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Spinal Flashcards

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1
Q

Describe the vertebral column

A

Extends from the foramen magnum to the tip of the coccyx

7 cervical
12 thoracic
5 lumbar
5 sacral
4 coccygeal

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2
Q

Sacral hiatus

A

Lamina of the last sacral vertebrae is incomplete and bridged only by ligaments
-we use this as a landmark- caudal is not spinal but low lying epidural

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3
Q

Purpose of transverse process

A

Muscular attachment

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4
Q

When stacked the notches and articulating surfaces of the spine form the:

A

Intervertebral foramina

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5
Q

Consequence of disc thinning (poor disc health)

A

Compression impinges spinal nerve exiting intervertebral foramina

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6
Q

Photo of vertebral body anatomy

A
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7
Q

Pedicle

A

Connection on either side of the vertebral foramen connecting the lamina and the vertebral body

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8
Q

3 landmark ligaments on the journey to the subarachnoid space

A

Supraspinous
Interspinous
Ligamentum flavum

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9
Q

Point spinal cord terminates at the conus medullaris

A

L1

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10
Q

Cauda equina

A

Nerve pathways that continue in a collection of rootless floating in CSF past the conus medularis

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11
Q

Anchor of spinal cord in sacrum

A

Filum terminale

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12
Q

Layers of meninges around spinal cord

A

Dura
Arachnoid
Pia

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13
Q

Pia mater

A

Covering directly in contact with spinal cord

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14
Q

Space we are aiming for with a spinal block

A

Subarachnoid, filled with CSF

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15
Q

Epidural space

A

Continuous POTENTIAL space outside the dural sac but inside the vertebral canal

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16
Q

Distance between the skin and lumbar epidural space

A

2.5-8cm
Highly variable

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17
Q

What does the epidural space contain?

A

Veins, fat, lymphatics, segmental arteries, nerve roots

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18
Q

Artery of adamkiewicz

A

Arises from aorta, typically unilateral providing major blood supply to the anterior, lower two thirds of the spinal cord

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19
Q

Blood supply of the spinal cord

A

A single anterior spinal artery and paired posterior spinal arteries

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20
Q

Hour many people have left sided artery of adamkiewicz?

A

75%

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21
Q

Injury to of artery of adamkiewicz

A

Ischemia

Anterior spinal artery syndrome=
Paralyzed with preserved sensory input

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22
Q

Sensory tract

A

Dorsal root-posterior

Afferent signaling

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23
Q

Motor signaling

A

Anterior-ventral root

Efferent

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24
Q

SNS/sympathetic chain

A

Thoracolumbar innervation

SNS signaling to the body is a blow horn and immediately goes everywhere

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25
Gray ramus
Unmyelinated, post ganglionic
26
White ramus
Myelinated preganglionic
27
Impact of local anesthetic on an action potential
Does not let fiber meet threshold so that it can fire
28
Impact of acidity on locals
Impairment due to ionization
29
Amount of a nerve that needs to be blocked
3 nodes or 5-6 mm of unmyelinated fibers
30
Ester metabolism and identification
One i Hyrolyzed by plasma esterases
31
Amide metabolism and identification
Two i’s Lidocaine Biotransformation in liver
32
Basic properties of local anesthetics
Weakly basic tertiary amines Poorly water soluble Prepared in strong acids
33
Pka
Ph at which drug is 50% ionized and 50% nonionized
34
Speed of onset factor with local anesthetics
Pka
35
Potency of locals and why
Lipid solubility Axon and myelin sheath are composed of lipids
36
Factor that impacts duration of action of locals
Protein binding -the sodium ion channel is the protein!!
37
Short acting local
Chloroprocaine 30-45 min Rapid onset short duration, redose every 30 min for surgical anesthesia
38
Intermediate local (standard)
Lidocaine 1-2% depending on application Epi increases duration by 50% NOT USED in spinal-transient neurological symptoms
39
Mepivacaine
1.5-2% Intermediate -60-80min Suitable for ambulatory
40
Long duration local
Ropivacaine Less potent and shorter than Bupivacaine -Lisa hates this for spinals
41
Bupivacaine
Potent Duration 150 min (95% protein bound)
42
What do we not use in hyper allergic patients?
Esters -break down into PABA
43
Allergic reactions and locals
Very little cross sensitivity between esters and amides
44
What do we tell patients who had a reaction at the dentist?
Dentists use large doses of epinephrine in highly vascular locations…. Feels like an adverse reaction but its really just the epi
45
Variables in LA effect on nerve fibers
Size of fiber Myelination Drug concentration achieved and duration of contact
46
Are C fibers unmyelinated or myelinated?
Unmyelinated
47
Why do we get sensory block without motor?
Size
48
Baricity
Ratio of the density of a local anesthetic at a specific temperature compared to the density of CSF at the same temperature
49
Average block height when injected at height of lumbar lordosis
T4-T6 Supine “high points”= C5, L3
50
Supine low points of spine
T5 S2
51
Variables impacting intrathecal LA spread
Volume is less significant than Dose Site POSITION- during and immediately following block
52
Barbotage
Turbulent flow of CSF (pulling back and re-injecting multiple times to check placement)
53
Three most important modifiable factors in distribution of locals anesthetic (spinal)
Baricity Position of patient Dose of anesthetic
54
Dermatome visual
55
Cardiovascular considerations with blocks
Sympathectomy- don’t kill your patients with cardiovascular disease;) Don’t trend patients that get hypotensive with a spinal- you’ll just get better coverage of t1-t4….
56
Neuraxial blockade and pulmonary
Patients may not be able to feel themselves breathing… but they are! Usually minimal effect
57
Mechanism of decreased surgical blood loss with neuraxial blockade
Blocking surgical stress prevents the neuro endocrine stress response that would cause increased bleeding/vascular permeability
58
Neuraxial and the bladder
Loss of autonomic control results in urinary retention until the block wears off
59
Absolute contraindications for neuraxial
Patient refusal Sepsis at site Coagulopathy or anti coagulation (uncorrected) Elevated ICP Uncorrected hypovolemia Allergy
60
Two names for spinal anesthesia
Intrathecal injection Subarachnoid block
61
Placement of LA below this level of spine in adults and kids helps avoid spinal cord trauma
L1 in adults L3 in kids
62
Cutting needle
Quincke
63
Two pencil point needles
Whitacre and sprottle
64
3 components of the spinal needle set up
Obturator (stylet) Spinal needle Introducer (large bore)
65
This spinous process is most prominent at the base of the neck
C7
66
Correlates with the base of the scapula
T7
67
Usual space/vertebra in line with iliac crests
L4 L4-L5 interspace
68
How do you know you’re in the subarachnoid space?
CSF
69
Block level for hip
T10
70
Block level for vagina/bladder/prostate
T10
71
Block height for lower extremities
T12
72
Bromage scale
More common in PACU Grade I-IV I-free movement of legs IV unable to move legs or feet
73
Alice test
Pinch test for feeling
74
Two most common complications of neuraxial anesthesia
Failed block PDPH
75
Material risk
What the normal human wants to know about -don’t scare the shit out of your patients
76
Minor/moderate/major complications of SAB
77
Best monitor?
Patient
78
Spinal induced hypotension
Sympathetic blockade-vasodilation T1-T4 or cardiac reflexes _load with fluids to compensate for reduced venous return?
79
PDPH, risk categories
Incidence varies Reduced risk: older patients, smaller gauge needle, pencil point, BMI>30 Increased risk: female, history of PDPH, large needle
80
Describe PDPH headache
Postural headache typically either a frontal or occipital headache that radiates N/V -thought to be caused by traction or on pain sensitive structures due to leak of CSF/pressure changes
81
Cranial nerves involved in PDPH
VI and VIII
82
What is PDPH not associated with?
An aura- this would most likely be a migraine
83
Treating PDPH
Usually resolves in 5-7 days -hydration -caffeine -NSAIDs -bed rest Epidural blood patch after 24 hours
84
Cauda equina syndrome
Nerve compression leading to motor/sensory Loss of lower extremities -can be due to neurotoxic effects of LAs, associated with continuous spinals
85
Epidural hematoma
Less of a risk with SAB Anticoagulation greatly increases risk Look at clotting times and platelet count
86
Symptoms of epidural hematoma formation
Severe back pain Progression of sensory/motor deficits- block should not progress!! Index of suspicion should be high if block is lasting longer than expected
87
Treatment of epidural hematoma
Surgical decompression -always have an evacuation plan in place if working rurally
88
Anticoagulation guideline app
ASRA
89
What we need to have memorized from Anticoagulation table (wait times)
Heparin 4-6 hours prior with normal aPTT Lovenox (enoxaparin)- >12 hours Aspirin/NSAIDs-no wait
90
Common 0.75% Bupivacaine dosing to T10
8-12mg
91
Chloroprocaine 3% dose t10
30mg
92
What increases our risk of urinary retention?
Opioid adjuncts
93
Dosing fentanyl intrathecal
10-20 mcg
94
What do we do when we dose intrathecal opioids?
Check the label! You are injecting into the spine-take it seriously Doses differ between epidural and spinal
95
96
Platelet count required for neuraxial
>100,000 75-100k if stable here
97
98
99
Grams/mL and mg/mL in a 10% solution
10gm/100ml Or 100mg/ml

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