spinal and epidural part one (exam one) Flashcards
(148 cards)
1
Q
clinical indications for neuroaxial
A
lower abdomen, perineum, and lower extremities surgical procedures
orthopedic surgery
vascular surgery on the legs
thoracic surgery (adjunct to GETA)
2
Q
Neuraxial anesthesia benefits
A
REDUCED:
* narcotic usage
* bleeding
* respiratory complications
* PONV
* thromboembolic events
* postop ileus
3
Q
other benefits of neuraxial anesthesia
A
greater mental alertness
less urinary retention
quicker to eat, void, and ambulate
avoid unexpected overnight admission from complications of GA
quicker pacu discharge times
preemptive anesthesia
Blunts the stress response from surgery
4
Q
relative contraindications of neuraxial anesthesia
A
Deformities of the spinal column
preexisting disease of the spinal cord
chronic headache/backache
inability to perform SAB/Epidural after 3 attempt
5
Q
examples of deformities of spinal column
A
spinal stenosis
kyphoscoliosis
ankylosing spondylitis
6
Q
Examples of preexisting diseases of the spinal cord
A
multiple sclerosis
Post-polio syndrome
7
Q
coag risk factors for epidural hematoma
A
- INR > 1.5 (ASRA)
- Platelets <100,000 consider trends
- Nagelhout x2 (PT,aPTT, bleeding time)
- known coagulation disorder or taking anticoagulants
8
Q
what are absolute contraindications of neuroaxial anesthesia
A
coagulopathy
patient refusal
evidence of dermal site infection
9
Q
what are the normal lab times for PT, INR, aPTT, Bleeding time, platelet
A
PT= 12 to 14 sec
INR= 0.8 to 1.1
aPTT=25 to 32
bleeding time= 3-7 mintues
plt= 150,000-300000
10
Q
heparin effects which part of coag cascade?and what labs are monitored
A
intrinsic
PTT,ACT
11
Q
Coumadin effects which part of the coag cascade? what labs are monitored
A
extrinsic
PT, INR
12
Q
What is a death spiral
A
13
Q
other absolute contraindications to neuroaxial
A
severe or critical heart disease
HSS(idiopathic hypertrophic subaorticc stenosis)
operation > duration or local anesthetic
increased icp
severe chf (EF <30-40%, preload dependence)
14
Q
what is considered critical or severe valvular heart disease
A
AS =/ <1.0cm2
MS < 1.0cm2
15
Q
spinal vs epidural onset
A
spinal-rapid
epidural-slow
16
Q
spinal vs epidural spread
A
spinal- higher than expected may extend extracranially
epidural-as expected, can be controlled with volume of LA
17
Q
spinal vs epidural nature of block
A
spinal-dense
epidural-segmental
18
Q
spinal vs epidural motor block
A
spinal-dense
epidural-minimal
19
Q
spinal vs epidural hypotension
A
spinal-likely
epidural-less than spinal
20
Q
spinal vs epidural duration
A
spinal-limted and fixed
epidural- unlimited
21
Q
spinal vs epidural placement level
A
spinal- L3-4, L4-5, L5-S1
epidural-any level
22
Q
spinal vs epidural difficulty of placement
A
spinal-no
epidural-skill
23
Q
spinal vs epidural dosing of LA
A
spinal-dose based (mg)
epidural-volume based (ml)
24
Q
spinal vs epidural concentration of LA
A
spinal- concentrated and fixed (5 mins)
epidural-varies
25
spinal vs epidural local anesthetic toxicity
spinal-no toxicity
epidural- has toxicity
26
spinal vs epidural gravity influence
spinal: no gravity influencce
epidural: yes position
27
spinal vs epidural manipulation of dermatome spread after dosing
spinal- yes (1st 5 min) position changes baricity (iso, hyper, and hypo), dose
epidural- incremental dermatome spread based on volume 1-2ml per segment
28
How many vertebrae are there
33
29
How many pairs of spinal nerves does a human have
31
30
C, T,L,S spine and coccyx has how many vertebrae
C=7
T=12
L=5
S=5(fused)
coccyx=4(fused)
31
C, T,L,S spine and coccyx has how many nerves
C=8 cervical spinal nerve pairs
T=12
L=5
S=5
C=1
32
c1 and c2 nicknames
c1= atlas
c2= axis
33
3 abnormal curvature of the spine
scoliosis, kyphosis, lordosis
34
each vertebra except for c1 is divided into how many parts
2 parts
35
which part of the vertebra is known as the body
anterior segment
36
which part o f the vertebra is known as the vertebral arch
posterior segment
37
what two structures link the anterior and posterior segments together
lamina
pedicle
38
which two connections form the vertebral foramen a crucial space within the vertebra
lamina and pedicle connection
39
the vertebral foramen houses
spinal cord, nerve roots and epidural space
40
what tells us we are midline
spinous process
41
the lumbar, thoracic and cervical vertebrae are different why
the orientation of their spinous processes
42
what kind of needle approach is needed for cervical and thoracic spinous process
cephalad approach
their spinous process tilts downward (caudal direction)
43
what makes it easier to reach the spaces around the spinal cord like the epidural and intrathecal spaces
the lumbar spinous process sticks out directly backward (posterior)
44
what are the intervertebral discs
soft pads between each vertebra that act as shock absorbers
45
openings between the vertebrae where spinal nerves exit the spine
intervertebral foramina
46
the anterior side of the foramen is formed by the?
vertebral body and the intervertebral disc
47
the posterior side of each foramen is formed by
facet joints (part of the vertebrae)
48
when the intervertebral disc wear down what happens
foramina become smaller
49
the narrowing of the foramina can
press on the spinal nerve causing pain, numbness or weakness
50
what parts are the facet joints made up of
inferior articular processes of one vertebra connecting with the superior articular process of the vertebrae right below it
51
what is the function of the facet joint
help guide and limit spines movement- keeps back motion controlled
52
if a facet gets injured
it can press on nearby spinal nerves
53
symptoms of injured facet joint
this pressure can cause pain and muscle spasms in the area of skin served by that nerve (dermatome)
54
superior aspect of illac crest
L4
55
posterior superior illiac spine
S2
56
the horizontal line that runs accross the top edges of the hip bones (iliac crests) and matches the L4 vertebra
Tuffiers line
57
what helps identify the correct spaces between vertebrae for inserting spinal anesthesia needle
Tuffiers line
58
The space above the tuffiers line aligns with ?
L3-L4 vertebrae
59
The space below the tuffiers line aligns with?
L4-L5 vertebrae
60
in infants up to one year the intercristal line corresponds with
L5-S1 intervertebral space
61
another name for tuffers line
intercristal line
62
describe the sacrum
triangular-shape section of fused vertebra (5)
lamina of S5 is incomplete and bridged only by ligaments
63
where is the sacral hiatus
at the base of the sacrum and aligns with the S5 vertebra
64
the sacral hiatus will be covered by
sacrococcygeal ligament
65
what acts as an access point to caudal anesthesia
sacral hiatus
66
the projections of the articular processes are known as
cornu
67
horns or bony protuberances that guard the area of the sacral hiatus
sacral cornu
68
landmark for caudal anesthesia
sacral cornua
69
the lamina of S5 is incomplete and bridged by
only ligaments
70
spinal cord rostral origin
medulla oblongata
71
the spinal cord tapers off at the
conus medullaris
72
in adults where does the spinal cord end
L1 and L2
73
in infants the spinal cord ends at
L3
74
cauda equina is a bundle of spinal nerves extending from
conus medullaris to the dural sac
75
cauda equina consists of nerve roots from
L2 to S5 vertebrae and coccygeal nerve
76
the subarachnoid spaces ends at the
dural sac
77
dural sac ends where in adults and infants
adults S2
infants S3
78
the structure that continues downward from the end of the spinal cord
filum terminale
79
the filum terminale is a continuation of
pia mater
80
the filum terminale extends from the
conus medullaries to the tailbone (coccyx)
81
the main function of the filum terminale
anchor the spinal cord to the coccyx
82
parts of the filum terminale
internal filum terminale
external filum terminale
83
the internal filum terminale begins and extends to
begins: conus medullaris
extends: dural sac
84
the external filum terminale starts and extends to
begins: dural sac
extends: into the sacrum
85
what supplies the blood to the spinal cord
one anterior spinal artery
two posterior spinal arteries
86
the anterior spinal artery originates from
originates from vertebral artery
87
The anterior spinal artery supplies what portion of the spinal cord
supplies the front (motor) portion of the spinal cord
anterior 2/3 of the spinal cord
88
the posterior spinal arteries emerges
emerge from the cranial vault
89
the posterior spinal arteries originates
originates from the vertebral artery
90
the posterior spinal arteries supplies
supply the posterior (sensory) portion of the spinal cord
91
the posterior spinal arteries are paired and have collateral anastomotic links from?
the subclavian and intercoastal arteries
92
the posterior spinal collateral connections help protect from
protect the sensory part of the spinal cord from ischemia
93
which part of the spinal cord arteries are more vulnerable to ischemia and why
anterior spinal artery
a single artery not as many protective links
94
if the anterior spinal artery is affected by ischemia it can lead to
motor paralysis
loss of pain and temperature sensation below the level of lesion
95
what are causes of ischemia leading to anterior spinal artery syndrome
low blood pressure (profound hypotension)
mechanical blockage
blood vessel disease(vasculpathy)
bleeding (hemorrhage)
96
crucial artery that supplies blood to the lower 2/3rds of the spinal cord
Artery of Adamkiewicz
97
Artery of Adamkiewicz arises from
the aorta between the T7 and L2 regions
98
Damage to the artery of adamkiewicz can lead to
anterior spinal artery syndrome
99
supraspinous ligament runs along and connects what
runs along the back, connecting the tips of the spinous processes from the upperback down to the lower back.
100
which ligament is located between the spinous processes, providing stability by joining adjacent vertebrae
interspinous ligament
101
which ligament is thick in the lower back and form the sidewalls of the space outside the spinal cord (epidural space)
ligamentum flavum
102
piercing the ligamentum flavum indicates
entry into the epidural space during procedures
103
which ligament runs along the back side of the vertebral bodies inside the spinal colum
posterior longitudinal ligament
104
what does the anterior longitudinal ligament do
attaches to the front of the vertebral bodies, running the length of the spinal column
connects to the outer fibers of the intervertebral discs to bind the vertebrae together
105
which layers are traversed during the midline approach for spinal anesthesia
skin
subcutaneous fat
supraspinous ligament
interspinous ligament
ligamentum flavum
epidural space
Dura mater
subdural space
Arachnoid mater
subarachnoid space
106
what layers are traversed during the paramedian approach
skin
subcutaneous fat
ligamentum flavum
dura mater
subdural space
arachnoid mater
subarachnoid space
107
when is the paramedian approach preferred
the interspinous ligament is calcified
the patient cannot flex their spine
108
what position is acceptable for a paramedian approach
sitting
lateral (lying on side)
prone (face down)
109
what is the needle insertion technique for a paramedian spinal approach
insert needle 15 degrees off the spine's midline
position needle lateral and 1cm inferior to the space between the vertebrae (interspace)
110
what does the epidural space contain and where is it located
located outside the dura mater
contains fat and small blood vessels (epidural veins)
111
what are the boundaries of the epidural space
cranial border
caudal border
anterior border
lateral border
posterior border
112
where is the cranial border of the epidural space
at the top, near the base of the skull at the foramen magnum
113
where is the caudal border of the epidural space
at the bottom, near the ligament connected to the coccyx (sacrococcygeal ligament)
114
where is the anterior border of the epidural space
in front, lined by the posterior longitudinal ligament along the vertebrae
115
what makes up the posterior border of the epidural space
ligamentum flavum and the bony plates of the vertebrae (vertebral lamina)
116
contents of the epidural space
contain nerves, fatty tissue, lymphatics and blood vessels
117
epidural space drug absorption
fatty tissue in the area can decrease the availability of certain drugs
118
a valveless venous plexus in the epidural space that drains blood from the spinal cord and its linings
Batsons plexus
119
density of veins increase in what direction
laterally
120
what conditions cause epidural vein engorgement and why is it important
obesity and pregnancy
increases the risk of complications during needle procedures
121
theoretical band of connective tissue located between ligamentum flavum and the dura mater
pilca mediana dorsalis
122
what is the potential impact of the plica mediana dorsalis if it exists
acts as a barrier in the epidural space
affect medication spread
123
how is the pilca mediana dorsalis clinically relevant
can play a role in difficulty epidural catheter insertion
unilateral blocks on arm
124
where is the subarachnoid space located
between the arachnoid mater and the pia mater
125
what does the subarachnoid space contain
cerebrospinal fluid (CSF), nerve roots, and spinal cord
126
what is the primary target when performing a spinal anesthetic procedure
subdurachnoid space
127
if needle is advanced too far anteriorly what can happen
it could pass through several layers (pia mater, spinal cord and the posterior longitudinal ligament) before reaching the bone
128
when is the pop felt during spinal anesthesia
when the needle passes through the outer membrane, the dura mater
129
what kind of space is the subdural space
potential space
130
where is the subdural space located
the potential spacce between the dura mater(outer layer) and arachnoid mater (middle layer)
131
what can cause a high spinal effect
when a local anesthetic is inadvertently injected in the subdural space during an epidural
132
what does high spinal mean
the medication affects a larger area than intended
133
what can result in a failed spinal block
a local anesthetic is accidentally injected into the subdural space during a spinal
134
what differentiates the epidural space from the subdural space
it has no veins
135
what is in the subarachnoid space thats not present in the subdural space
CSF
136
layers of the meninges in order of outermost to inner
dura mater
achranoid mater
pia mater
137
a tough fibrous shield that protects the spinal cord
dura mater
138
location of dura mater
starts at the large opening at the foramen magnum and extends down to the dural sac
139
what is the first layer encountered by the needle after advancing through epidural space
dura mater
140
thin layer of connective tissue that lies directly beneath the dura mater
Arachnoid mater (second meningeal layer)
141
what does the Arachonid mater do
acts as a protective middle layer between the dura mater and pia mater
142
which of the meninges layer is a highly vascular structure
pia mater
143
the delicate innnermost layer that covers the spinal cord
pia mater
144
why should we never puncture the pia mater during spinal anesthesia
it is directly attached to the surface of the spinal cord
145
what is important for local anesthetic reabsorbtion
pia mater
146
Each spinal nerve is formed by the
joining of anterior nerve root and posterial nerve root
147
what nerve root carries motor and autonomic information from the spinal cord
anterior nerve root
148
what nerve root brings sensory infomation from the body back to the spinal cord
posterior nerve root
