APEX - Neuraxial

Question 1

Each vertebra can be divided into what two segments?

Answer 1

Anterior and Posterior segment

Question 2

What two structures join the anterior and posterior segments of the vertebra and form the vertebral foramen?

Answer 2

The laminae and pedicles

Question 3

What part of the vertebra contains the spinal cord, nerve roots, and epidural space?

Answer 3

The vertebral foramen

Question 4

How do the spinal nerves exit the vertebral column?

Answer 4

The spinal nerves exit the vertebral column by way of the intervertebral foramina

Question 5

The transverse processes project (in what direction), while the spinous process projects (in what direction)

Answer 5

The transverse processes projects LATERALLY, while the spinous process projects POSTERIORLY.

Question 6

The cervical and thoracic spinous processes angle is in what direction?

Answer 6

The cervical and thoracic spinous processes angle is a CAUDAL direction. This requires a more cephalad approach with the needle.

Question 7

Lumbar spinous processes projects in what direction?

Answer 7

Lumbar spinous processes projects in a POSTERIOR direction. This makes access to the epidural and intrathecal spaces easier.

Question 8

The supraspinous ligament joins what part of the vertebra

Answer 8

The tips of the spinous processes

Question 9

How does the Interspinous Ligament connect the vertrebras?

Answer 9

The Interspinous Ligament travels adjacent to and joins the spinous processes

Question 10

What is the significance of the Ligamentum Flavum?

Answer 10

Piercing the ligamentum flavum contributes to the loss of resistance when the needle enters the epidural space.

Question 11

What ligaments will you pierce using a Midline approach?

Answer 11

Supraspinous ligament
Interspinous ligament
Ligamentum flavum

Question 12

What ligament will you pierce using a paramedian approach?

Answer 12

Ligamentum flavum

The paramedian approach bypasses the suprasponous and interspinous ligaments.

Question 13

What space is between the Ligamentum flavum and dura mater?

Answer 13

Epidural space

Question 14

What space is between the dura mater and the arachnoid mater?

Answer 14

Subdural space

Question 15

What space is between the Arachnoid mater and Pia Mater?

Answer 15

Subarachnoid space

Question 16

What are the layers of the meninges? (In order from outside in)

Answer 16

Dura
Arachboid
Pia

DAP

Question 17

What is the subdural space?

Answer 17

The potential space between the dura matter and the arachnoid mater

Question 18

What is the subarachnoid space?

Answer 18

This space is just past the arachnoid mater. It contains CSF, nerve roots, rootlets, and the spinal cord. This is the target when performing a spinal anesthetic.

Question 19

What is the Dura mater?

Answer 19

• It is the first meningeal layer.
• After the needle advances through the epidural space, it comes into contact with the dura matter.
• The Dura matter is a rough fibrous protective shield that protects the spinal cord.

Question 20

What is the arachnoid mater?

Answer 20

• A think layer of connective tissue that neighbors the dura mater.
• The second meningeal layer

Question 21

What is the Pia Mater?

Answer 21

• This is the external covering of the spinal cord.

- This is the meningeal layer.

Question 22

How many vertebrae does the sacrum consist of?

Answer 22

5 Vertebrae

Question 23

At what level of the spinal column does the superior iliac spines coincide with?

Answer 23

S2

Question 24

The sacral hiatus is cover by what ligament?

Answer 24

It is covered by the sacrococcygeal liagment

Question 25

How many paired spinal nerves does the spinal cord have?

Answer 25

31 paired spinal nerves

Question 26

What is a dermatome?

Answer 26

A dermatome is an area of skin that is innervated by a dorsal nerve root from the spinal cord.

Question 27

What is the site of action for spinal anesthesia?

Answer 27

In the subarachnoid space, the primary site of local anesthetic action is on the myelinated preganglionic fibers of the spinal nerve roots.

Question 28

What is the site of action for an epidural anesthesia?

Answer 28

LA in the epidural space must first diffuse through the dural cuff before they can block the nerve roots.

Question 29

With spinal anesthesia, which fibers are blocked first, second, and last?

Answer 29

Autonomic fibers are blocked first (B fibers) Sensory fibers are blocked second (C and Adelta) Motor neurons are blocked last (A g, A b, Aa)

Question 30

With neuraxial anesthesia, how is bradycardia caused?

Answer 30

Bradycardia is caused by the blockage of the preganglionic cardioaccelerator fibers at T1-T4, this is causes a relative increase of parasympathetic tone.

Question 31

With neuraxial anesthesia, what causes apnea?

Answer 31

Apnea is usually the result of cerebral hypoperfusion, it is NOT the result of the phrenic nerve paralysis or high concentrations of local anesthetics in the CSF

Question 32

For neuraxial anesthesia, if a patient is on aspirin, what do you do?

Answer 32

Proceed with neuraxial anesthesia if: patient has normal clotting mechanism and patient is not on any other blood thinning agents

Question 33

For neuraxial anesthesia, if a patient is on Eptifibatide (Integrilin), what do you do?

Answer 33

Hold the medication 8 hours before the block placement

Question 34

For neuraxial anesthesia, if a patient is on abciximab (Rheopro), what do you do?

Answer 34

Hold the medication 1-2 days before the block placement

Question 35

For neuraxial anesthesia, if a patient is on Clopidogrel (Plavix), what do you do?

Answer 35

Hold the medication for 7 days before the block placement

Question 36

For neuraxial anesthesia, if a patient is on Ticlopidine (Ticlid), what do you do?

Answer 36

Hold the medication for 14 days before the block placement

Question 37

For neuraxial anesthesia, if a patient is on SQ heparin for DVT prophylaxis, what do you do?

Answer 37

Proceed with neuraxial anesthesia if: Patient has normal clotting mechanism and Patient is not on other blood thinning drugs

Question 38

For neuraxial anesthesia, if a patient is on IV heparin, what do you do?

Answer 38

Hold for 2-4 hours before the block placement. Hold for 1 hour after the block placement. Hold for 2-4 hours after the indwelling catheter has been removed.

Question 39

For neuraxial anesthesia, if a patient is on Enoxaparin, what do you do?

Answer 39

Hold 12 hours for the prophylactic dose (1x daily) Hold for 24 hours for the therapeutic dose (2x daily) Hold 12 hours before removing indwelling catheter Hold 2 hours after the indwelling catheter has been removed.

Question 40

For neuraxial anesthesia, if patient is on Warfarin, what do you do?

Answer 40

Hold for 5 days before the block placement. Can remove catheter if INR less than 1.5

Question 41

For neuraxial anesthesia, if patient is on Garlic, Ginko, Ginseng, Glucosamine, or Chondroitin, What do you do?

Answer 41

Proceed with neuraxial anesthesia if patient is not on other blood thinning drugs

Question 42

Where is the conus medullaris in adults and children?

Answer 42

Adults L1-L2 | Infant L3

Question 43

What is the Cauda Equina?

Answer 43

A bundle of spinal nerves extending from the conus medullaris to the dural sac

Question 44

Where is the Dural sac?

Answer 44

Adults S2 Infant S3 The subarachnoid space terminates at the dural sac

Question 45

What is the Filum Terminale?

Answer 45

This extends from the conus medullaris to the coccyx

Question 46

What are the S/S of Cauda Equina Syndrome?

Answer 46

Bowel and bladder dysfunction, sensory deficits, weakness, and/or prarlysis

Question 47

What causes Cauda Equina Syndrome?

Answer 47

Neurotoxicity is the result of exposure to high concentrations of local anesthetics

Question 48

What causes transient neurologic symptoms?

Answer 48

patient positioning, stretching of the sciatic nerve, myofascial strain, and muscle spasms. It is highly unlikely that neurotoxicity causes TNS

Question 49

What are the S/S of transient neurologic symptoms?

Answer 49

severe back and butt pain that radiates to both legs. | In general it develops within 6-36 hours and persist for 1-7 days.