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Advanced Anesthesia 2 > Spinals and Epidurals - Quiz 6 > Flashcards

Spinals and Epidurals - Quiz 6 Flashcards

1
Q

Label 1-9 of the Vertebra

A
  1. Spinous Process
  2. Transverse Process
  3. Vertebral Arch Lamina
  4. Pedicle
  5. Body
  6. Head of Rib
  7. Superior Articular Process
  8. Vertbral Foramen
  9. Spinal Cord
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2
Q

Which part of the vertebra allows for the passage of nerves?

A

Lateral Notches

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3
Q

What angle should the needle be when placing in Cervical & Thoracic Vertebrae?

A

Cephalad Angle

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4
Q

What makes Lumbar Vertebrae easier to place needles?

A

Larger with Less Overlap & Larger Gaps

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5
Q

Label 1 - 15 of the Sacral Vertebra

A
  1. Sacral Canal
  2. Superior Sacral Notch
  3. Auricular Surface
  4. Sacral Tuberosity
  5. Posterior Sacral Foramina
  6. Sacral Hiatus
  7. Sacroccocygeal Notch
  8. Apex of Coccyx
  9. Transverse Process of Coccyx
  10. Cornua of Sacrum & Coccyx
  11. Inferolateral Angle
  12. Lateral Crest
  13. Intermediate Crest
  14. Median Crest
  15. Superior Articular Facet
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6
Q

What was the 3 Intervertebral Ligaments from Superficial to Deep?

A

Supraspinous Ligament

Intraspinous Ligament

Ligamentum Flavum

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7
Q

Which Intervertebral Ligament is strong, connects the apices of the spinous processes, and is the major ligament of Cervical and Upper Thoracic Regions?

A

Supraspinous Ligament

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8
Q

Which Intervertebral Ligament is Absent or Poor Quality in the Cervical Region and Thin, especially in the Lumbar?

A

Intraspinous Ligament

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9
Q

Which Intervertebral Ligament is the Strongest and looks like a contiguous ligament?

A

Ligamentum Flavum

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10
Q

The Ligamentum Flavum is _____ on the lateral edge, ______ midline, like a V

A

The Ligamentum Flavum is THIN on the lateral edge, THICK midline, like a V

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11
Q

At the L2 - L3 level, the Ligamentum Flavum measures _______ thick

A

At the L2 - L3 level, the Ligamentum Flavum measures 3 - 5 mm thick

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12
Q

Which Ligaments of the Spine covers the Anterior & Posterior parts of the Vertebra?

A

Anterior & Posterior Longitudinal Ligaments

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13
Q

Where is the Epidural Space located?

A

Between Ligamentum Flavum & Dura Mater

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14
Q

Where does the Epidural Space Originate and End?

A

From Base of Cranium to Sacral Sulcus

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15
Q

How far is the Epidural Space from the Skin?

A

Varies - From 2.5 - 8 cm

Average is about 5 cm from Skin

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16
Q

How far does the Spinal Cord extend for Adults & Kids?

A

Adults: Medulla to L2

Kids: Medulla to L3

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17
Q

Which Layer of the Spinal Cord contains CSF?

A

Arachnoid Mater

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18
Q

How are the 31 Pairs of Spinal Nerves distributed?

A

8 Cervical

12 Thoracic

5 Lumbar

1 Coccygeal

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19
Q

Where do Thoracic Nerves run along in relation to the Ribs?

A

Inferior Margin of Rib

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20
Q

Slide 18 - Levels

A
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21
Q

How far along the Spinal Cord is the Brachial Plexus?

A

C4 - T1

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22
Q

How far along the Spinal Cord is the Lumbar & Sacral Plexus?

A

L2 - S3

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23
Q

How far along the Spinal Cord is the Cauda Equina?

A

L1 - S5

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24
Q

Which part of the Spinal Cord is the entering Sensory Root and which is the outgoing Motor Root?

A

Dorsal - Entering Sensory

Ventral - Outgoing Motor

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25
Q

What is the Laminae II called?

A

Substanca Gelatinosa - Where IV & Neuraxial Opioids work

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26
Q

What are the Afferent & Ventral Tracts of Grey Matter?

A

Afferent: I - VI

Ventral: VII - IX

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27
Q

Which part of the highly organized White Matter is exclusively Ascending Sensory Fiber Tracts?

A

Dorsal White Matter

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28
Q

What do the Lateral & Ventral White Matter do?

A

Descending Motor Tract

Ascend to Brain

Reflex - Start and End w/in Spinal Cord

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29
Q

Where are the Sensory/Afferent Receptors location?

A

Epidermis & Dermis: Pain & Temp

Dermis: Pressure, Touch, Vibration, Proprioception

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30
Q

What are the 2 Classifications of Sensory Receptors?

A

Extroceptors - Near Suface of Skin

&

Proprioceptors - Deeper than Skin Surface

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31
Q

How do peripheral sensory signals travel to the Thalamus with the Dorsal Medial Lemniscus tract?

A

Dorsal Root –> Cross over Medulla (1st to 2nd Order) –> Goes up Medial Lemiscus Tract via Brainstem (2nd Order) –> Thalamus (3rd Order Neuron)

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32
Q

How do peripheral sensory signals travel to the Thalamus with the Anterolateral Pathway?

A

Dorsal Horn –> Laminae I, IV, V, VI –> Crossover at Anterior Commissure –> Anterolateral White Columns –> Associated Tract (Spinothalmic) –> Thalamus –> Interpretation in Brain

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33
Q

What are the differences b/t the Dorsal Medial Lemnisucus versus the Anterolateral System?

A

Dorsal Medial Lemniscus: Large, Myelinated, High Spacial Orientation with a 30-110 m/sec conduction speed - Descrete Senses

Anterolateral: Small, Myelinated, Low Spacial Orientation with a 40 m/sec conduction speed - Broad Senses

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34
Q

What kind of sensations does the Dorsal Medial Lemniscal system transmit?

A

Touch

Vibrations

Skin Movement

Joint Position

Fine Pressure

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35
Q

What kind of sensations does the Anterolateral system transmit?

A

Pain

Thermal

Crude Touch

Tickle

Itch

Sexual

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36
Q

Where do Preganglionic B Fibers Originate and Exit?

A

Originates in Tnermediolateral Gray Horn T1 - L2/L3

&

Exits via Ventral Nerve Root - Whtie Rami Cummincans

37
Q

What does stimulation of the SNS fiber in the Superior Cervical Ganglia cause?

A

Midrasis - Pupil Dilation

&

Blood Vessel Constriction in Head

38
Q

What happens when the Superior Cervical Ganglia, Central SNS, or Paravertebral Ganglia is damaged?

A

Horners Syndrome:

Miosis - Small Pupil

Ptosis

Anhydrosis - No Sweat

39
Q

What are the 4 Stages of Pain Transmssion?

A
  1. Tranduction
  2. Transmission
  3. Modulation
  4. Perception
40
Q

How do motor signals travel through the Corticospinal Tract?

A

Precentral Gyrus –> Crosses Medulla –> Form Pyramids –> Leave Spinal Cord or Enter Ventral Horn to Synapse w/ Lower Motor Neurons

41
Q

What happens if damage occurs to the Neurons of the Corticospinal Tract that have inhibitory effects on the Lower Motor Neurons?

A

Hyperreflexia & Spasticity

42
Q

What happens with Upper Motor Neuron Paralysis?

A

Hyperreflexia d/t Impeded Suppressor fibers

43
Q

What happens when Lower Motor Neurons are damaged?

A

Flaccid Paralysis

44
Q

How are Cutting Epidural/Spinal needles placed?

A

Longitudinal

45
Q

What is the purpose of the Stylet regarding Epidural/Spinal Needles?

A

Prevents introduction of Dermal Cells, leading to Dermoid Spinal Cord Tumor

46
Q

What are absolute contraindications to Spinals?

A

Patient Refuse

Lack of Cooperation

Coagulopathy

Infection at Site

Hypovolemia

Neuro Disease

Increased ICP

47
Q

What factors affect the Uptake & Spread regarding Spinals?

A

Local Anesthetic Concentration

Nerve Surface Area

Lipid Content of Nerve

Blood Flow to Nerve

48
Q

What factors affect distribution regarding Spinals?

A

Baricity

Position

Dose

49
Q

What factors affect the Level regarding Spinals?

A

Baricity

Position

Dose

Site of Injection

Age

Speed of Injection

Volume

Concentration

50
Q

Which Local Anesthetics are Isobaric & Hyperbaric?

A

Tetracaine

Lidocaine

Bupivacaine

51
Q

What kind of Baricity does Tetracaine & Lidocaine have?

A

Hypobaric

Isobaric

Hyperbaric

52
Q

What are the main cardiovascular side affects of Spinals?

A

Hypotension & Bradycardia - treat w/ Fluids or Vasopressors

53
Q

What are the GI effects from Spinals?

A

T6 - L2 Sympathetic Innervation

↑Secretions

Relaxed Sphincters

Bowel Constriction

N/V

54
Q

What is the LA Spinal dose suggestion for Lidocaine?

A

25-50 mg (25-100 mg)

55
Q

What is the recommended LA Spinal dose for Tetracaine & Bupivacaine?

A

5 - 20 mg

56
Q

What baricity should the LA be if the patient is getting a Spinal in the prone position?

A

Iso or Hypobaric

57
Q

What are the different approaches for placing a Spinal?

A

Median

Maramedian

Taylor

58
Q

What should be done if bone is felt when placing a Spinal?

A

Withdraw both needle & stylet to skin & Redirect

59
Q

What should be done if the patient experiences paresthesia during Spinal placement?

A

Stop Advancing, Remove Stylet, Check for CSF

60
Q

What is a Paramedian approach good for when placing a Spinal?

A

Calcified Intraspinous Ligaments or Difficult Positioning

61
Q

How is the needle inserted with a Paramedian approach?

A

1 cm Lateral & 1 cm Inferior to Space w/ a Medial & Cephelad angle

62
Q

Which ligament is first to give resistance with a Paramedian Spinal approach?

A

Ligamentum Flavum

63
Q

What are the complications r/t Spinals?

A

Cauda Equina Syndrome

Arachnoiditis

Meningitis

PDPH

Hematoma

High Spinal

CV Collapse

64
Q

With PDPHm the headache is worse when when the patient is ________, and gets relief when the patient is _________

A

With PDPH the headache is worse when when the patient is UPRIGHT, and gets relief when the patient is SUPINE

65
Q

How are PDPHs treated?

A

Epidural Blood Patch - Mainstay

Fluids

Caffeine

Bedrest

Pain Meds

Sumatriptan

66
Q

Spinal Hematomas are considered an ________, and requires immediate Neuro Consult & MRI

A

Spinal Hematomas are considered an EMERGENCY, and requires immediate Neuro Consult & MRI

67
Q

What are absolute contraindications for Epidurals?

A

Patient Refuse

Hypovolemia

Increased ICP

Infection at Site

68
Q

What are the effects of an Epidural below T4?

A

Vasomotor Tone Effected

↓Venous Return & CO

69
Q

What are the effects of Epidurals Above T4?

A

Cardiac Sympathetic Fibers Effected

Profound HYPOtension & Bradycardia

70
Q

What factors affect Epidural Coverage?

A

** ​VOLUME **

Site

Concentration

Age

Height

Pregnancy

Obesity

71
Q

Regarding Epidurals, what is the volume needed for each level of block?

A

1 - 2mL per level

72
Q

Regarding Epidurals, the Lumbar gets more spread ________, while the Thoracic gets and _____ spread

A

Regarding Epidurals, the Lumbar gets more spread CEPHALAD, while the Thoracic gets and EVEN spread

73
Q

Pregnant & Obese patients require a ________ dose for an Epidural d/t Vein Engorgement & Increased Fat Tissue

A

Pregnant & Obese patients require a DECREASED dose for an Epidural d/t Vein Engorgement & Increased Fat Tissue

74
Q

When should each Epidurally injected Local Anesthetic be redosed?

  • Chloroprocaine
  • Lidocaine
  • Mepivacaine
  • Bupivacaine
  • Ropivacaine
A
  • Chloroprocaine: 45 min
  • Lidocaine: 60 min
  • Mepivacaine: 90 min
  • Bupivacaine: 120 min
  • Ropivacaine: 120 min
75
Q

How is the Epidural Space identified with the Loss of Resistance technique?

A

Once in the Intraspinous Ligament, advance syringe slowly while tapping or placing continuous pressure until LOR.

76
Q

How is the Epidural Space identified with the Hanging Drop technique?

A

Once in Intraspinous Ligament, place syringe with a lil fluid in the hub and advanced until drop sucks into needle

77
Q

What are the complications of an Epidural?

A

Hypotension

Unilateral Block

Inadequate Block

Back Pain

PDPH

Subdural/Subarachnoid Injection

Meningitis

Arachnoiditis

Nerve Injury

78
Q

What should be done if there is a Unilateral Block from an Epidural?

A

Pull Catheter Back

Unaffected side Down

Redose

Replace

79
Q

What should be done if there is an Inadequate Epidural Block?

A

Raise Head

Redose w/ Higher Concentration

Add Fentanyl

80
Q

A Subdural Epidural Injection will elicit a response after _________ and can lead to a High Spinal

A

`A Subdural Epidural Injection will elicit a response after 10 - 15 minutes and can lead to a High Spinal

81
Q

A Subarachnoid Epidural Injection leads to a ________

A

A Subarachnoid Epidural Injection leads to a FAST HIGH SPINAL

82
Q

What are signs of Meningitis from an Epidural?

A

Non-Positional Headache

Fever

Lethargy

Confusion

Nuchal Rigidity

83
Q

What should be done if Meningitis is suspected?

A

Head CT

Lumbar Puncture

Neuro Consult

Antibiotics

84
Q

How long should anticoagulants such as Warfarin be discontinued before placing an Epidural/Spinal?

A

4 - 5 Days

&

PT/INR < 1.5

85
Q

How should Heparin be managed regarding Epidurals/Spinals?

A

Sub Q: Hold until after Block

IV: Hold 1 Hour after Block & Remove 2-4 Hours after last Dose

86
Q

How long should Herbal supplements that cause bleeding be held before Epidurals/Spinals?

A

5 - 7 Days

87
Q

When should Ticlopidin & Clopidogrel be discontinued for Epidurals/Spinals?

A

Ticlopidine: 14 days

Clopidogrel: 7 days

88
Q

When should Abciximab be discontinued for Epidurals/Spinals?

A

Avoid Epidural/Spinal if patient is on Abciximab

89
Q

How should LMWH/Lovenox be mangaged regarding Epidurals/Spinals?

A

Place Block 10-12 Hrs after last dose

24 hrs if High Dose

Advanced Anesthesia 2 (8 decks)

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