Spinal and Epidural

Question 0

What is the ligamentum flavum also known as?

Answer 0

• “yellow ligament”

Question 1

Ligamentum flavum extends:

Answer 1

-extends from foramen magnum to sacral hiatus

Question 2

Pia mater:

Answer 2

-adheres to the spinal cord

Question 3

Dura mater:

Answer 3

• begins at foramen magnum and ends at S2

- abuts arachnoid mater (subdural space)

Question 4

Arachnoid mater

Answer 4

• physiological barrier for drugs moving btw the epidural space and spinal cord
• abuts pia mater- gives rise to subarachnoid space

Question 5

Subarachnoid Space:

Answer 5

• contains CSF- cont with cranial CSF

- houses spinal nerve roots and rootlets

Question 6

Spinal cord extends from:

Answer 6

-foramen magnum to conus medullaris (terminates at L1 or L2)

Question 7

Termination of dural sac occurs at what level?

Answer 7

S2

Question 8

What is a dermatome?

Answer 8

-the area of skin innervated by a spinal nerve and its segment

Question 9

What is a segment?

Answer 9

• rootlets of a single spinal nerve coming from the spinal cord

Question 10

CSF is found in what space?

Answer 10

-subarachnoid space

Question 11

CSF is produced by:

Answer 11

-choroid plexus

Question 12

Where is spinal anesthesia delivered?

Answer 12

• subarachnoid space

Question 13

Where is epidural anethesia delivered?

Answer 13

• epidural space

Question 14

Principal site of a neural blockade is:

Answer 14

• the nerve root

Question 15

T/F: Blockade can occur at any point AND all points along the neural pathways extending from the site of the drug admin to the interior of the cord.

Answer 15

True

Question 16

In a centroneuraxial blockade what fiber types are blocked?

Answer 16

• nociceptive
• motor
• proprioceptive
• autonomic

Question 17

The purpose of the centroneuraxial blockade is to block?

Answer 17

• the nociceptive impulses

- but ANS and motor are blocked too

Question 18

Considerations for regional techniques:

Answer 18

• anatomy
• age
• pregnancy
• pathophysiology

Question 19

What procedures would you give GA and an epidural/SAB?

Answer 19

• major abdominal procedure

- lower extremity vascular cases

Question 20

When would a SAB/epidural block be indicated for analgesia?

Answer 20

• postoperative

- labor and delivery

Question 21

Major absolute contraindication for a neuroaxial block

Answer 21

-patient refusal

Question 22

Cardiovascular effects of neuroaxial blocks depend on:

Answer 22

• spread and blockade of the ANS

Question 23

What changes would be seen if CV effects occurred with a neuroaxial block?

Answer 23

• decreased BP, HR, MAP, CO and SVR

- decreased CO is typically d/t venous dilation/pooling

Question 24

Major pulmonary side effects of a neuroaxial block:

Answer 24

- as block ascends, accessory muscle paralysis occurs | - perception of ineffective breathing and decreased ability to cough

Question 25

Phrenic nerve associated with what level of the spine? What is the first sensation that this nerve may be seeing LA?

Answer 25

- C3 to C5 | - pinky finger tingling may indicate block is ascending

Question 26

Effect of neuroaxial block on GI/renal:

Answer 26

- hyperperistalsis - N/V - bladder dysfunction

Question 27

Effect of neuroaxial block on metaolic/endocrine:

Answer 27

- decrease stress response r/t surgery - decrease cortisol release - catecholamine release may be decreased

Question 28

Lateral decubitus position:

Answer 28

- forehead to knees

Question 29

Which SAB needle will be more likely to cause a Postdural Puncture Headache- Sprotte (pencil point needle) or Quincke (cutting needle)?

Answer 29

- Quincke (cutting needle)

Question 30

Most common technique for a spinal block?

Answer 30

- median approach

Question 31

Why would you do a paramedian approach for SAB?

Answer 31

- for pts who cannot adequately flew b/c of pain or whose ligaments are ossified - spinal needle is pace 1.5 cm laterally and caudad

Question 32

What layers do you go through to place and epidural?

Answer 32

- skin - subq tissue - supraspinous ligament - infraspinous ligament - ligamentum flavum - EPIDURAL SPACE

Question 33

What layers do you go through to place a SAB?

Answer 33

- skin - subq tissue - supraspinous ligament - infraspinous ligament - ligamentum flavum - (epidural space) - dura mater - (dural space) - arachnoid mater - SUBARACHNOID MATER - CSF

Question 34

Landmarks for SAB?

Answer 34

- identify superior iliac crests and L4

Question 35

Epidural placement uses what kind of technique?

Answer 35

- loss of resistance technique (air filled glass syringe)

Question 36

The epidural space is located directly after which ligament?

Answer 36

- ligamentum flavum

Question 37

Typically, how far is the ligamentum flavum from the skin in a normal sized adult?

Answer 37

- 4 to 6cm

Question 38

How much do you advance your epidural catheter once in the epidural space?

Answer 38

- 2 to 3 cm

Question 39

For SAB/epidural needle placement position the needle bevel needs to be inserted:

Answer 39

- needle bevel is inserted parallel to longitudinal fibers

Question 40

In PARTURIENTS the epidural catheter is advanced:

Answer 40

- 4 to 6 cm

Question 41

The density of a solution to the density of another substance.

Answer 41

Baracity

Question 42

What is hyperbaric solution mixed with and why? What is the SG?

Answer 42

- dextrose - allows LA to settle in dependent areas - SG greater than 1.11

Question 43

What is hypobaric solution mixed with and why? What is the SG?

Answer 43

- sterile water - allow LA to go upward (broken right hip ex) - SG less than 1.005

Question 44

What is isobaric solution mixed with? What is the SG?

Answer 44

- mixed with CSF | - less than 1.006

Question 45

Factors influencing block height

Answer 45

- dose - site of injection - baracity - position of patient

Question 46

When can a patient go to the floor after a spinal?

Answer 46

- PACU to the floor after 4 dermatome regression less than T10, stable and comfortable

Question 47

When can a patient be discharged home after a spinal?

Answer 47

SDS to home after ambulation without orthostatic changes, + void

Question 48

Delivery of LA to the epidural space via injection through the sacral hiatus

Answer 48

- Caudal block

Question 49

Major complications of spinal/epidural/caudal blocks:

Answer 49

- hypotension - sudden cardiac arrest - post dural puncture HA - epidural hematoma

Question 50

Post dural puncture headache, treatment?

Answer 50

-epidural blood patch, bedrest, hydration, oral analgesics, epidural saline injection

Question 51

Why does post dural puncture HA occur?

Answer 51

- d/t intracranial pressure with compensatory cerebral vasodilation

Question 52

Epidural hematoma is primarily caused by:

Answer 52

- a coagulation defect | - can cause paralysis

Question 53

S/S of LA toxicity:

Answer 53

- neuro changes - seizure followed by CNS depression, apnea, hypotension - transient radicular irritation - cauda equina syndrome

Question 54

Dural mater/sac extends from where to where?

Answer 54

-foramen magnum to S2

Question 55

T1 to T4 is known as the:

Answer 55

-cardioaccelerators, unopposed vagal response

Question 56

The continuous catheter technique for epidural placement, what needle is used?

Answer 56

Tuohy needle

Question 57

Specific gravity of CSF

Answer 57

-1.004 to 1.008

Question 58

What is the primary cause of an epidural hemotoma?

Answer 58

-coagulation defect