112: The Spine Part 1 – Learning vs memorizing

Hello and welcome to episode 112 of the Physician Assistant Exam Review Podcast. This week we’re going to be talking about spinal disorders. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review, where we teach PA students to dominate PA school and ultimately pass the PANCE and land their dream job. If you find this show helpful, please do me a favor and your friends a favor. Please share it with them. I get tons of feedback from people saying how they’ve listened to the podcast since day one of PA school and how it’s helped them get through and they’ve learned so much.

Do your friends and me a favor and share it with them.

Let’s get more people on board. That’s my goal here is to help as many PA students as possible and you are integral in that pursuit. I need your help. I absolutely need your help. That’s the biggest way the show gets to more people is by you sharing it.

All right. I am recording this on July 4th on Independence Day. So happy Independence Day. This is one of my favorite holidays just because the meaning packed behind it. The signing of the Declaration of Independence is obviously one of the most profound things that’s happened in the history of the world, right? The founding of this country. Just an amazing document.

And if you haven’t read it or haven’t read it recently, I strongly recommend that you go ahead and do that. It’s not hard to find. Won’t take you that long. If you’re at this level, then you can read fairly well, fairly quickly. Take some time to go through that document. It’s very moving. And I think it would give you a newfound appreciation for what this country stands for, what freedom looks like, all of those things.

Now, let’s move on a little bit. I’m mentioning that this is being recorded on July 4th specifically because I’m hosting two, only two more cohorts of the 33 Days to Pass the PANCE program in 2023. One will be held in August and one will be held in November. Initially, I was thinking about doing one in September, but it’s just become too overwhelming for me to invest the time and energy into those students that I need to, as well as the things that are growing for Physician Assistant Exam Review in general. So I’ve cut out the September cohort and there’s only going to be in August and in November left in 2023. The registration for the August cohort will begin on Monday, August 10th at 6am. I’m also only taking 40 people in that cohort.

So if you’re interested, I strongly recommend that you get on board early because although registration is set to run through that week, I’m going to shut it down once we hit the cap for the class, because I want to be able to focus on the people in the class. And it needs to be that size is the bottom line. So I will be shutting down if we get to that number. Well, now we may not get to the number. I can’t say when we will. But if you’re interested and you definitely want your spot in the August cohort, then I would get on, like I said, on Monday and make sure that I was in there. That will be, I’ve talked to a lot of students about the 33 Days program on their way out the door.

And I’ve had a number of them say, yeah, two or three months before would actually be helpful because the things we teach, the things we go over, it’s nice to have some time to practice them, sometimes to work with them, sometimes to create them, to turn them into habits, right? It’s one of the reasons why it’s over 33 Days, but it’d be nice to have a little bit more time. So if you’re taking your test in September or October or November, don’t feel like doing the August cohort would be too early for you. I think that would be perfect. A lot of students have said that that would work out really well. Anyway if you’re interested, you can find more information at physicianassistantexamreview.com/33, and that will get you more information on the 33 Days program. I just finished the June cohort.

It ended yesterday, as a matter of fact, and this group was amazing. They were absolutely a ton of fun, very engaged. I had a lot of people who had students who were in their first year of PA school because they wanted to learn how to take tests better. They wanted to learn how to study better. I had students who had failed the PANCE two and three times. I had someone who had failed the PANRE two or three times, and they’ve just made amazing progress. So this one person wrote in just today, this morning, and I was very thankful to hear it.

I’m just going to read to you what she wrote, what she emailed me. Day 33 exclamation point. Thank you, Brian, for all your daily lessons. I’ve looked forward to getting up and listening to them every morning as I complete my daily walks. Seriously, they’ve helped me so much. I just finished my second practice test and it felt great. No testing anxiety the entire time.

On my first practice exam, I got a 66. And honestly, I was pretty excited with that score, seeing I was trying to implement new testing strategies and I’m a recovering failure. And now I just got a 77 on my second practice exam. Clearly, I’m more excited about that score. I love seeing my progress, but more importantly, how far I’ve come mentally. I owe it all to your lessons and motivation. You deserve an award for being so motivating.

I still don’t take the PANCE for my third and final time for a few weeks, so I will continue each day doing what I’ve learned, but I just wanted to publicly thank you for putting in the work so we can all put in the work and also benefit from this program. So that was posted inside the group discussion and it really was nice to hear, but it’s also really nice to see the progress that this individual has made throughout these 33 Days. You can see in just a short period of time there’s the movement in the scores that she’s been able to attain and I have no doubt she’s going to crush it on the day of her PANCE. So anyway, let’s go ahead and move on to our discussion of the spinal disorders. Today we’re going to be covering part one as I’m going through it, turned into it’s a little bit longer than I expected. So we’re going to split it up into two parts. So we’re going to start with our priming questions.

The shopping cart sign is a symptom of what disorder? The shopping cart sign is a symptom of what disorder? Numbness of the posterior calf may indicate a dysfunction of which nerve root? Numbness over the posterior calf may indicate a dysfunction of which nerve root? Decreased strength of great toe dorsiflexion may indicate a dysfunction of which nerve root? Saddle anesthesia should make you think of what diagnosis? Saddle anesthesia should make you think of what diagnosis?

What is the minimum you should wait to order imaging on a patient with generalized low back pain and no significant history? What is the minimum you should wait to order imaging on a patient with generalized low back pain and no significant history?

All right, so hopefully you could answer one or two of those. And as we move through this, you will pick up on a couple of the others. But please keep an eye out, keep an ear out for the answers to those. Again, that’s what the priming questions are for, is to get you involved, to get you moving, to get you thinking. Not letting this material wash over you, but putting you in a position to work with the material. So we’re going to start with low back pain, so strains and sprains. Here you’re going to split this into acute, less than six weeks, and chronic, greater than 12 weeks, right?

Usually we don’t find a cause, and imaging is not recommended for nonspecific back pain for at least four to six weeks. So, we’re not going to get x-rays of people when they walk in the door with back pain, right? Not immediately. Clinical presentation. Patients come in because they twisted their back and now they can’t move. Pain in the lower back, point tenderness over the lower back, or sciatic pain, pain shooting down the leg. Lab studies and physical exam findings.

You’re going to inspect and palpate the back. And you may find some muscular issues. You’re going to test for check for range of motion. You’re going to do a straight leg raise looking for a herniated disc, and we’ll get into that in a minute. Assess L5 and S1 nerve roots looking for a herniated disc. We’ll get into that in a moment. And then imaging only after several weeks of pain or if there is some indication such as a fall or concern of metastatic disease.

Treatment. So here we just have generalized low back pain, right? Treatment’s going to be NSAIDs, acetaminophen, maybe opioids, maybe a muscle relaxer, physical therapy, exercise is going to be key. Laying on the couch makes these things worse. You have to be careful because you don’t want to do a lot, but certainly walking, getting people up and moving. Heat tends to work real well. And then most patients will improve within a few weeks.

Herniated discs. So 98% of herniated discs, which are symptomatic, occur at L4, L5, or L5, S1. This is a herniation of the nucleus pulposus through the annulus fibrosus. I’m thinking everybody at this point knows that. I could be wrong. But for whatever reason, at least I felt like I had a really good picture of herniated discs in my head before we began this. Causes are degeneration of tissue secondary to age.

Trauma. Repetitive lifting and bending. Clinical presentation. This is pain radiating from my back down my leg. You get weakness. Incontinence as possible, and sexual dysfunction. Because we’re pinching off nerve roots is really the problem with that disc.

So what happens is that disc herniates into a space that should be otherwise occupied or empty for nerve roots, right? Or up against the spinal cord. Lab studies and physical exam findings. You can do a straight leg test. So here you dorsiflex the ankle of a patient lying supine. You lift the leg with the knee straight. Knee straight is key.

Attempt to lift the leg until the hip is at 90 degrees and radiculopathy is a positive sign. A cross-straight leg test is another one you can do. Here you’re going to elevate the unaffected leg in the same manner. If symptoms appear in the affected leg, then this is also a positive sign. So we’re putting tension onto that disc space. Checking L5 nerve, you get a decreased ankle strength. Decreased strength of the great toe dorsiflexion, numbness of the medial foot and the web space between the first and second toes.

Let me say that again. Checking for the L5 nerve root, you get decreased ankle strength, decreased strength of great toe dorsiflexion, and numbness of the medial foot and web space between the first and second toe. Checking the S1 nerve root, numbness over the posterior calf, numbness of the lateral foot, weakness of plantar flexion. And a decrease in the Achilles reflex from the S1 nerve root. Treatments. NSAIDs are a good place to start. We just want to decrease that inflammation.

And epidural steroid injection. Again, epidural steroid injection is a localized steroid, right? So we’re going to decrease the inflammation in a local setting. So an NSAID, if you’re going to take an oral NSAID, it’s going to decrease inflammation throughout the body. If you’re going to inject that and a steroid into a specific area, we’re going to decrease inflammation in that area profoundly. Physical therapy, and then lastly, surgical treatment, which include a discectomy. So going in and taking that disc out that’s in the space it shouldn’t be in.

So removing that piece that has herniated. And then if you’re going to do this in the cervical spine, it may be an anterior cervical discectomy and fusion. So, you may go in and take the entire disc out, and then you put a bone block between the two vertebrae, and you fuse the two adjacent vertebrae. So, you completely remove that disc. Cauda equina is next. I should have done that after spinal stenosis, but that’s okay. Cauda equina syndrome.

This is the lumbar nerve roots of two to five, sacral nerve roots of one to five, and the coccygeal nerve. This is at the base of the spinal cord, right? You get where the nerve roots all come down, and it looks like a horsetail if you see the image of this. These nerves innervate the pelvic organs and the lower limbs. In most adults, the spinal cord ends, and the cauda equina begins at L1, L2. Cauda equina syndrome is when there is pressure on this section, on these nerve roots. And the causes of this, if you just stop and think about it, again, this is one of those things I wouldn’t memorize, but if you think about it, herniated disc, pressing in there, osteoarthritis, compression fractures, congenital, so a narrow spinal canal, trauma, tumor, that’s in the canal, right?

And an inflammatory condition, anything that’s going to create and fill up the space where that cauda equina should be can create cauda equina syndrome. Clinical presentation. The two I’d be watching out for on my test or in my clinic as I did when I was on call, saddle anesthesia and bowel or bladder incontinence. So we have a spine surgeon in the group I was in. And these are two words. I was always, two things I was always on the lookout for if I got a call about one of his patients, right? Especially after surgery.

Saddle anesthesia or bowel or bladder incontinence. Because cauda equina is a surgical emergency. You can also get sexual dysfunction, pain in the lower extremities, and paraplegia. Lab studies and physical exam findings, paraplegia, altered sensation to pain in the lower limbs. Then you get a CAT scan or an MRI to demonstrate what’s going on there. Acute onset of cauda equina syndrome is an emergency requiring immediate attention. So they need surgical decompression here, right?

Again, these are not, I want to be clear. And I’ve said this hundreds of times on this podcast. These are not things you memorize. These are things you understand. This is not a memory trick. This is an understanding thing. If I think about how do I deal with pressure on the cauda equina, if I’m in a position where I’ve lost bowel or bladder function and I’ve got saddle anesthesia I’ve got to go in and fix it.

I’m going to surgically decompress that canal. There’s something pressing that needs to be removed. The concept is not difficult. The practice is difficult but the idea is pretty straightforward. Don’t memorize it. Picture it in your mind and understand it.

Alright, we’ve got one more for today. Like I said, I wanted to keep the spine section a little bit shorter rather than going double length on it. I sort of figured it’d be smarter to break it up and have you be able to hold onto it more. Plus, it’s a holiday, so I want to get this recorded. I’m on my way to a friend’s house to a pool party and then off to a minor league baseball game to watch the fireworks. But I still wanted to get the show out today. So to be perfectly honest, that’s also part of the reason why this one got split up.

Anyway, spinal stenosis is next, and I probably should have done this before cauda equina. This is a narrowing of the spinal canal resulting in compression of the spinal cord or nerve roots coming off the spinal cord. So this is, again, one of those things. Don’t memorize that definition. Don’t do it. Instead, picture the spinal cord moving through the canal and then picture what might happen if that canal was narrowed for some reason. You’d put pressure onto that spinal column.

You’d put pressure onto the nerve roots. And we know from learning about things like carpal tunnel and all kinds of things in your life, of course, by now you know that if you pinch off nerves, they get unhappy, right? You get decreased sensation, you get paresthesias, you get tingling and numbness when you put compression on nerves. So it’s the same thing here.

Now, what would cause spinal stenosis? What would cause a narrowing of that spinal canal? Can you think of a few things that we’ve already mentioned in this particular episode that might cause a spinal narrowing? How about a herniated disc? That’s exactly what we were talking about. We’re going to put pressure onto that spinal cord. We’re going to fill up that canal with a disc that is not where it’s supposed to be, or at least part of a disc.

What about osteoarthritis? What if we just have some arthritis into that canal? Some bony overgrowth, some osteophytes. Certainly they could create some pressure onto the spinal cord or onto the nerve roots. A narrowing can be formed simply through aging and osteoarthritis. Compression fractures can absolutely affect those nerve roots. You could have a congenital narrow spinal canal.

You could have trauma. If you had a tumor with a mass effect inside that canal, or any other inflammatory conditions. Again, I’m picturing carpal tunnel syndrome, the things that make carpal tunnel syndrome so painful, that inflammation through that canal, it’s the same idea here, just on a larger scale. Clinical presentation. This is pain with lying down, low back pain. They can have gait issues. Pseudoclaudication is a good one.

This is the patient gets pain down their legs. The patient gets pain down their legs. So it’s similar to claudication, but they have good pulses. It’s not a vascular issue. It’s a nerve issue. They can get anesthesia or paresthesias. They can get weakness down the legs.

Radiculopathy, so pain and weakness or numbness radiating down a particular nerve distribution. Then again, you could get loss of bowel or bladder function depending on what we’re pressing against. And then the other thing patients will talk about when they come in is the shopping cart sign. So they get relief of symptoms while bending forward and pushing a shopping cart because you’re adjusting the strain on that spinal canal. That flexion of the spine can alleviate some of the pressure on those nerves. Lab studies and physical exam findings. You get an x-ray, an MRI, perhaps a myelogram or an electromyogram for nerve conduction.

Treatments, we always start small with NSAIDs and Tylenol to help relieve some of that inflammation and pain. Exercise and physical therapy. Again, you can do an epidural steroid injection. Some of this depends on what you think is causing the problem, though, right? So these are the generalized treatments, but you’re going to do specific treatments based on what you believe the problem is being caused by. And that’s what the MRI and the electromyogram are for. Lumbar decompression, so surgical.

You’re going to remove the bone and ligament overlying the spinal canal and basically let it breathe, give it some space, just like you would do a carpal tunnel. Right, you’d cut the ligaments. You’d open this up to allow the nerve the space that it needs. So it’s surgical correction.

All right, so that ends our talk on the spinal disorders for today, spinal disorders part one. Very, very quickly, our study tip for today, I just want to talk briefly about what I mentioned throughout this, is the idea that a deep understanding is going to retain information far longer than memory tricks, right? So we all use memory tricks to get us by, but we wonder why we don’t retain information. Well, it doesn’t stick. While it’s not with us on exam day or it disappears the day after the exam. It’s because you’re using a trick to get you through. A much better process is to know the information, to learn the information, to make it part of you.

We talked about associations not too many shows ago. It’s important that you understand the material rather than just memorizing words. So today, for spinal stenosis, you should be able to think of the reasons that might cause that. Same as cauda equina, right? They’re not that different. Why would a straight leg test be an issue? Why would that work on a herniated disc?

Those are the kinds of questions you should be asking and you should be considering. Not memorizing lists of causes, but understanding what the situation looks like and what might cause those problems. Understanding what the situation looks like and why a straight leg raise would cause symptoms to be increased. Not memorizing the shopping cart sign, but picturing the elderly man or woman coming into your office. And when you ask them, they say, yeah, I do feel better when I’m leaning forward like this after I’ve been in pain for a little while and understanding why that works. It creates much more durable memory than memorizing these lists.

Now, you’re certainly welcome. You know, I have all the notes over on the website, physicianassistantexamreview.com. All of the notes are along with the show, so you can go in and read every bullet point and memorize each bullet point. But if that were it, I would just have you read the notes. But it’s not. That’s why I do the podcast, is to fill in the color, to fill in the stories, because that’s what creates the durable knowledge, not the lists upon lists upon lists. That’s how we don’t remember anything, right?

That’s how we fight our own brains. I can’t remember my shopping list by the time I get to the store, let alone these. You’ve got to create those mental images. You have to create that deep understanding. That’s how you get the stuff to stick.

All right, let’s answer our priming questions. Shopping cart sign is a symptom of what disorder? Hopefully you got this one nailed at this point. Shopping cart sign is a symptom of what disorder? Spinal stenosis. Numbness of the posterior calf may indicate a dysfunction of which nerve root? S1.

That’s that Achilles reflex. Decreased strength of the great toe dorsiflexion may indicate a dysfunction of which nerve root? Again, are you picturing what dorsiflexion looks like or are you just memorizing the words? What does great toe dorsiflexion look like? It’s lifting up of the great toe, right? That should be a picture in your mind. Decreased strength of lifting up the great toe may indicate a dysfunction of which nerve root?

The answer is L5. Saddle anesthesia should make you think of what diagnosis? This should terrify you, so it should jump right out. Saddle anesthesia should make you think of what diagnosis? Cauda equina syndrome. And what is the minimum you should wait to order imaging on a patient with generalized low back pain and no significant history? That’s one I feel like is going to show up on your exam.

Four weeks. The answer there is four weeks.

All right, fantastic. Thank you so much for participating and being a member of this community and listening to the full episode today. I really do appreciate it. Happy Independence Day. And once again, if you are interested and you’re taking your exam anywhere towards the end of this year, I do recommend that you check out physicianassistantexamreview.com/33 to look into the 33 Days to Pass the PANCE program. We’ve had amazing success over the past year. We had four cohorts last year and three already this year.

So, seven cohorts of just fantastic people really making huge differences in their lives and in their work. So, that’s just been an absolute blast. I’d love for you to be a part of it.

All right. So, until next time where we pick up with the spinal cord, the second part of the spinal cord, and again, you can get those questions over at physicianassistantexamreview.com/MSK.

All right. Good luck. Take care. If you’re taking your exam anytime soon, good luck on that.