Conditions of the Spine Covered on the Physician Assistant Exam
Back pain is one of the most common, frequent, and ordinary reasons people visit healthcare providers, so the Physician Assistant Exam will expect you to know your stuff. Many cases of back pain are self-limiting; however, you’ll likely see some special cases on the PANCE.
Ankylosing spondylitis (AS), also called a sacroiliitis, is a rheumatologic condition that predominantly affects young men in their late teens to early 40s. It causes significant back pain and stiffness in the low back, particularly the iliosacral region.
Here are two key points to remember about ankylosing spondylitis:
A radiograph of the lumbar spine can show a classic bamboo spine: The entire spine looks like a rigid stick of bamboo, pressing on nerves and causing increasing numbness in the lower part of the body. Over time, the spinal discs fuse, and the stiffness and pain get worse.
Labwise, ankylosing spondylitis is associated with the antigen HLA-B27. Other medical conditions associated with the HLA-B27 antigen are inflammatory bowel disease (IBD), Reiter’s syndrome, and psoriatic arthritis.
The course of ankylosing spondylitis can be variable. In some people, it can remit spontaneously, and in others, it can worsen. At its worst extreme, it can cause fusion of the spine.
Because ankylosing spondylitis is a rheumatologic condition, it can affect more than the lower back. Other medical complications can include pulmonary fibrosis and uveitis. In uncommon cases, ankylosing spondylitis affects the aorta as aortitis.
Treatments for ankylosing spondylitis can include anti-inflammatories and immunosuppressive medications, if needed.
Dangerous curves: Scoliosis
Scoliosis refers to a lateral curving of the spine. Most of the time, no one knows why someone gets scoliosis; hence, it’s sometimes called idiopathic scoliosis.
Scoliosis can be diagnosed at a very young age, before the child has symptoms of back pain. A doctor may suspect scoliosis if the shoulders aren’t symmetrical. On exam, you ask the child to bend forward. The key is determining the degree of lateral curvature. If you suspect scoliosis on physical exam, you need a radiograph to further evaluate the scoliosis and determine the degree of lateral curvature.
Symptoms over time can include back pain and just plain fatigue. Treatment depends on the degree of the curvature, or Cobb angle. If the curve is mild, then the child can be followed with no acute intervention. If the curve is more than 20 degrees but less than 40 degrees, then the child needs to be evaluated for a back brace. If the curvature is greater than 40 degrees, surgical intervention is needed.
Don’t be a slouch: Kyphosis
Whereas scoliosis is a lateral curvature of the spine, kyphosis is a type of curving that can cause permanent slouching forward. You see it most often in older adults, due to acquired problems of the vertebrae and discs, including osteoarthritis of the back and osteoporosis. If osteoporosis is present, check for compression fractures. Also ask about any traumatic events in the past or any congenital problems.
You can identify kyphosis by physical examination and radiographic imaging. Recommendations
A herniated disc can be exceedingly painful — the condition has brought the best of men and women to their knees. Disc herniation occurs when the nucleus pulposus pushes through a weak area in the disc. It causes pain because of nerve compression.
The lumbar area is the most common area for a disc herniation to occur. The thoracic area isn’t often affected. Herniated discs can also occur in the lower cervical area, but this isn’t common.
The pain from a herniated disc can be extreme, and the person may experience numbness as well. Do a thorough neurological examination, especially if you have a high suspicion that a radiculopathy is present.
You may order imaging studies, including an MRI, especially if you find evidence of a neurologic disease. Treatment for a herniated disc is supportive and can include nonsteroidals, steroids, and physical therapy. Surgery may be indicated if conservative measures don’t sufficiently improve symptoms.
Causes of cauda equina syndrome are many and can include a herniated disc and spinal stenosis. Other causes are spinal trauma, epidural hematoma, infection, inflammation, and malignancy. Presenting symptoms can include back pain, paresthesias, and problems with the bowel and bladder. As symptoms worsen, the affected person may lose bowel and bladder tone and experience a loss of reflexes. This is an emergency and requires decompression of the affected area.
Spinal stenosis is a common cause of back pain caused by a narrowing of the lumbar spine. This condition involves both a narrowing of the spine as well as a narrowing of the foramen, which is where the nerves exit the spine. The most common cause is osteoarthritis that affects the spine. Prior spinal trauma and/or herniated discs also play a role in the development of spinal stenosis.
Spinal stenosis normally presents with low back pain that’s worse with ambulation. As the condition worsens, the person may experience weakness associated with any type of weight-bearing. Other symptoms can include numbness and tingling.
Imaging studies include radiography and MRI. The MRI and/or CT scan is a more detailed test, but you can detect changes of osteoarthritis on a plain back radiograph.
Treatment of spinal stenosis includes physical therapy, medications, and injections to help with pain. If these don’t help, then the person may need surgery. You can refer the patient to an orthopedic physician at that point.
Pott’s disease: TB of the spine
Tuberculosis can affect organs in the body outside of the lung, including the spine. Tuberculosis as it affects the spine is called Pott’s disease, named after the British surgeon Percivall Pott. It can affect the vertebrae and the intervertebral space. Presenting symptoms can include back pain, fever, weakness, and paresthesias. The treatment is medications used for the treatment of tuberculosis, and sometimes pain medication. Surgical intervention may be needed.