131 Neuro: Spinal Cord issues

Hello and welcome to the Physician Assistant Exam Review Podcast. Today is episode 131. We’re going to be covering spinal cord conditions. It has been some time since I’ve been behind the microphone here. We entered the June cohort of the 33 Days to Pass the PANCE program, and that wound up taking up a ton of my time and moving directly into peak baseball travel tournament season where I’ve been in Atlantic City. I’ve been in Newark. I’ve been in Greenville, North Carolina.

I’ve been in Atlanta, Georgia. I’m headed to Boston soon with a sophomore who has aspirations of playing college baseball. It has taken up a ton of my time. But I’m thrilled to be back here. I’m thrilled to be looking at coming up on the end of Neuro. That’s something I’ve been really, really wanting to put behind us and feeling terrible that we’re still mired in this section. And part of it may be just that it’s not my cup of tea.

That’s not my area of expertise. Might be one of the reasons why I’m not diving into this. But regardless, here we are and we need to finish it up. And sometimes that’s how it goes when you’re studying, right? Like it may not be your favorite topic. It may not be your favorite thing, but here it is. And you got to suck it up and get through it.

So that’s what we’re going to do today with neuro. We’re going to finish up spinal conditions today. And then in the next full length episode, we’re going to cover malignant and benign neoplasms. And then that should really finish us up on the entire section. One thing before we jump in and get started is that next week, I have a little sliver of time before I’m off to the next thing. And so what I decided to do with that was on Monday and Tuesday next week, so that’s July 28th and 29th at 8pm Eastern time, I’m going to be doing a Master Class on passing the PANCE. I’ve done it a couple of times in the past, it goes over great.

The goal of that Master Class is to increase your scores on your PANCE, but really any high stakes exam by between five and 10% just off of what we’re going to go over in that particular class. So you can register for that at physicianassistantexamreview.com/masterclass. Share it with your friends. If you know anyone who’s struggling, that would be fantastic. And I can’t wait to host that. Those are just so much fun. So I can’t wait to see you there.

All right, let’s go ahead and jump into our priming questions for today’s episode. What is the hallmark clinical triad of cauda equina syndrome? What is the hallmark clinical triad of cauda equina syndrome? Which imaging modality is the gold standard for diagnosing spinal epidural abscess? Which imaging modality is the gold standard for diagnosing spinal epidural abscess? What is the recommended initial treatment approach for confirmed cauda equina syndrome? What is the recommended initial treatment approach for confirmed cauda equina syndrome?

And the last one is what are the two most common pathogens responsible for spinal epidural abscess?

All right, so we’re going to jump right in and get started with cauda equina. So those are what we’re going to be covering today is cauda equina syndrome, epidural abscess, and then spinal cord injuries in general. And the way that we typically do this is we go through each of these. We talk a little bit about each one independently. And then we’d like to talk a little bit about how they compare and contrast and how they’re going to come to you on exams. So for cauda equina syndrome, this is a neurosurgical emergency. This is really, really important.

I remember when I first was on first graduated PA school, my very first job was with an orthopedic surgeon, and we were in a group. And we did foot and ankle surgery, but within that group was a spine surgeon. And one of the very first things that my surgeon explained to me when we were on call was like, hey, if you have a patient who calls in with back pain, you need to make sure they’re not having a cauda equina syndrome. And that’s really easy to do, but you have to ask some key questions because this is a emergency that you can’t miss. And I love that thought process because when I look at certain things, and you’ve heard me talk about this before, I like iterative learning, right? So we go through, I want to learn, I can’t learn everything all at once. So I’m going to learn the most important things?

Well, the most important things are the things that can kill someone, the things that can cause permanent damage, right? So you want to be aware of those in particular. So cauda equina is a really, is a very important one for that because you don’t want to miss it. So this is a neurosurgical emergency due to compression of the cauda equina and nerve roots, usually from a disc herniation, tumor, or trauma. The clinical presentation, and this is what I was getting at, what he wanted me to ask if I were on call of the nursing staff to make sure the patient wasn’t having these symptoms was severe low back pain, which is what they would call it with, bilateral leg radiation, saddle anesthesia. So where the area that would be in contact with the saddle, if you’re riding a horse, you would be numb through that area. Bowel or bladder dysfunction.

So this was a big one. This was the easiest one to ask and get a good answer on. Are they having bowel or bladder dysfunction? Decreased rectal tone and then lower extremity weakness. Lab studies and physical exam findings for this: immediate MRI of the lumbar spine. That’s going to be your gold standard to show that nerve root compression. And a rectal exam showing decreased sphincter tone is going to be the rest of your physical exam.

Treatment is really straightforward. This is emergent surgical decompression within 24 to 48 hours. We have to get the pressure off that nerve root. Supportive care is pain management, and maybe they might need a catheter if they’re having bladder dysfunction.

Now, again, to me, both clinically and then on my exams, I want to know what’s the important thing? Like, how do I tell the difference? And what what are the other things in differential diagnosis that are less worrisome or more worrisome, etc.? In this case, there’s nothing really more worrisome. So, what’s going to separate this from lumbar radiculopathy? What’s going to what’s going to separate this from sciatica? What’s going to separate this from normal post-operative spine patient pain?

And the answer is going to be that rapid onset of bilateral symptoms, and then that bowel and bladder dysfunction. That’s really going to be your major keys there.

Next, we have epidural abscess. So a spinal epidural infection, commonly, most commonly caused by staph aureus. That seems like an easy test question, most commonly caused by staph aureus. Risk factors are going to be IV drug use, recent spinal, or immunosuppression. Clinical presentation. So you have a classic triad for an epidural abscess. This is something I would definitely mark down and know.

Fever, localized spinal tenderness, to progressive neurological deficits. So we have a fever, we have localized spinal tenderness, and we have progressive neurological deficits. It’s not that hard to understand and wrap your head around. Why would you have a fever? Well, you have an abscess, you have an infection. Why would you have localized spinal tenderness? You could push on that abscess that gives them pain.

Progressive neurological deficits, this depends on where it is and what it’s compressing along. That should be noticeable. So you have an insidious onset of worsening back pain, fever, neurological symptoms over days to weeks. This doesn’t happen instantly, right? This isn’t the cauda equina. This isn’t right away. This takes a little time to develop.

And if you think about developing an abscess, it takes some time. Lab studies and physical exam findings. Your normal infectious things, so elevated ESR, CRP, and leukocytosis. But what’s going to be our definitive diagnosis? It’s going to be an MRI with gadolinium, and you’ll see a ring-enhancing lesions with surrounding inflammation. We’re going to do immediate empiric IV antibiotics, so something like vancomycin plus ceftriaxone. And then our definitive treatment is going to be what?

So think it through. This is where I want you to understand you don’t have to know everything to get some things right. So, epidural abscess, we’re going to give antibiotics, but what else are we going to do? Surgical drainage, right? If I have progressive neurological deficit and a large abscess, I’m going to have to do something else. I’m going to have to solve this problem because sometimes if you have a giant abscess, antibiotics don’t get in there, right? So, you have to go in and drain it.

How does this look different than the other things we just talked about? So, this is different from cauda equina because the time frame is different. It’s also different because what else? You don’t have that pain over with palpation with a cauda equina. We also have fever here. That’s going to really stand out. If you get a back pain with fever, geez, that’s pretty much going to be epidural abscess, right?

How about spinal cord injuries next? These are traumatic injury causing varying neurological deficits based on level and completeness. So what I’m trying to say here is the symptoms are going to vary. You have a traumatic injury of some kind, but the symptoms are going to be neurologic, but based on where that injury is. So obviously the clinical presentation is going to be acute trauma history. And you have neurological deficits. So if it’s cervical injuries, you can get a tetraplegia or quadriplegia.

If it’s a thoracic or lumbar injury, you can get a paraplegia. Something that I think may be of value for you is the idea of neurogenic shock. So this is hypotension and bradycardia. This is seen with injuries above the T6 level due to disrupted autonomic pathways. I don’t know. I just kind of feel like I could see a question on that. And that’s kind of, maybe you could consider it obscure, but I don’t know.

I think neurogenic shock is something I would know. Hypotension and bradycardia. Lab studies and physical exam findings. Well, what are we going to do for our labs finding? Physical exam findings, right? You’re going to do a CT scan for assessment of bone injuries and an MRI to evaluate the soft tissue, so spinal cord involvement, etc. Initial management is going to be stabilization, right?

We don’t want them moving more. That’s the whole point. When you see people at an accident site, they say, don’t move, right? The cervical collar, spine immobilization. We’re going to want to watch their airway. If they have neurogenic shock. So if they have that hypotension and bradycardia, what are we going to do for that?

We’re going to give them IV fluids and vasopressors. We may have to move to surgical decompression and stabilization depending on what’s going on. And steroids is possible, high-dose steroids, to decrease inflammation in the spinal cord. But that would have to be extremely soon after the injury. And that brings us right to the end of spinal cord injuries. This was a little bit quicker than I was anticipating. You’d be amazed how long it takes to put the notes together to get that much information out.

And also keep that in mind as you are sitting in lectures with your faculty, how much time and effort it takes to put these lectures together. You would be shocked at how much energy goes into it for how what appears to be such little content. Anyway, so this was spinal cord injuries. I do not want to combine it with neoplasms. I think neoplasms is enough on its own. I want to keep it separate. So that’s the other reason why we’re going to keep this one short.

And then the last reason we’re going to keep it short is because I haven’t put an episode out in a long time, and I really want to get back to it. I want to make sure that we’re giving you guys everything that you need, helping you along the way. In fact, our study tip for today falls right in line with that. Our study tip for today is consistency. Consistency is such a game winning strategy and something that I am terrible at. I tend to be the guy who goes to the gym for a month and absolutely kills it. I’m the guy who signs up for a challenge and has no problem completing that challenge.

But then once that’s over, the wheels come off a little bit, right? So and you’ve seen that in how I put these podcasts out how I do a lot of the work around here, there’s a lot of ups and downs. The podcast is fantastic and helps a lot of students and I get great feedback on it. But then I start a cohort for the 33 Days and then that takes me away for a while. And then I move into something else. So one of my focuses is really on consistency and it applies to pretty much everything we do, but studying in particular. And that’s why I bring it up here because studying in large bursts is not really what your brain’s designed to do.

So sitting for six or eight hours in the library on a Saturday, that’s all well and good. But honestly, you get more out of a good three hours on Saturday and a good two hours on Sunday than you would have six or eight hours on Saturday. That multiple touches is really, really valuable. That coming in and out is really valuable. Our brains just can’t stay motivated. You know, we wonder why we lack motivation. You know, lack motivation.

You’re reading a medical textbook for six hours. You’re not going to be all that motivated. It’s not hard to understand how that works, right? And it also, when you do things multiple times for multiple days, it starts to train your brain to to accept that these are important, that this this thing you have deemed it to be important, so therefore we should remember it. Your brain is a forgetting organism, organ, not a remembering organ. It’s designed to forget most of what you come in contact with. So one way that you get it to remember is by having multiple touches, multiple contacts with things.

That’s how you train your brain to recognize something as important. So by studying consistently 30, 40 minutes a day, an hour a day, two hours a day, whatever fits into your schedule, I can’t tell you what works for you. But see if you can’t break that up. And then yeah, certainly you can have bigger chunks on the weekends, or you can have bigger chunks on a day off and things, of course, but don’t let a day go by without putting in some work, right? Even if it’s 20 minutes, even if it’s half an hour, put in some work on those days, and you’ll find an incredible difference in your ability to retain information and then subsequently also in your ability to trust yourself. And it’ll help to fight off that imposter syndrome quite a bit, actually, if you can remain consistent and disciplined. I don’t want to go down that whole rabbit hole right now, but that would be the other possibility.

All right, let’s jump in and answer our priming questions. Hopefully you can get these now that we’ve gone through this section. What is the hallmark clinical triad of cauda equina syndrome? Bilateral leg radiation, saddle anesthesia, and bowel and bladder dysfunction. Severe lower back pain with bilateral leg radiation, saddle anesthesia, and bowel and bladder dysfunction. Which imaging modality is the gold standard for diagnosing spinal epidural abscess? How are we going to diagnose it?

MRI with gadolinium. What is the recommended initial treatment approach for confirmed cauda equina syndrome? How do we treat cauda equina? Emergent surgical decompression within 24 to 48 hours. What are the two most common pathogens responsible for spinal epidural abscesses? Well, I mentioned staph aureus. I did not put streptococcus in there.

I should probably add that to the notes. Staph aureus and Streptococcus.

Fantastic. All right. Well, it was so fun to be back. So glad to be doing this. So glad to be putting the notes together. It’s been a great, great year with the 33 Days program. It’s been a great year with the podcast.

Been a great year with the students on the email list. It’s just been a ton of fun, and I want to thank you so much for that. I’m glad to be excited. I’m excited to get back to this. Again, as a way to give back and a way to help, I’m putting on that Master Class next week, Tuesday. I’m sorry, Monday and Tuesday, July 28th and 29th, 8 p.m. Eastern time.

Definitely go over to physicianassistantexamreview.com/masterclass to sign up for that. And again, if you know someone who’s struggling, if you have a student or a friend or someone behind you in school, anywhere, please let them know about that link. Let them know about the Master Class going on next week. Both days are going to be exactly the same, so don’t feel like you need to come to one or the other. Come to just choose the one that works best for you.

All right, take care.