Musculoskeletal Diseases (Exam II) Flashcards
What is the pathophysiology of scleroderma?
- Autoimmune-mediated inflammatory vasculitis
-Fibrosis of skin and internal organs from abnormal deposition of extracellular collagen
-Microvascular changes produce tissue fibrosis and organ sclerosis - Also known as Systemic Sclerosis
What mnemonic guides the main symptoms associated with scleroderma?
Expound on the mnemonic.
- **Calcinosis
- **Raynaud’s
- **Esophageal reflux
- **Sclerodactyly
- **Telangiectasia’s
What signs and symptoms might be seen with Scleroderma?
- Skin: Taut skin, Contractures & myopathy
NS: Nerve compression
CV: Systemic and pulmonary HTN, Dysrhythmias, Vasospasms in small arteries of fingers, CHF
Pulmonary: Pulmonary fibrosis
Renal: Decreased RBF
GI: Xerostomia, poor dentition, fibrosis of GI tract and refulx
What does xerostomia mean?
Dry mouth
What treatments are used for scleroderma?
- Symptoms alleviation
- ACE-inhibitors: only treatment that has shown to alter course of disease
- PPIs for reflux
- Digoxin: improve CO
- Steroids
- CCBs for Raynaud’s
Pulm. HTN tx: PDE inhibitors, O2, anticoagulation and diuretics
What airway and pulmonary considerations exists for scleroderma?
- Pulmonary fibrosis (↓ compliance)
- Decreased ROM for airway
- Avoid increasing PVR
Anesthesia management for Airway and motion
- decreased mandibular motion
- small mouth opening
- decreased neck ROM
- oral bleeding
What dose of metoclopramide would be utilized for GI tract fibrosis from scleroderma?
Trick question. Metoclopramide would not work in this scenario.
What other scleroderma anesthesia management considerations are there?
- risk of corneal abrasions
- keep warm (Raynaud’s)
- VTE 3x more common in this population (steriod stress dose)
What is Duchenne’s Muscular Dystrophy (DMD)?
What initial symptoms are present at 2-5 years of age?
- X-linked dystrophin disorder resulting in muscle atrophy.
Dystrophin is a large protein that plays a major role in stabilization of the muscle membrane - (Ages 2-5) = waddling gait, frequent falling, can’t climb stairs, Gower’s sign.
What s/s are seen with DMD?
List:
CNS
Musculoskeletal
CV
Pulm
GI
- **CNS - intellectual disability
- **MS - kyphosis, muscle atrophy, ↑ CK
- **CV - ↑ HR, cardiomyopathy, short PR & tall R-wave
- **Pulm - weakened respiratory muscles and weak cough, OSA **30% of deaths are due to pulmonary reasons
- **GI - hypomotility & gastroparesis
What are the anesthetic concerns and interventions relevant to DMD patients?
- Airway
- Pulmonary
- CV
- GI
- Airway - weak laryngeal reflexes & cough
- Pulm - weakened muscles, increased secretions, possible vent support up to 36 hours
- CV - Get pre-op EKG & echo
- GI - delayed gastric emptying
What drug should be avoided with DMD patients?
- Succinylcholine (Rhabdo & ↑K⁺, MH)
use NDMBs
What type of anesthesia is prefereable for a DMD patient?
Regional (vs GA)
Why might one use less volatile gasses with DMD patients?
- DMD patients have ↑risk of malignant hyperthermia.
Ensure you have Dantrolene
What is the pathophysiology of myasthenia gravis?
- Chronic Autoimmune disorder
- ↓ function of NMJ post-synaptic ACh receptors.
- Muscle weakness and rapid exhaustion of voluntary muscles
αlpha sub-units of ACh receptor are bound by antibodies.
What organ is linked with the production of anti-ACh antibodies?
- Thymus
Which condition is characterized by partial recovery with rest?
Myasthenia Gravis
What test is used to diagnose myasthenia gravis?
Edrophonium/Tensilon Test
- 1-2 mg IVP
- Myasthenia symptoms improve with injection = (+) test
What signs/symptoms might be seen with myasthenia gravis?
- Ptosis & diplopia
- Dysphagia & dysarthria
- Muscle weakness
- Isolated respiratory failure
- Myocarditis
Differentiate Myasthenic Crisis and Cholinergic Crisis.
- Myasthenic Crisis - Insufficient drug therapy and resulting respiratory failure.
- Cholinergic Crisis - too much -stigmine drug = SLUDGE-M symptoms.
- Differentiate by: Edrophonium/Tensilon Test
1-2 mg IVP
Improves myasthenic crisis, makes cholinergic crisis worse
What drugs are the firstline treatment for Myasthenia Gravis?
What would be done if drugs were ineffective?
- Anticholinesterases
-Pyridostigmine > neostigmine - Surgical Thymectomy: induces remission, reduces need for immunosuppresants
What drugs/treatments other than pyridostigmine or surgery could be used for myasthenia gravis?
- Corticosteroids
- Azathioprine
- Cyclosporine
- Mycophenolate
- Plasmapheresis: removes antibodies from circulation
- Immunoglobulin: temporary effect
What anesthetic considerations exist for myasthenia gravis?
- Aspiration risk & weakened respiratory muscles.
- Sensitivity to NMBs (intubate without if possible)
- No succinylcholine (resistant to it)
What is osteoarthritis (OA)?
What makes the pain better?
- Degeneration of articular cartilage with minimal inflammation.
- Pain better at rest.
- Pain is worse with motion.
What are Heberden nodes?
What disease process do they indicate?
- Bony swellings of the distal interphalangeal joints.
- Osteoarthritis
What spinal complications occur from osteoarthritis?
- Vertebral degeneration
- Nucleus pulposus herniation
- Nerve root compression
What are the treatments for osteoarthritis?
- PT & exercise
- Maintenance of muscle function
- Pain relief
- Joint replacement surgery
Are osteoarthritis or rheumatoid arthritis patients prescribed corticosteroids?
- RA patients (no steroids for OA)
What anesthetic considerations exist for OA?
- Airway ROM
What is rheumatoid arthritis?
What hand condition is often seen on inspection?
- Auto-immune systemic inflammatory disease
- Swelling of the Proximal Interphalangeal, metocarpophalangeal, and elbow joints.
- Rheumatoid factor - IG is present in 90% of pts
What joints are usually spared by rheumatoid arthritis?
- Thoracic & Lumbosacral spine
What pathology is this and what are these lesions called?
- Discoid lesions characteristic of SLE.
What is the Stellate ganglion and why do we care?
The stellate ganglion is a collection of sympathetic nerves found anterior to the neck of the first rib.
It gives off sympathetic nerve branches to the brachial plexus, which lies laterally, as well as tributaries to the subclavian and vertebral arteries and the brachiocephalic trunk.
can block the nerve instead of putting on beta blockers
Upper extremity innervation
The Brachial Plexus
Brachial Plexus blocks
Median nerve innervation
Nerve roots: C6 – T1 (also contains fibers from C5 in some individuals)
Motor functions: Innervates the flexor and pronator muscles in the anterior compartment of the forearm (except the flexor carpi ulnaris and part of the flexor digitorum profundus, innervated by the ulnar nerve). Also supplies innervation to the thenar muscles and lateral two lumbricals in the hand.
Sensory functions: Gives rise to the palmar cutaneous branch, which innervates the lateral aspect of the palm, and the digital cutaneous branch, which innervates the lateral three and a half fingers on the anterior (palmar) surface of the hand.
Innervation of the hand
Lower Extremity Sensory Innervation
Lumbar plexus extension
The anterior rami of the L1-L4 spinal roots divide into several cords. These cords then combine together to form the six major peripheral nerves of the lumbar plexus. These nerves then descend down the posterior abdominal wall to reach the lower limb, where they innervate their target structures.
A useful memory aid for the branches of the lumbar plexus is: I, I Get Leftovers On Fridays. This stands for the Iliohypogastric, Ilioinguinal, Genitofemoral, Lateral cutaneous nerve of the thigh, Obturator and Femoral.
Lateral Femoral Cutaneous
This nerve has a purely sensory function. It enters the thigh at the lateral aspect of the inguinal ligament, where it provides cutaneous innervation to the skin there.
Roots: L2, L3
Motor Functions: None.
Sensory Functions: Innervates the anterior and lateral thigh down to the level of the knee.
Obturator Nerve
Roots: L2, L3, L4.
Motor Functions: Innervates the muscles of the medial thigh – the obturator externus, adductor longus, adductor brevis, adductor magnus and gracilis.
Sensory Functions: Innervates the skin over the medial thigh.
Femoral Nerve
Roots: L2, L3, L4.
Motor Functions: Innervates the muscles of the anterior thigh – the illiacus, pectineus, sartorius and quadriceps femoris.
Sensory Functions: Innervates the skin on the anterior thigh and the medial leg.
Sacral Plexus
The sacral plexus is a network of nerve fibers that supplies the skin and muscles of the pelvis and lower limb. It is located on the surface of the posterior pelvic wall, anterior to the piriformis muscle.
The plexus is formed by the anterior rami (divisions) of the sacral spinal nerves S1, S2, S3 and S4. It also receives contributions from the lumbar spinal nerves L4 and L5.
