it's a low defect through Level two,

37:07.490 --> 37:08.780
then you have a fracture.

37:08.790 --> 37:10.020
What do I mean by this?

37:10.530 --> 37:10.740
Mhm.

37:11.330 --> 37:12.430
Here's our friend again.

37:12.430 --> 37:12.900
You see,

37:12.910 --> 37:14.300
here's C two body,

37:14.300 --> 37:15.950
here's the dense hypoplastic,

37:15.950 --> 37:18.890
this is a high defect fractures of the dense occur through

37:18.890 --> 37:20.300
this Level Level two.

37:20.380 --> 37:20.780
So,

37:20.780 --> 37:22.330
if you're up at the top,

37:22.350 --> 37:23.840
if you're up at the top,

37:24.330 --> 37:26.850
you probably have a congenital anomaly.

37:26.850 --> 37:27.270
Okay,

37:27.270 --> 37:28.490
so that was point number one,

37:28.500 --> 37:31.140
all this kid had was a unilateral

37:31.140 --> 37:32.190
fracture of C.

37:32.190 --> 37:34.290
Two and that's what was given him pain,

37:34.580 --> 37:37.360
but this was unstable and he needed to be fused for

37:37.360 --> 37:38.090
this anomaly.

37:38.090 --> 37:39.710
But nobody picked this up.

37:39.710 --> 37:42.660
He was 14 years old before I ended up in this car accident

37:42.930 --> 37:45.860
and then a whole lot of time was spent in deciding whether this was

37:45.860 --> 37:46.910
fractured or not.

37:47.230 --> 37:50.200
A clue here was that on frontal view and we're going

37:50.200 --> 37:51.110
to come back to this.

37:51.250 --> 37:54.200
This looks very weird And you can believe that caused him a

37:54.200 --> 37:56.610
lot of trouble about 11:30 PM on Friday.

37:57.230 --> 37:57.560
I mean,

37:57.560 --> 37:59.280
they even got polyrhythms at that time.

37:59.280 --> 38:01.350
That's how much trouble it caused them.

38:01.360 --> 38:03.980
And it was all anomaly and you'll see later

38:04.010 --> 38:05.770
why it should have been anomaly.

38:05.770 --> 38:06.750
But the point is,

38:06.800 --> 38:09.130
if it's high and there are other

38:09.140 --> 38:09.860
anomalies,

38:10.220 --> 38:13.030
it's an anomaly almost for sure if it's

38:13.030 --> 38:15.670
low and everything looks good like in this

38:15.670 --> 38:16.150
infant,

38:16.280 --> 38:19.070
you have a fracture through the base of the dense

38:19.520 --> 38:22.110
same thing in an older child and an adult.

38:22.260 --> 38:23.010
The problem,

38:23.010 --> 38:23.460
however,

38:23.460 --> 38:26.290
is is that a lot of un united,

38:26.820 --> 38:29.510
dense fractures tend to have a smooth surface

38:29.510 --> 38:30.130
between them.

38:30.140 --> 38:33.120
And how do you tell the difference if the defect is

38:33.120 --> 38:35.340
low between anna Don toyed fracture,

38:35.350 --> 38:37.460
UN united and an auditorium.

38:37.460 --> 38:39.240
And this is basically what we use.

38:39.820 --> 38:42.400
If the superior article looks like a normal

38:42.400 --> 38:45.310
dense and there are no other anomalies present,

38:45.920 --> 38:48.060
then chances are you have a fracture,

38:48.920 --> 38:51.900
if the thing looks peculiar and doesn't look

38:51.900 --> 38:54.900
like a normal dens and other anomalies are

38:54.900 --> 38:55.580
com are,

38:55.590 --> 38:56.390
are present.

38:56.650 --> 38:59.290
Then you have an old inventory.

38:59.290 --> 38:59.410
Um,

38:59.410 --> 39:00.640
with a hypoplastic,

39:00.640 --> 39:01.090
dense,

39:01.100 --> 39:03.340
Just pause there for a minute and repeat that

39:03.820 --> 39:06.790
you're not going to run into trouble with a regular acute

39:06.790 --> 39:09.230
fracture through the base of the dense.

39:09.230 --> 39:11.420
I mean you may have trouble picking it up and so forth,

39:11.430 --> 39:13.190
but that's not going to be the problem.

39:13.190 --> 39:16.080
The problem is going to be in the old un united fracture

39:16.320 --> 39:19.290
that moves and develops sclerosis and sort of

39:19.290 --> 39:22.000
a pseudo are throw sis and it's low.

39:22.620 --> 39:25.220
How are you going to distinguish that from a low

39:25.220 --> 39:28.200
congenital defect with a lot of hyperplasia of

39:28.200 --> 39:28.840
the dense.

39:29.120 --> 39:31.820
This is the way if it looks like a dense

39:32.420 --> 39:33.710
and there are no anomalies,

39:33.930 --> 39:36.140
then chances are it's an old fracture.

39:36.230 --> 39:38.100
Now we can summarize it this way.

39:38.100 --> 39:40.820
Three cases our friend who came

39:40.820 --> 39:43.760
in in the automobile accident and I

39:43.760 --> 39:46.170
showed you the frontal view and look at this plane film.

39:46.180 --> 39:46.650
Look at that.

39:46.650 --> 39:47.330
See one,

39:47.500 --> 39:49.290
This whole area looks anomalous.

39:49.500 --> 39:51.850
This was high an

39:51.850 --> 39:52.580
anomalous.

39:53.210 --> 39:54.600
It's clearly an anomaly.

39:54.710 --> 39:55.750
But look at this one.

39:56.060 --> 39:56.870
It's low.

39:56.880 --> 39:57.880
There is the body of C.

39:57.880 --> 39:58.150
One.

39:58.150 --> 39:58.570
Low.

39:58.580 --> 39:59.950
Is this anomaly or not.

39:59.950 --> 40:00.720
If we look at it,

40:00.910 --> 40:03.610
see one is underdeveloped but the main thing

40:03.840 --> 40:05.120
is that this obstacle,

40:05.120 --> 40:07.980
the superior optical does not look like a

40:07.980 --> 40:09.190
normal dans anymore.

40:09.190 --> 40:10.120
It's triangular.

40:10.120 --> 40:13.070
It's weird looking that favors anomaly and it

40:13.070 --> 40:13.940
was an anomaly.

40:14.210 --> 40:17.120
Now here's a patient with a past history of

40:17.130 --> 40:20.010
trauma and Adan toyed fracture and

40:20.010 --> 40:22.010
shows up later on with this picture.

40:22.210 --> 40:22.400
Now,

40:22.400 --> 40:23.310
here's this thing,

40:23.360 --> 40:24.190
it is low,

40:24.190 --> 40:25.270
there is the body of C.

40:25.270 --> 40:25.620
Two.

40:25.920 --> 40:27.790
Is this an anomaly or a fracture?

40:28.070 --> 40:30.980
This still looks like a dense and if you

40:30.980 --> 40:32.270
look at the plain films,

40:32.280 --> 40:33.670
it's hard to see the fragment.

40:33.670 --> 40:34.860
It's a little d mineralized,

40:34.920 --> 40:37.860
but the plain films show no anomalies of any

40:37.860 --> 40:38.580
other kind.

40:38.820 --> 40:41.680
This should be and was a low

40:41.680 --> 40:44.470
defect secondary to an old un united

40:44.470 --> 40:45.620
fracture with a suit.

40:45.620 --> 40:48.010
Our throats is there and an unstable spine.

40:48.010 --> 40:48.160
Well,

40:48.160 --> 40:50.030
both of them are unstable,

40:50.110 --> 40:52.940
but the point is that this is the result of old

40:52.940 --> 40:53.590
trauma.

40:53.630 --> 40:54.750
This is anomaly.

40:54.910 --> 40:57.730
This is clearly anomaly because of the high defect.

40:57.740 --> 40:58.240
Okay,

41:00.310 --> 41:02.960
I'm gonna scoot along here because we're probably

41:03.710 --> 41:05.140
getting close to our time.

41:06.300 --> 41:08.070
This is the weirdest one of all.

41:09.670 --> 41:11.810
And if you don't appreciate this one,

41:11.820 --> 41:14.440
you're just gonna you're gonna make a mistake on the first film,

41:15.310 --> 41:18.130
you're gonna think that this is the dens after I told you or

41:18.130 --> 41:21.000
the S hold onto medium or something when you have

41:21.000 --> 41:21.780
no dents.

41:22.350 --> 41:25.000
C one gets awfully big

41:25.010 --> 41:25.700
entirely.

41:25.710 --> 41:26.600
It over grows,

41:27.510 --> 41:29.160
This is the anterior arch of c.

41:29.160 --> 41:29.550
one.

41:30.970 --> 41:32.250
Look at the alignment here,

41:32.260 --> 41:34.220
look at the poster arch of c.

41:34.220 --> 41:36.720
one this is really kind of unstable,

41:36.720 --> 41:39.600
but it's not as bad as if you had an episode on titanium

41:39.600 --> 41:42.170
in there because there is no assault on toy Diem here,

41:42.390 --> 41:43.330
there's nothing there.

41:43.710 --> 41:46.100
If you have that extra awesome toronto sodium,

41:46.290 --> 41:49.020
it takes up space in the spinal canal.

41:49.230 --> 41:50.970
This is no dens at all.

41:50.980 --> 41:52.610
This is nothing with flexion.

41:52.680 --> 41:55.310
Watch this thing here with flexion.

41:55.420 --> 41:57.130
You'll see now that this is C.

41:57.130 --> 41:57.550
One,

41:57.780 --> 41:58.350
this is C.

41:58.350 --> 41:59.890
One and there is no dense.

41:59.890 --> 42:02.770
This is complete absence of the dense

42:03.500 --> 42:05.120
and here it is on frontal view,

42:06.000 --> 42:06.820
nothing there.

42:07.230 --> 42:08.920
So to summarize this,

42:09.700 --> 42:12.070
we can use this diagram and say that

42:12.080 --> 42:14.720
anomalies of the dense have a wide

42:14.720 --> 42:16.770
spectrum number one,

42:16.770 --> 42:18.750
you can have normal number two,

42:18.750 --> 42:21.720
you have the oss terminally number three.

42:21.760 --> 42:23.760
When the oss terminally gets big,

42:23.770 --> 42:26.600
it becomes the episode on titanium and you usually have

42:26.600 --> 42:28.870
hyperplasia of the dens

42:28.900 --> 42:30.870
unstable spine here,

42:30.960 --> 42:32.120
cord compression.

42:32.800 --> 42:35.420
Then you may not have the also an anti sodium at all.

42:35.420 --> 42:37.450
Just a hyper plastic dens,

42:37.630 --> 42:40.520
you may or may not have instability there and

42:40.520 --> 42:43.520
then you may have no dens and no also don't odium

42:43.630 --> 42:45.980
and that's usually an unstable

42:45.980 --> 42:46.700
situation.

42:46.700 --> 42:49.650
So from here on in is abnormal one

42:49.650 --> 42:52.320
way or another and you have instability

42:52.400 --> 42:55.310
and this is probably the worst situation of all the

42:55.310 --> 42:56.260
episode on toity.

42:56.260 --> 42:59.080
Um on the basis of this diagram would be an

42:59.090 --> 43:02.030
overgrown Osk terminally now everyone

43:02.030 --> 43:03.170
might not agree with that,

43:03.170 --> 43:05.520
but I find it convenient to think of it that way.

43:05.560 --> 43:08.210
And it helps me understand these

43:08.510 --> 43:08.900
C.

43:08.900 --> 43:09.970
One anomalies.

43:09.970 --> 43:10.220
C.

43:10.220 --> 43:10.440
Two.

43:10.440 --> 43:11.960
Anomalies of the dens.

43:13.400 --> 43:16.380
This next thing is really not so much science

43:16.800 --> 43:19.680
as I saw it before and there's nothing that could

43:19.680 --> 43:20.690
look like it again.

43:20.830 --> 43:22.370
So it's got to be anomaly.

43:22.540 --> 43:24.510
If you see this on frontal view,

43:25.000 --> 43:27.740
if you see this on frontal view then you ought to

43:27.740 --> 43:28.690
think of anomaly.

43:28.730 --> 43:29.990
I'm not gonna go into detail.

43:29.990 --> 43:32.780
It looks like that looks like a bunch of lego

43:32.780 --> 43:35.580
toys sort of stacked correct on one side and

43:35.580 --> 43:36.920
incorrect on the other side.

43:37.300 --> 43:40.190
And if you draw a diagram you can have it look like this

43:40.260 --> 43:43.180
and it'll look like that and don't spend a lot of

43:43.180 --> 43:43.960
time looking at it.

43:43.960 --> 43:45.980
Just kind of get the idea there are triangles,

43:45.980 --> 43:48.690
squares and everything in there because we have

43:48.690 --> 43:51.520
three cases of this that I want to show you there and

43:51.520 --> 43:54.350
there and there and when it looks

43:54.350 --> 43:55.070
like that,

43:55.080 --> 43:56.490
that's anomaly you see.

43:56.530 --> 43:58.700
So whatever you see on the lateral view,

43:58.840 --> 44:01.680
if you're concerned about it and you pick up this kind of

44:01.680 --> 44:02.840
stuff on the frontal view,

44:02.840 --> 44:05.780
you go back and say which is what they should have done that friday

44:05.780 --> 44:08.720
evening when they saw that kid with the big auditorium

44:08.720 --> 44:11.650
displaced posterior lee should have said this is the

44:11.650 --> 44:13.390
weirdest looking thing I ever saw.

44:13.400 --> 44:15.310
I mean you couldn't fracture it this way.

44:15.390 --> 44:18.330
This requires an exacto knife to

44:18.330 --> 44:21.250
do this right or a little bolt

44:21.250 --> 44:23.180
of lightning and about the third trimester,

44:23.180 --> 44:23.430
right?

44:23.470 --> 44:26.430
I mean there's no way to get this thing out

44:26.430 --> 44:29.180
of a fracture that's got to be kind of done a different

44:29.180 --> 44:29.490
way.

44:29.500 --> 44:31.390
So there's no science to it at all.

44:31.390 --> 44:32.860
This is step like deformities.

44:32.860 --> 44:32.930
A.

44:32.930 --> 44:35.300
C one C two segmentation abnormalities.

44:35.520 --> 44:37.210
It looks anywhere near this.

44:37.340 --> 44:38.400
It's anomaly.

44:38.450 --> 44:40.160
And that's all I want to say about that.

44:40.390 --> 44:42.340
And we'll be left with one topic then.

44:42.480 --> 44:44.520
Occipital ization of C.

44:44.520 --> 44:44.920
One,

44:45.120 --> 44:46.810
which I think you're all familiar with.

44:49.190 --> 44:50.300
But how do you tell it?

44:50.790 --> 44:52.000
How does it result?

44:52.160 --> 44:52.480
Well,

44:52.480 --> 44:53.660
occipital ization of C.

44:53.660 --> 44:56.590
One is really just a failure of proper segmentation of the

44:56.590 --> 44:57.960
base of the skull from C.

44:57.960 --> 44:58.320
One.

44:58.790 --> 45:01.490
This is how I like to first detected and many

45:01.490 --> 45:03.980
times you will detect it on the scale film.

45:03.980 --> 45:06.950
First of all things look pretty crowded up there,

45:06.950 --> 45:07.500
don't they?

45:08.090 --> 45:09.260
And you're looking for c.

45:09.260 --> 45:09.940
one and c.

45:09.940 --> 45:10.130
two.

45:10.130 --> 45:10.320
Well,

45:10.320 --> 45:12.830
fortunately this one came out of the exam at

45:12.830 --> 45:13.330
labeled,

45:13.330 --> 45:13.770
you see.

45:13.880 --> 45:14.920
So it's easy.

45:15.290 --> 45:17.470
But sometimes out of our excitement,

45:17.470 --> 45:18.560
they're not labeled.

45:18.570 --> 45:21.110
And then I would say it looks crowded.

45:21.160 --> 45:23.060
You can't find your landmarks.

45:23.180 --> 45:25.020
And I want you to note here that C.

45:25.020 --> 45:26.900
Two looks kind of big and plumpy.

45:27.170 --> 45:27.910
That's good.

45:27.930 --> 45:29.110
But it's also bad.

45:29.170 --> 45:30.850
I want you to concentrate on that.

45:31.070 --> 45:31.650
There's C.

45:31.650 --> 45:34.080
One of course the poster arch is

45:34.080 --> 45:37.080
fused because it ought to look like this.

45:37.090 --> 45:37.670
There's C.

45:37.670 --> 45:37.910
One.

45:37.910 --> 45:40.350
You ought to be able to pick it out to pick out the Adan toyed.

45:40.710 --> 45:41.090
Okay,

45:41.090 --> 45:41.900
so first of all,

45:41.900 --> 45:43.260
you ought to be able to pick out,

45:43.260 --> 45:44.670
see one at the base of the skull.

45:44.670 --> 45:47.380
But the most important thing I like to look for

45:47.700 --> 45:48.660
is find C.

45:48.660 --> 45:49.160
Two.

45:49.400 --> 45:50.240
Don't look for C.

45:50.240 --> 45:50.620
One.

45:50.810 --> 45:51.420
Find C.

45:51.420 --> 45:51.780
Two.

45:51.870 --> 45:52.210
C.

45:52.210 --> 45:55.130
Two Almost always is the biggest arch

45:55.140 --> 45:56.890
and spineless process up there.

45:57.090 --> 45:58.410
And why do I say that?

45:58.790 --> 46:01.580
Because if you find the biggest one

46:01.830 --> 46:03.740
up there and it's the first one,

46:03.740 --> 46:05.830
you see something's wrong.

46:07.480 --> 46:09.540
See the first one you see should be smaller,

46:09.550 --> 46:10.340
it should be c.

46:10.340 --> 46:10.680
one.

46:10.930 --> 46:12.150
It should look like this.

46:12.690 --> 46:12.990
C.

46:12.990 --> 46:14.020
one is smaller than c.

46:14.020 --> 46:14.410
two.

46:14.980 --> 46:17.460
If you see the big one up there,

46:17.460 --> 46:20.400
something's wrong and then start looking around and it does look crowded.

46:20.620 --> 46:21.520
It's occipital.

46:21.520 --> 46:21.780
Ized.

46:21.790 --> 46:23.480
So that's one good way to find it.

46:23.850 --> 46:25.320
If you want to confirm it.

46:25.560 --> 46:27.050
The biggest one up here is C.

46:27.050 --> 46:28.700
Two flex them.

46:29.380 --> 46:32.360
And when you flex them it will not separate right from

46:32.360 --> 46:33.780
the basic maybe fibers.

46:33.780 --> 46:34.970
It may be unilateral,

46:34.970 --> 46:36.080
it may be bilateral,

46:36.080 --> 46:37.080
it maybe bony,

46:37.240 --> 46:38.220
there may be no C.

46:38.220 --> 46:39.850
One arch at all.

46:40.010 --> 46:41.660
The first thing though it's crowded,

46:41.870 --> 46:44.010
you can't find your ordinary landmarks.

46:44.120 --> 46:45.240
And the second thing,

46:45.420 --> 46:48.410
the biggest spine ist process that you visualize up

46:48.410 --> 46:49.910
there often will be,

46:50.080 --> 46:52.980
Well the one you visualize will be the biggest and that

46:52.980 --> 46:53.590
should be c.

46:53.590 --> 46:53.970
two.

46:53.980 --> 46:55.500
And that should be abnormal.

46:55.980 --> 46:57.620
Here's another thing that you may not.

46:57.630 --> 47:00.610
Well this is normal to show how it separates off the base of the

47:00.610 --> 47:00.990
skull.

47:01.580 --> 47:03.750
Here's another thing that you might not appreciate.

47:03.870 --> 47:06.850
And I think over the last eight or

47:06.850 --> 47:09.410
10 years I've been able to pick up

47:09.420 --> 47:12.120
three of these on the basis of skull films done for

47:12.120 --> 47:12.880
something else.

47:13.150 --> 47:15.940
Unilateral or bilateral eccentric

47:15.940 --> 47:17.850
stenosis of the foramen magnum.

47:17.850 --> 47:20.330
You notice here is a good finding,

47:20.490 --> 47:23.180
especially with unilateral occipital ization

47:23.350 --> 47:26.350
because normally the foramen magnum should look like

47:26.350 --> 47:26.740
this.

47:27.480 --> 47:30.420
Nice and symmetrical very seldom is an asymmetric.

47:30.610 --> 47:33.290
If it's asymmetric like this you have

47:33.290 --> 47:35.440
unilateral occipital ization.

47:35.440 --> 47:38.210
Maybe bony unilateral on one side fibers on the

47:38.210 --> 47:39.830
other but it's abnormal.

47:40.140 --> 47:41.580
So the flexion is good.

47:41.700 --> 47:44.280
You can see it on the town's view initially.

47:44.280 --> 47:47.000
You suspected because of the crowded appearance

47:47.180 --> 47:49.780
at the the occipital

47:49.780 --> 47:52.220
cervical junction and the inability to

47:52.220 --> 47:53.270
define your C.

47:53.270 --> 47:56.220
One arch anti really post early in the dens and so

47:56.220 --> 47:56.620
forth.

47:56.620 --> 47:58.320
So that's how you pick it up.

47:58.330 --> 47:59.960
You confirm it with reflection.

48:00.060 --> 48:02.150
And then you usually go onto

48:02.420 --> 48:04.700
tomography or and or maya la graffiti to

48:04.700 --> 48:07.290
demonstrate any number of associated

48:07.290 --> 48:08.250
abnormalities.

48:08.470 --> 48:11.380
And of course they may have arnold chiari malformation on the

48:11.380 --> 48:12.070
monogram.

48:12.070 --> 48:13.290
But I'm going to show you too.

48:13.570 --> 48:15.980
Or three plain film findings that you

48:15.990 --> 48:17.230
frequently find with this.

48:17.230 --> 48:17.980
Number one.

48:17.990 --> 48:20.800
Obviously the one of concern is in vaginal

48:20.800 --> 48:23.790
ation of the dance into the frame and magnum well above

48:23.790 --> 48:25.910
this line which I don't think is anybody's in particular.

48:25.910 --> 48:27.740
I can't I never could remember those lines.

48:28.270 --> 48:30.600
And anyway I think they all come from the hard palate.

48:30.600 --> 48:33.460
But this line is just to show you where the frame and magnum

48:33.460 --> 48:33.680
is.

48:33.680 --> 48:35.620
I'm not saying it's anybody's in particular.

48:36.150 --> 48:38.980
The whole thing is shoved up there and the whole spine is

48:38.980 --> 48:40.590
sort of displaced posterior lee.

48:41.570 --> 48:44.060
Now here's hyperplasia of the dense.

48:44.470 --> 48:46.870
If you want to take this back to our dens

48:46.870 --> 48:49.790
anomalies this is hyperplasia with

48:49.790 --> 48:51.340
Noah's opponent Odium.

48:51.340 --> 48:51.870
Okay.

48:51.930 --> 48:54.560
But it's also associated this time with

48:54.560 --> 48:57.490
occipital ization because you see see one is bound to

48:57.490 --> 49:00.450
the base of the skull and the anterior arch now is

49:00.450 --> 49:02.990
right beneath the tip of the cli vous and

49:03.000 --> 49:05.250
often it is even more posterior.

49:05.250 --> 49:08.220
So basilar imagination hyperplasia

49:08.230 --> 49:10.010
or dysplasia if you like.

49:10.010 --> 49:12.680
Of the dense because hyperplasia may be too

49:12.680 --> 49:13.280
limiting.

49:13.320 --> 49:15.170
And then fusion of C.

49:15.170 --> 49:15.900
Two and C.

49:15.900 --> 49:16.370
Three.

49:16.380 --> 49:19.130
All this says is that if you find occipital

49:19.130 --> 49:22.070
ization you must go on and check

49:22.070 --> 49:23.680
it out for these other problems.

49:23.680 --> 49:25.760
Now this in itself is not a big problem.

49:25.760 --> 49:27.780
It's just to sort of round up the discussion.

49:28.070 --> 49:30.790
This is the thing that you want to make sure is not

49:30.800 --> 49:31.230
present.

49:31.230 --> 49:32.770
In other words imagination.

49:33.140 --> 49:35.010
Pressing on the medulla.

49:35.110 --> 49:37.140
Do you have arnold chiari malformation?

49:37.140 --> 49:40.040
You may do maya lager afi in a patient like

49:40.040 --> 49:43.040
this occipital ization as you know often

49:43.040 --> 49:45.990
presents with peculiar neurologic findings.

49:45.990 --> 49:48.650
They may think they have some dim eliminating disease.

49:48.660 --> 49:51.560
They may think they have syringa Malia may think

49:51.560 --> 49:53.290
they have a poster of faucet tumor.

49:53.670 --> 49:56.610
So it is important because the guy,

49:57.970 --> 50:00.580
hopefully the guy that should know most

50:00.580 --> 50:02.470
about or the girl,

50:02.670 --> 50:03.390
pardon me,

50:03.400 --> 50:04.670
I've got a girl in the front row here.

50:04.780 --> 50:05.580
Gotta be careful.

50:06.060 --> 50:07.780
I am old fashioned,

50:07.780 --> 50:08.780
I still say guy.

50:09.160 --> 50:11.860
Uh uh so I can't get

50:11.870 --> 50:13.750
to say just people or person.

50:14.250 --> 50:15.840
Anyway that'll all change eventually.

50:15.840 --> 50:18.620
We'll get back to guy and girl which is the only way

50:18.620 --> 50:19.080
gang.

50:19.560 --> 50:22.430
And I don't

50:22.430 --> 50:25.280
like this business of uh of a person

50:25.410 --> 50:26.280
to neutral.

50:26.760 --> 50:29.200
I like positive and negative.

50:29.210 --> 50:31.610
But anyway that's a side point and so forth.

50:31.620 --> 50:34.490
So the guy or the girl that ought to know

50:34.490 --> 50:37.480
most about this ought to be the radiologist because

50:37.480 --> 50:40.400
you may pick this up and always watch for that

50:40.410 --> 50:42.780
when they come in with peculiar neurologic findings.

50:42.790 --> 50:45.650
Always look at the upper cervical spine on a

50:45.650 --> 50:48.630
skull film and you'll be surprised at how much you see

50:48.630 --> 50:48.890
there,

50:49.160 --> 50:50.740
we can douse that.

50:50.740 --> 50:53.660
And I would like to summarize a few points for you here before

50:53.660 --> 50:56.630
closing because I want to reiterate a couple of things

50:56.630 --> 50:57.490
that are important.

50:58.320 --> 50:59.160
Number one,

51:00.970 --> 51:01.860
C one and C.

51:01.860 --> 51:03.550
Two are prone to anomalies.

51:04.060 --> 51:07.050
So you see if you think you have

51:07.050 --> 51:07.990
an injury at C.

51:07.990 --> 51:08.790
Four and C.

51:08.790 --> 51:09.610
Five or C.

51:09.610 --> 51:10.190
Six,

51:10.860 --> 51:12.450
you probably have an injury at C.

51:12.450 --> 51:12.760
Four,

51:12.760 --> 51:12.980
C.

51:12.980 --> 51:13.640
Five and C.

51:13.640 --> 51:14.390
Six and C.

51:14.390 --> 51:15.470
Seven and so forth.

51:15.470 --> 51:17.110
You know there are anomalies that occur there.

51:17.960 --> 51:20.470
But if you think you've got an injury at C.

51:20.470 --> 51:21.170
One and C.

51:21.170 --> 51:21.640
Two.

51:21.740 --> 51:24.590
Be careful because anomalies are very common as you

51:24.590 --> 51:27.460
all appreciate these things are difficult for you to pick up

51:27.470 --> 51:29.840
often or did differentiate.

51:30.460 --> 51:33.260
And so if you get that orientation at least you'll

51:33.260 --> 51:35.840
stop yourself and say gosh is this an

51:35.840 --> 51:36.830
assault on toity?

51:36.830 --> 51:39.040
Um and then you'll go and look it up if you don't remember.

51:39.040 --> 51:42.030
It's hard to remember all this stuff because it's kind of it's

51:42.040 --> 51:42.850
embryology,

51:42.850 --> 51:44.300
it's weird looking and so forth.

51:44.300 --> 51:46.180
The general orientation is important.

51:46.560 --> 51:49.560
And I would ask you then finally if you're going to

51:49.560 --> 51:52.550
use the poster cervical line in those

51:52.550 --> 51:55.540
pseudo dislocation use it under the proper

51:55.540 --> 51:56.500
circumstances.

51:56.510 --> 51:57.740
Do not use it if C.

51:57.740 --> 51:59.690
Two is not offset on C.

51:59.690 --> 52:00.060
Three.

52:00.950 --> 52:01.720
If it is,

52:02.140 --> 52:03.580
the line is very helpful.

52:04.150 --> 52:07.120
If you follow the criteria that I outlined earlier

52:07.550 --> 52:09.950
and don't have to move the spine around at all.

52:09.950 --> 52:12.210
Just take the first film you get if it's offset,

52:12.220 --> 52:13.390
measure it on that one.

52:13.520 --> 52:16.110
And finally if you can't make up your

52:16.110 --> 52:19.040
mind and you're in doubt don't slough it off as

52:19.040 --> 52:19.660
a normal.

52:19.990 --> 52:22.760
Say it may be abnormal.

52:22.770 --> 52:25.730
It may be normal but we better make real sure

52:25.850 --> 52:28.630
that it's abnormal and then do whatever you have to do

52:28.790 --> 52:31.480
to define whether it's normal or not only

52:31.490 --> 52:33.970
depend on that line when you're sure that everything is good.

52:33.970 --> 52:34.830
A good lateral,

52:34.830 --> 52:37.770
you know where your measurements are it's offset and it comes

52:37.770 --> 52:40.380
within normal range I can tell you that most

52:40.380 --> 52:43.160
cases if not all of them you'll be okay but if

52:43.160 --> 52:45.250
there's any doubt do something else.

52:45.250 --> 52:45.960
Don't rely on it.

52:45.960 --> 52:46.820
Get another film.

52:47.250 --> 52:48.420
That's the easiest thing to do.

52:48.420 --> 52:49.130
Get another film.

52:49.130 --> 52:52.110
You'd be surprised how that bails you out in many

52:52.110 --> 52:52.720
cases.

52:53.250 --> 52:53.880
Thank you.

52:59.650 --> 53:02.490
A medical media production from W R E M

53:02.490 --> 53:03.480
c t V.