Hello, and welcome to episode 113 of the Physician Assistant Exam Review Podcast. This week, we’re going to continue with spinal disorders. My name is Brian Wallace. I’m the founder here at Physician Assistant Exam Review, where we teach PA students how dominate PA school and ultimately pass the PANCE and land their dream job. If you find the show helpful, here’s what I would really appreciate. If you share it with your classmates, if you share it with your friends, if you share it with your colleagues, if you share it with your faculty members, your professors, the way that this show grows, the way that I can help more people is through you telling people about the show. I don’t do really any advertising.

I don’t really promote it anywhere. I spend most of my time focused on creating content for you guys. So you sharing it is an extremely important piece of the puzzle. So I would really appreciate that. And I believe if you’re getting something out of it, so it’s your classmates and your faculty members as well. So pass it along to the class behind you, pass it along to your classmates. And again, let everybody know that this is helping you make progress.

Like I said, that can’t be overstated how important that is to me and how important it can be to the people that you work with.

Now, today we’re going to get into spinal disorders. A couple of things real quick before we do that. Number one is if you want to pick up the list of 25 questions pulled straight from The Final Step for orthopedics, for musculoskeletal, you can do that at physicianassistantexamreview.com/MSK. That’s for musculoskeletal / MSK. Another thing you can do on the website at physicianassistantexamreview.com is you can pick up the very first edition of the Physician Assistant Exam Scholars newsletter. I have that available to you on the homepage. If you just head over to the homepage, you’ll see it.

You can go ahead and pick that up. We’re going to be talking about a little bit about what’s in that issue today because it’s something I’ve been teaching to the 33 Days group. And while I’m talking about the 33 Days group, the August group is making their way through. They just finished week one. They’re doing great, making some real progress, really enjoying what’s going on there. If you’re interested in doing or completing the 33 Days program this year in 2023. The very last cohort will be in November.

November 2023 is the last cohort for this year. I don’t know yet what the dates are for next year, how many I’m going to do or how that fills in. I haven’t really thought through it yet. But if you want to be guaranteed, if you want to get into that program November 2023, you can head over to physicianassistantexamreview.com/33, and you can go ahead and register today for that program. Like I said, I’ve opened registration up for that. So that’s available so you can plan and get things ready. And what I’ve heard from people is, one, it’s been really effective for those individuals who are still in school and looking for new ways to learn, to study, to get through their material.

And two, for people who either are taken there, in this case, it would be your PANCE in mid to late December, January or February, really two to three months. It seems like a great time to get involved there. Yeah, and I think that about covers it. So, anyway, we’re halfway through the summer. I’m actually looking forward to looking at where my kids may be soon going back to school, which is helpful for me. I don’t know how you guys, where you are in your journey, but with a 14 year old in the house who’s up all night and sleeps half the day, it certainly changes my approach to things. So, I’ll be looking forward to him going back to school and the bus comes at 6 30 in the morning.

So, it’ll be a big, big adjustment for our whole family, but that’s not too far around the corner. So I hope you’re getting the most out of these last few weeks of summer. Even if you’re in school, make sure you’re taking some time for yourself. Make sure you’re taking some time to get to the beach, to get to the pool, to get some refreshment for your brain, right? To get that, to get things relaxed and calm down for a minute. I know a lot of what we do is that constant on, that constant pressure. And it’s so important to take a minute and pull up from that.

And the summer’s a great time to do that because you’re in the middle of this season where there aren’t really a lot of holidays or generally aren’t a lot of family obligations. There isn’t a lot of other things going on. So it’s a good time to pull up and use your weekends for a little restorative activity. I know that that’s not always easy. You know, I joke with students who email me and say that they’ve passed the PANCE and I say, so what did you do? Study today? And they say, I tried so hard not to, but it feels so uncomfortable, right?

Because you’re so used to studying, you’re so used to putting in that time, but it is okay to give yourself a break. And like I said, I think summer is a great time to work that in.

All right, let’s go ahead and get started with our priming questions. So these are a little tough, at least they would have been for me, especially if you haven’t studied musculoskeletal yet. But again, with all of our priming questions, what I really want from you is to get your brain working. You know, I spent a lot of time in our meeting last night for the 33 Days group. We do weekly meetings there. We get together and talk about, you know, what struggles people are having and also go over the lessons that I teach. But one of the key things is getting your brain working, getting your brain involved, not just passively sitting and listening to me talk, not just passively sitting in your lectures, but really getting moving.

So priming questions. At what Cobb angle is surgery recommended for scoliosis? Are you going to know this one off the top of your head? Probably not. But I want you to be listening as we go through it, looking for the answer. At what Cobb angle is surgery recommended for scoliosis? What is the x-ray finding associated with ankylosing spondylitis?

What is the x-ray finding associated with ankylosing spondylitis? Can you name two causes of kyphosis? Do you know what kyphosis is? That’s probably a better question. Name two causes of kyphosis. And what is the most common demographic for ankylosing spondylitis? Who’s going to walk through your door that you should be considering looking into ankylosing spondylitis for?

Perfect. All right, well, we’re going to start there with ankylosing spondylitis. That’ll be our first diagnosis, our first disease for today, our first disease state. So ankylosing spondylitis, this is sometimes a tough one to wrap your head around because it’s not something you probably have seen before and it’s a little bit different. So it’s a chronic inflammation affecting the axial skeleton, resulting in the fusion of the vertebrae. If you can hold onto that, you’re doing pretty well. Men are affected three times as often as women.

Most often affecting patients ages 20 to 30 years old. Now here’s the other caveat, and I think this may come up on your exam. I can see writing a question about this. Because of the way that this presents with back pain for, you know, mostly back pain in a 20 to 30-year-old male and maybe some stiffness, there’s a huge delay in the diagnosis of this. Because no one’s looking for it, right? You have a 20 to 30-year-old male come in complaining of some stiffness and some back pain. There’s a whole road we go down first before we start thinking about ankylosing spondylitis.

So I could see them writing a test question that’s pretty straightforward but would fool you, just like it would fool you in the clinic, right? It’s not being tricky. They’re trying to get you to think like you would in the clinic. So the clinical presentation here is what I just said, which is just really just back pain. And some stiffness. But the key thing is, it’s greater than three months. It’s not getting better.

There’s nothing, no therapy, nothing’s helping. Lab studies and physical exam findings, this diagnosis is difficult and often delayed, like we said. There are also the changes, you’re going to get an x-ray at some point, but the changes on x-ray are very delayed. So there is a test called Schober’s test, which is if you mark L5 with the patient standing, so you just use a marker, mark five centimeters below L5 and call this point one, mark 10 centimeters above L5 and call this point two. So we’re just making marks on a patient’s back. At L5, five centimeters above, I’m sorry, five centimeters below and 10 centimeters above. With the patient bending over, the distance between one and two should be greater than 20 centimeters.

If not, this indicates decreased flexion of the spine.

Okay, does that make sense? So you’re going to put a mark on the patient’s L5 and then put a mark just below L5, five centimeters below and call that 0.1, and then 10 centimeters above and call that 0.2. Then you’re going to have them lean forward, measure the distance between the two points, and that should now be greater than 20 centimeters. If not, you have decreased spine flexion. And is an indication that they may be having an issue, right?

Now, I’m sitting here thinking as I’m doing the math on this that I’m not so sure if you did this to me that I’d be able to make that 20 centimeters. I’m incredibly tight. I’ve been working on it for a while, but it still is an issue for me. I don’t think it’s ankylosing spondylitis. I think it’s incredibly tight hamstrings. So, that’s something else to work on. Anyway, x-ray changes may not be seen for up to 10 years.

And the x-ray changes you’re looking for, can you come up with it? Do you remember what it is? It’s the bamboo spine, that fusion of the vertebrae. So it looks like an image of bamboo. And if you haven’t seen it, pull it up. It’s very, very clear and obvious when you look at it as a way to describe this x-ray. Early diagnosis is achieved by demonstrating sacroiliitis on MRI or x-ray, a positive HLA-B27, and then also two of the following.

So this is kind of an annoying thing to get the early diagnosis on because it’s almost like, what is it, endocarditis, where you have a major indicators and then lesser indicators. I can’t remember them off the top of my head, but this is very similar. So you want to demonstrate sacroiliitis on an MRI or an x-ray, you need a positive HLA-B27, and then also two of the following. So two of the following, two of these things are, let me give you the list. Dactylitis, which is an inflammation of the fingers. Enthesitis of the heel, which is inflammation at the bone tendon junction. A family history of spondyloarthritis.

History of inflammatory back pain, arthritis, psoriasis, inflammatory bowel disease, uveitis, elevated C-reactive protein, or good response to non-steroidal anti-inflammatory drugs. So let me run through that list one more time. You need to demonstrate sacroiliitis on an MRI or x-ray. You need a positive HLA-B27. And then any two out of this list, dactylitis, enthesitis of the heel, family history of spondyloarthritis, history of inflammatory back pain, arthritis, psoriasis, inflammatory bowel disease, uveitis, elevated C-reactive protein, or a good response to non-steroidal anti-inflammatory drugs. Got it. So we need the first two and then any two from that list.

Treatment. First and foremost is to use good posture. As I say that, I put my shoulders back and sit up a little straighter. NSAIDs, opioids.

Next, we have disease-modifying anti-rheumatic drugs, so DMARDs, tumor necrosis factor alpha, physical therapy and exercise, and finally, surgery to correct symptomatic issues. You’re not really solving the problem with surgery, but you may be able to relieve some symptoms. So DMARD’s, tumor necrosis factor, NSAIDs, opioids, physical therapy, and exercise.

All right, kyphosis or humpback. This is a significant increase in the curvature of the thoracic spine. And this increases with age, right? The incidence goes up with age because it’s caused by vertebral body fractures and degenerative disc disease. So, it makes sense that this would increase with age. The clinical presentation is that humpback, that kyphosis, you’d see it. Lab studies and physical exam findings.

There are specific measurements that you would do of the spine. And you’d get an x-ray, an MRI, and a CAT scan. Treatment here is going to be bracing, physical therapy, and kyphoplasty. So, not that you need to know it for your exam, but the kyphoplasty is kind of cool. It was a as a student, it was a I remember trying to scrub in on a kyphoplasty case, and the PA and the surgeon were like, you really you don’t need to. And I recommend you try to scrub on everything just because getting your hands in gloves is an important exercise. So, I push our students to scrub on every single case, but this one is percutaneous.

So they put essentially needles into the space between the vertebrae and they inject cement in there to help support the structure of that degenerative vertebral body. And that’s what a kyphoplasty is. So they’re actually shoring up the structure of that bone. Easy enough to look into, easy enough to Google and watch a little video on and give you a better idea what’s going on there. Again, you don’t really need to know. It’s good to know that surgery is the next step. Having the full picture, though, definitely helps anchor it a little bit in your mind.

Next, we have scoliosis. This is diagnosed at a spinal curvature of more than 10 degrees from side to side. So that’s a number I’d probably remember, 10 degrees. And the important thing here is once growth has stopped, the condition will usually not get worse. You probably remember being checked for this as a kid. Your well visits. But usually, once someone stopped growing, this condition does not get worse.

Clinical presentation, again, routine physical exam, or obvious deformity, right? Lab studies and physical exam findings. Adam’s forward bend test with the patient standing in front of you. Have the patient bend forward as far as possible. Look for one side of the rib cage to be higher than the other. So as much as you’re looking for that curve in the spine, if you look at the ribs, it’ll be more dramatic. On x-ray, we look at the Cobb angle.

So here you draw a line that is parallel to the superior end plate of one vertebrae and another line parallel to the inferior plate of another vertebrae. So what we’re doing is we’re drawing the, we’re extending the lines of the vertebrae to make them more obvious. Then you look at the angle at which these two lines intersect. That’s the Cobb angle. Now think about it for a second. If the vertebrae were parallel to each other, then these lines would never intersect no matter how far out you went. Right?

Does that make sense? Can you picture that in your head? So normal straight spine the end plates of the vertebrae are parallel to each other. But if you have someone with scoliosis those end plates are no longer parallel to each other so all you’re doing is drawing lines on the end plates to the vertebrae and extending them out and then measuring the angle at which they intersect. If that Cobb angle is less than 20 degrees, then you can just kind of keep an eye on it. It’s not too abnormal. Again, if someone’s just about done growing, it may not be an issue.

If it’s greater than 20 degrees or it’s changing, then you’re probably going to want to brace that person.

Now, bracing isn’t really going to fix the deformity, but it will help prevent it from getting worse. And then lastly, once we get above 50, we start to talk about the posterior spinal fusion, surgically correcting this issue, fusing the spine out straight with screws and rods. So, let me run through that again. Hopefully, you understand what the Cobb angle is. If it’s less than 20, no big deal. We just keep an eye on it. We want to keep measuring it to see where we’re at and to make sure it’s not getting worse, but we can leave that alone.

Between 20 and 50, we’re going to do bracing to hold them in place. Greater than 50, now we’re talking about probably needing to do something to surgically correct it. And our last one for spine and for today is going to be thoracic outlet syndrome. Thoracic outlet syndrome. This is similar in concept to carpal tunnel syndrome, right? So hopefully we can use the association to use those two together to get a better picture, right? We can use that analogy to better understand what we’re talking about.

So thoracic outlet syndrome is similar in concept to carpal tunnel syndrome. There is a tunnel formed by the top ribs, the clavicle, and the muscles of the neck. The brachial plexus, subclavian vein, and subclavian artery all pass through this tunnel. If there’s compression of this tunnel, you wind up with thoracic outlet syndrome. Make sense? So we’ve created a tunnel with the top ribs, the clavicle, and the muscles of the neck. If you compress the structures that pass through there, you wind up with thoracic outlet syndrome, just like compressing the carpal tunnel.

Risk factors here. So this makes sense if you think about it. If you have the presence of a cervical rib, that will increase the risk of causing pressure through that tunnel. It’s fairly rare, but it does occur. An injury like whiplash that causes swelling and inflammation in this area can decrease the size, the diameter of that tunnel, right? It makes sense. Another thing would be mass effect.

So, a tumor that puts pressure there. They also reference bodybuilders, guys with no necks, right? You put a lot of muscle into that area, you’re tightening down that that passageway. Also, significant weight gain can put pressure on that tunnel and lead to thoracic outlet syndrome.

Now, the clinical presentation and the treatment depends on which of those structures is most affected. We’re talking about the brachial plexus, the subclavian vein, and the subclavian artery. So if the vein is compressed, think about for a second, what outcomes could you have? What would be the presentation? You’d get an edema built up in the arm, right? In the hand. You could get pain and paresthesias and a possible DVT.

See if you have someone with a DVT in their arm with no other indications, this might be something to think about, right? Because that’s not all that common. If the artery is compressed, if the subclavian artery is compressed, what is that going to look like? So stop and think. Don’t just sit here and let me tell you. Think about what would be the clinical presentation if the subclavian artery was compressed. Well, you might get a cool or pale limb, right?

Now, that’d have to be some pretty severe compression. But if you’re not getting blood flow, or you’re reducing the blood flow into that hand and arm, that would be the next steps. You could get pain and tingling in the arm and hand. Right? Same idea. What happens when you cut off blood flow? And you can wind up with a possible aneurysm from the pressure buildup behind that blockage.

What if it’s in the brachial plexus? Well, you’re going to get pain and paresthesias, right? I mean, that makes sense. You can get weakness and atrophy of the limb. Again, all things that make sense if you understand the underlying diagnosis and what’s going on here. This is where I talk about I don’t need to memorize these lists if I get what the disease is. It frees up a lot of brain space, a lot of power in your head.

If you stop memorizing lists and start really looking at the bigger picture of diseases like this, if I were just to memorize these 10 symptoms, I would struggle not just struggle. I would not be able to do it. I’m telling you right now, there’s no chance I could remember these symptoms. That’s not how I do it. Instead, you stop and think, what would happen if the vein was compressed, if subclavian vein was compressed? What would happen if the subclavian artery was compressed? Compressed.

What would happen if the brachial plexus was compressed? Then it’s easy to think through the next steps. You don’t have to memorize the whole list. Make it so you can figure it out on test day or sitting in front of your patients. Lab studies and physical exam findings, what are we going to use? So here we go again. Don’t memorize this.

How would you look for this? How would you look for a compression in that space? Or you might use an ultrasound to check for blood flow, right? You could use a chest x-ray to look for a cervical rib. Another thing you might not think of is we could do a brachial plexus block, meaning you could anesthetize the brachial plexus and if the pain goes away, then you know you found the right answer. So you can block that nerve. And again, if you block that nerve and it numbs it up and they don’t have the issue, then you can be pretty confident that you have a brachial plexus.

What do you call it? An issue.

Let’s just call it an issue with the brachial plexus. Treatment. So again, I’m just going to keep pushing on this, right? Because to me, thinking is your biggest weapon here. So this is such an easy one to use it on. So treatments. What are we going to do for treatments?

How are we going to treat this problem? But what are you going to do if the patient has an extra rib? Well, you might go in and take that rib out. You might cut a hole in that rib to open up that passageway, just like we do for carpal tunnel. What if they’re having brachial plexus symptoms? You might be able to do a Botox injection to loosen it up. You might be able to do physical therapy to loosen it up.

If they’re having venous or arterial occlusion, you may need to use a blood thinner.

Now, I also have listed here, if there’s an aneurysm, you’re going to have to repair that, but that’s really a secondary thing. So, it’s really how do we open up that space and make sure the blood keeps flowing? Physical therapy, Botox, surgery, blood thinners. I hope that that makes sense. Again, I don’t want you memorizing lists. I want you understanding what the picture looks like so you can close your eyes and come up with the plan of who would come in with this. What would they look like?

What symptoms would they be complaining about? How weird would it be that you wouldn’t really understand at first because it’s not so obvious that would get you to this conclusion? What tests would you need to use to come up with it to solidify your hypothesis? And then how would you treat it? So that’s going to bring us to the end of the content section. But there’s really two study tips I want to cover today. One is what I just got done saying.

I know I do it a lot. But I want you to be aware of it. The idea of thinking and not memorizing. We talked about it in the last show. But I’m just going to keep pushing it and pushing it because it’s so important. Memorizing lists doesn’t work. There’s too much to know.

Too much information. You can’t memorize lists. You have to learn. So the second part of learning and the second part of what I want to talk about today I just finished, or I just published the August issue of the Physician Assistant Exam Scholars newsletter, which in case you don’t know, is a newsletter I publish every month. This is issue 65, just went out. So I’ve been doing that for almost five and a half years now on better ways to study, better ways to think, better ways to take tests, ways to help you get through school, just like what we do here, but a much more in-depth look. And this past month, the August issue, the whole theme of it was key terms.

How to use key terms. Why we use key terms. The five different reasons why they’re incredibly valuable. How to spot them on tests. How to study with them. How to help them improve your anxiety. How to have them help you improve your test scores.

But there was something that came up in this particular episode, in this particular content that I wanted to touch on that was also in that newsletter, which is the idea that there’s a difference between buzzwords and key terms. Buzzwords are your very straightforward pathognomonic terms. So things like honey-crusted lesions equals impetigo. That’s a buzzword, right? Projectile vomiting equals pyloric stenosis. Buzzwords. I take key terms a whole lot further and do a whole lot more with them than just buzzwords.

Buzzwords are key terms for sure, but there’s a lot more to it than just the buzzwords. And the reason I bring it up here is because as I was writing this, the one that really jumped out at me was for ankylosing spondylitis. Ankylosing spondylitis has a buzzword, right? Bamboo spine is your buzzword. If you see that, then you know what it is. But there’s another key term in the presentation that jumped out at me that I don’t know that everybody would get or see or consider a key term, but I certainly do. And that’s the idea that a patient walking through the door with ankylosing spondylitis is going to be a 20 to 30 year old male so the key term that I create for ankylosing spondylitis is a male patient under 40 with back pain and stiffness for more than three months.

So the question I might write in The Final Step, which is the book I wrote full of key terms, is a male patient between 20 and 30 shows up in your office with back pain and stiffness that has not been relieved in three months. What diagnosis are you thinking? It’s a little longer than a buzzword, right? It’s a bigger picture than just a simple buzzword. But it describes what the patient looks like coming through the door, and it’s really the only one I can come up with that fits the bill, right? And that’s part of the key. One of the really important things I always have an eye out for is making sure there’s only one associated answer.

So could it be something else with a 35-year-old with back pain for more than three months? Yes, of course. It could be a slipped disc, of course. But when you throw in the stiffness and the no relief, it’s got to be in your differential. It’s got to be right at the top of your differential with no trauma, right? With nothing else going on. So when I write my index cards, when I write my flashcards, when I wrote the questions for The Final Step, that’s the kind of thing I’m looking for.

How can I differentiate ankylosing spondylitis from everything else when the patient walks through the door? So, that if I have this person come in, there’s a little alarm bell that goes off in my head that says, hey, wait a minute, there’s something fishy here. Maybe I should keep digging. And the same thing when I come across it on a test question. So, keep an eye out for those, I don’t know what you call them, bigger key terms, longer key terms. Things that will lead you to a diagnosis, lead you to a treatment, to a specific diagnosis, to a specific treatment, not just your buzzwords. Buzzwords have their place, but they’re not nearly as valuable as what I’m talking about.

And like I said, I went into incredible depth in the August issue on key terms, picking them out, using them, and so on. If you’re interested, the September issue is going to be all about test questions, all about the way test questions are designed, how to approach them, how to look at them. That’s the Physician Assistant Exam Scholars newsletter for September. It’s going to be all on that.

Now, let’s talk about and finish up with answering our priming questions. At what Cobb angle is surgery recommended for scoliosis? I tripped over this three or four times, so hopefully I spent enough time there that you’ve got it greater than 50, right? Less than 20, we just watch it. 20 to 50, we’re going to brace. And over 50, we’re going to talk about surgery. What is the x-ray finding associated with ankylosing spondylitis?

The bamboo spine. Name two causes of kyphosis. Vertebral fractures and degenerative disc disease. And what is the most common demographic for ankylosing spondylitis? Males between 20 and 30 years old. Make sense?

All right. I hope you got a lot out of today’s show. Like I said, if you did, please share it with someone you know, someone you care about, someone you think will benefit from it, whether that’s your faculty or the class around you or the class below you. That would be great too. Anyway, until next time, good luck on your exams. Take care and I’ll see you then.