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Neuraxial Flashcards

1
Q

Name the 5 divisions of the spinal column. How many in each?

A

Cervical - 7
Thoracic - 12
Lumbar - 5
Sacrum - 5 fused
Coccyx - 4 fused

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2
Q

What ligament covers the sacral hiatus? Why does this matter?

A

sacrococcygeal ligament

This is punctured during the caudal approach of the epidural space

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3
Q

Order the 5 ligaments of the spinal column from posterior to anterior

A

Supraspinous
Interspinous
Flavum
Posterior longitudinal ligament
Anterior longitudinal ligament

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4
Q

Which ligaments are punctured during a midline approach for an epidural ? How about Paramedian?

A

Midline - Supra + Inter + Flavum

Paramedian - Flavum

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5
Q

Which two ligaments should never be punctured?

A

Posterior longitudinal ligament
Anterior longitudinal ligament

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6
Q

List all structures during a subarachnoid block

A
  1. Skin
  2. Subq
  3. Muscle
  4. Supra
  5. Inter
  6. Flavum

(Epidural Space)

  1. Dura mater
    (Subdural Space)
  2. Arachnoid matter
    (Subarachnoid space)
  3. Pia matter
  4. Spinal cord
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7
Q

What is Batson’s Plexus? Why does this matter?

A

Epidural Veins

Drains venous blood from the spinal cord

(during pregnancy these veins become engorged, causing increased risk of needle injury or cannulation)

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8
Q

What is the Plica MEdiana Dorsalis?

A

Possible band of connective tissue between Flavum and dura matter. (unsure if it exists)

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9
Q

Which Spinal root blocks the 1st digit (Thumb)?

A

C6

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10
Q

Which Spinal root blocks the 2nd and 3rd digits?

A

C7

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11
Q

Which spinal root blocks the Pubic Symphysis?

A

T12

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12
Q

Which spinal root blocks the nipple line?

A

T4

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13
Q

Which spinal root blocks the Anterior knee?

A

L4

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14
Q

Which spinal root blocks the Xiphoid process?

A

T6

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15
Q

Which spinal root blocks the 4th and 5th digits?

A

C8

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16
Q

Which spinal root blocks the belly button?

A

T10

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17
Q

Skin dermatomes photo

A
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18
Q

Skin dermatomes photo

A
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19
Q

What innervates face?

A

Trigeminal nerve (CN5)

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20
Q

What is the site of action for spinal anesthesia?

A

Bathes the nerve roots - myelinated preganglionic fibers

Local anesthetics inhibit neural transmission

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21
Q

What is the site of action for epidural anesthesia?

A

Locals must diffuse the dural cuff

Can also leak through the intervertebral foramen to enter the paravertebral area and cause multiple blocks

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22
Q

Which factors affect the spread during a spinal block?

A

Baricity of the local
Patient position
Dose
Site of injection
Volume of CSF
Density of CSF

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23
Q

Which factors do not affect the spread of a spinal block?

A

-Vasoconstrictor
-Weight
-Gender
-Orientation of bevel
-Speed of injection
-Increased intra-abdominal pressure
-Barbotage

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24
Q

What is the primary determinant of spread for epidural?

A

Volume

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25
Q

Which type of fibers are blocked first? Second? Third?

A

Autonomic

Sensory

Motor

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26
Q

Why does it matter on the order of blockade?

A

autonomic is 2-6 dermatomes higher than sensory

Sensory is 2 dermatomes higher than motor

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27
Q

How is a differential blockade different with epidural anesthesia?

A

No autonomic block with epidural

Sensory block is 2-4 dermatomes higher than motor

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28
Q

Order of different nerve fibers?

A
  1. Beta
  2. C
  3. Alpha - Gamma and Delta
  4. Alpha - alpha and beta
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29
Q

Function of A Alpha nerves?

A

Heavy myelination

Skeletal muscle and motor proprioception

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30
Q

Function of A beta nerves?

A

Touch and pressure

Heavy myelination

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31
Q

Function of A gamma?

A

Skeletal muscle tone

Medium myelination

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32
Q

Function of A delta?

A

Fast pain
Temp
Touch

Medium myelination

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33
Q

Function of B fibers?

A

Preganglionic ANS fibers

Light myelination

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34
Q

Function of C sympathetic fibers?

A

Post ganglionic ANS fibers

NO myelination

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35
Q

Function of C dorsal root fibers?

A

Slow pain
Temp
Touch

NO myelination

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36
Q

What are cardiovascular effects of a neuraxial anesthesia ?

A

Vasodilates - Venous more than arterial

Reduction on venous return, CO, BP

Bradycardia by blockage of T1-T4 cardioaccelerator fivers

Unloading of cardiac mechanoreceptors (Bezold Jarisch Reflex)

Unloading of stretch receptors in the SA node

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37
Q

What are respiratory effects of a neuraxial anesthesia ?

A

-Accessory muscle is reduced

-intercostals (decreased inspiration and expiration)

-Abdominal muscles (Ability to cough and clear secretions)

-Apnea is from brainstem hypoperfusion, not phrenic nerve block

-Careful in COPD

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38
Q

What are the neuroendocrine effects of a neuraxial anesthesia ?

A

-Blocks stress response

Reduces catecholamines, renin, angiotensin, glucose, thyroid stimulating hormone, and growth hormone

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39
Q

What are GI effects of a neuraxial anesthesia ?

A

Neuraxial blocks sympathetic tone which increases parasympathetic tone in the gut

-Increases peristalsis, relaxes sphincters

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40
Q

What are liver and kidney effects of a neuraxial anesthesia ?

A

As long as systemic BP is maintained, there is NO effect

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41
Q

What are risks with coagulopathy and neuraxial anesthesia ? Labs?

A

Spinal or epidural hematoma

Plt < 100,000
PT, aPTT and or bleeding time twice the normal value

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42
Q

Which valve lesions are contraindicated with neuraxial anesthesia?

A

Aortic Stenosis

Mitral Stenosis

Hypertrophic Cardiomyopathy

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43
Q

What is the risk of neuraxial anesthesia and increased ICP ?

A

Sudden change in CSF can cause brain herniation

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44
Q

Relationship between neuraxial anesthesia and MS?

A

Should be okay but use lower dose and warn the patient their symptoms might be exacerbated

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45
Q

Specific gravity of CSF?

A

1.002-1.009

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46
Q

What is baricity? How does it affect local?

A

Describes the density of the local

-Isobaric is similar to CSF
-Hyperbaric is more dense than CSF
-Hypobaric is less dense than CSF

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47
Q

What solution is usually hyperbaric? What will happen?

A

Dextrose is usually hyperbaric

The solution will sink

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48
Q

What solution is usually hypobaric? What will happen?

A

Water (hypO)

The solution will rise

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49
Q

What solution is usually isobaric? What will happen?

A

Saline

Solution will remain in place

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50
Q

What solution is an exception?

A

Procaine 10% in water

This will be hyperbaric because there are so many molecules

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51
Q

What is a saddle block?

A

If the patient stays sitting with a hyperbaric solution

Solution sinks and coats the sacral nerve roots

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52
Q

If you lay a patient down with a hyperbaric solution, what will happen?

A

The solution will settle and pool in the sacrum and thoracic kyphosis

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53
Q

Hyperbaric photo

A
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54
Q

Hypobaric photo

A
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55
Q

Where will hypobaric solution settle?

A

Highest point in the spinal canal

Do not give to sitting up patient. It will rise to the head

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56
Q

What is the name of the cutting needle?

A

Cutting - Quincke

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57
Q

What is the name of the non cutting needles?

A

Pencil - Sprotte
Pencil - Whitacre

Rounded -Green

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58
Q

Pros and Cons of cutting?

A

Pros - less force

Cons - Less tactile, easily deflected, more likely to injure cauda equina, higher risk of PDPH

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59
Q

Pros and Cons of non cutting

A

Pros - More tactile, less likely to deflect, less likely to injure cauda equina, lower risk of PDPH

Cons- Need more force

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60
Q

Three different types of epidural needles ?

A

Crawford - 0 degrees
Hustead - 15 degrees
Tuohy - 30 degrees

Alphabetical order

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61
Q

Dosage for adult and child caudal anesthetic

62
Q

What are absolute contraindications to caudal anesthesia?

A

Spina bifida
Meningitis
Meningomyelocele of sacrum

63
Q

What are relative contraindications to caudal anesthesia?

A

Pilonidal cyst
Abnormal landmarks
Hydrocephalus
Intracranial tumor
Progressive degenerative neuropathy

64
Q

MOA of neuraxial opioids ?

A

Inhibit afferent pain the substantia gelatinosa (lamina 2) of the dorsal horn

Decreased cAMP
Decreased Ca in presynaptic
Increased K in postsynaptic
Epidural opioids diffuse systemically

65
Q

Do neuraxial opioids cause sympathectomy, skeletal muscle weakness, or change in proprioception?

66
Q

Opioid intrathecal and epidural dosage guise

67
Q

How does lipophilicity affect rostral spread in the subarachnoid space?

A

Hydrophilic drugs stay in subarachnoid space and travel towards brain (rostral spread)

Hydrophilic drugs diffuse out and enter systemic circulation

68
Q

Rank opioids from most lipophilic to most hydrophilic

A

Most lipophilic

Sufentanil
Fentanyl

Meperidine
Hydromorphone
Morphine

69
Q

Lipophilic or hydrophilic ; Which stays in the CSF longer?

A

Hydrophilic

70
Q

Lipophilic or hydrophilic ; Which has more CSF spread?

A

Hydrophilic has extensive spread

More rostral spread (towards brain)

Wide band of analgesia

71
Q

Lipophilic and hydrophilic ; Site of action?

A

Both are rexed laminae 2+3

but lipophilic also has systemic effects

72
Q

Lipophilic or hydrophilic ; Which has faster onset?

A

Lipophilic (5-10 minutes)

Hydrophilic (30-60 minutes)

73
Q

Lipophilic or hydrophilic ; Which has longer duration?

A

Hydrophilic (6-24 hours)

Lipophilic (2-4 hours)

74
Q

Lipophilic or hydrophilic ; Higher incidence of PONV and Pruritus ?

A

Hydrophilic for both

75
Q

Lipophilic or hydrophilic ; Respiratory depression?

A

Both can be early on (<6 hours)

Hydrophilic can also be late (>6 hours)

76
Q

Four most common side effects of neuraxial opioids?

A
  1. Pruritus (most common)
  2. Respiratory depression
  3. Urinary retention
  4. N/V
77
Q

Which local reduces efficacy of epidural opioids?

A

2-Chloroprocaine

78
Q

Which epidural opioids can reactivate herpes?

A

Morphine 2-5 days later

Spreads to trigeminal nucleus

79
Q

Pathophysiology of post dural headaches?

A
  1. CSF leaks from subarachnoid space
  2. CSF pressure is lost, cerebral vessels dilate
    3.Brainstem sags into the foramen magnum which stretches meninges and pulls on the tentorium
80
Q

Presentation of post dural headaches?

A

Fronto-occipital headache
N/V
Tinnitus
Diplopia
Photophobia

Sitting makes it worse, laying makes it better

81
Q

Higher risk for PDPH?

A

Young
Female
Pregnant
Cutting needle
Large needle
Using air for LOR with epidural
Needle is perpendicular to long axis

82
Q

What has no effect on PDPH?

A

Early ambulation
Continuous spinal catheter

83
Q

How to treat PDPH?

A

Best rest
Hydration
NSAIDS
Caffeine
Blood patch

NOT OPIOIDS

84
Q

How is a blood patch preformed ?

A

90% success rate

Sterile technique 10-20 mL of venous blood are aspirated and injected into the epidural and subarachnoid space

When pressure is felt by the patient, it is complete

Blood compresses the space and acts as a plug

85
Q

Most common side effects of a blood patch ?

A

Back ache and radicular pain

86
Q

What is the primary risk of neuraxial anesthesia in the anticoagulated patient? How does it present?

A

Epidural hematoma during initial block and the removal of the catheter

Presents - weakness, numbness, low back pain, bowel and bladder dysfunction

Treatment - surgical decompression

87
Q

Where does the spinal cord end in an adult? Subarachnoid space?

A

Adult - Ends at L1-L2 (conus medullaris)

Ends at S2 - (dural sac)

88
Q

Where does the spinal cord end in an infant? Subarachnoid space?

A

Ends at L3 (conus medullaris)

Ends at S3 (dural sac)

89
Q

What is the cause of cauda equina syndrome?

A

Neurotoxicity of high concentrations of local anesthetic

5% lidocaine and spinal microcatheters make it worse (because it exposes a small region to high amounts)

90
Q

How does cauda equina present?

A

Bowel and bladder dysfunction, sensory deficits, weakness, paralysis

Treatment is supportive

91
Q

What is the cause of transient neurologic symptoms? What factors increase the risk?

A

patient positioning, stretching of the sciatic nerve, myofascial strain, and muscle spasms

Lidocaine, lithotomy, knee scope, ambulatory surgery

92
Q

How does transient neurologic symptoms present?

A

Severe back and butt pain, down both legs
Develops 6-26 hours after and lasts for 1-7 days

Treatment - NSAIDS, opioids, trigger point injections

93
Q

What is the most common organism responsible for post spina bacterial meningitis?

A

Streptococcus (Found in mouth so wear mask)

Reaches CSF because of failure of sterile technique and bacteria already in blood at time of SAB

94
Q

Best way to prepare skin for neuraxial anesthesia?

A

Chlorhexidine + alcohol

**Chlorhexidine is toxic so wait for it to dry

95
Q

Mnemonic for brachial plexus

A

Reach - Roots - 5
To - Trunks -3
Drink - Divisions - 6
Cold - Cords - 3
Beer - Branches - 5

96
Q

What makes up the trunks of the brachial plexus?

A

Superior C5 + 6
Middle C7
Inferior C8 + T1

97
Q

What are the three cords? What makes them up?

A

Lateral C5-C7

Posterior C5 - T1

Medial C8+T1

98
Q

What are the 5 branches?

A

Musculocutaneous C5-7
Axillary C5-C6
Median C5-T1
Radial C5-T1
Ulnar C8-T1

99
Q

Where do the brachial plexus roots turn into trunks?

A

Just beyond the lateral border of the scalene muscles

100
Q

Where do the brachial plexus trunks turn into divisions?

A

Underneath the clavicle and over the first rib

101
Q

Where do the brachial plexus divisions turn into cords?

A

Under the pectoralis minor muscle

102
Q

Where do the brachial plexus cords turn into terminal branches?

A

In the axilla

103
Q

Sensory innervation of the upper extremity

104
Q

In addition to the brachial plexus, which nerve must be blocked to tolerate a upper tourniquet ?

A

Intercostobrachial (arises from T2)

5mL injected for a field blocker

105
Q

Which procedures is an ISB good for? Not good for ?

A

Shoulder, upper arm, clavicle

Not good for anything below elbow (spares C8-T1) roots

106
Q

Which approach usually results in phrenic nerve blockade?

A

ISB

**Issue with respiratory disease

107
Q

Which approach usually results in Horner syndrome?

A

ISB - blocking the stellate ganglion at C7

-ptosis
Miosis
anhidrosis

**Indicates successful block

108
Q

Discuss the relationship between shoulder arthroscopy, ISB, and hypotensive bradycardia episodes.

A

The bezold-jarish reflex is the proposed mechanism

Venous pooling in LE reduces venous return

Unloaded ventricle + SNS stimulation+ Epi uptake

109
Q

What is targeted for a supraclavicular block? What is this good for? Bad for?

A

Targets trunks and divisions.

Good for upper arm, elbow, wrist, and hand

Bad for shoulder

110
Q

Greatest risk for a supraclavicular block?

A

Pneumothorax

Can use the first rib as a blocker

111
Q

What does a infraclavicular block target? Good for? Bad for?

A

Targets the cords below clavicle

Good for upper arm, elbow, wrist, hand

**Favored over supraclavicular with patients that have respiratory complications (avoids phrenic nerve)

Not good for shoulder

112
Q

Is the axillary nerve blocked during an axillary block?

113
Q

What is an axillary block good for? What does it miss?

A

Good for forearm and hand

Does not cover the skim of the medial upper arm (intercostobrachial nerve)

Skin of the deltoid (axillary nerve)

114
Q

How is the radial nerve blocked?

A

Derives from the posterior cord

Injected 3-5mL between biceps and brachioradialis

115
Q

How is the ulnar nerve blocked?

A

Elbow flexed at 90 degrees and 3-5 mL is injected between olecranon and medial epicondyle of the humerus

***Too much volume can compress and cause ischemia

116
Q

How do you block the median nerve at the wrist?

A

5mL between flexor carpi radialis tendon and flexor palmaris longus tendon

117
Q

How is a bier block performed?

A

1, Apply double tourniquet
2. Place 22g PIV distally
3. Elevate extremity to allow passive exsanguination

  1. Wrap Esmarch bandage
    5.Inflate DISTAL cuff
  2. Inflate proximal cuff
  3. Deflate distal cuff
  4. Remove Esmarch bandage
  5. Inject large volume of lidocaine local -50mL
  6. Increase pressure to 250 (min 100)
118
Q

Notes about a Bier block?

A

Do not use bupivacaine due to risk of cardiac issues

Do not use epi or anything with preservatives

Can use toradol

TWO HOURS MAX INLFATION TIME

119
Q

When does tourniquet pain start? How to treat?

A

Starts as early as 25 minutes

Since Proximal cuff is inflated, must inflate the distal cuff first to prevent local going systemically

Inflate distal

Deflate proximal

120
Q

Most significant risk of a Bier block?

A

LAST

Tourniquet must be inflated for a minimum of 20 minutes

20-40 minutes can deflate but then must reinflate

40 minutes - deflate

121
Q

Where does the lumbar plexus arise from?

A

L1-L4 with occasional T12 and gives rise to 6 nerves

122
Q

Mnemonic for lumbar plexus?

A

I Invariably Get Lazy On Fridays

Iliohypogastric
Ilioinguinal
Genitofemoral
Lateral femoral cutaneous
Obturator
Femoral

123
Q

Which nerve roots give rise to each nerve in the lumbar plexus?

124
Q

Lower block table

125
Q

Lumbar sensory innervation

126
Q

What nerves are blocked during the psoas compartment block? What is another name for this block?

A

Lateral femoral cutaneous n

Femoral n

Obturator n

Also called the lumbar plexus block

127
Q

When is the lumbar plexus block useful?

A

When neuraxial is contraindicated or one extremity is preferred

128
Q

What are the borders of the femoral triangle?

A

S = Sartorius muscle
A = Adductor longus muscle
IL = Inguinal ligament

129
Q

Going from medial to lateral, what are the structures inside the triangle?

A

V = Vein
A = Artery
N = Nerve

130
Q

How many branches does the femoral nerve have? What are they?

A

Two

-Anterior branch innervates the ventral surface of the thigh and sartorius muscle

-Posterior branch innervates quadriceps, knee joint, and medial ligament

-Posterior branch gives rise to the saphenous nerve

131
Q

What does the saphenous nerve innervate?

A

Sensory - medial aspect of the knee to the medial malleolus

Motor - NONE

Good when combined with popliteal or ankle block

132
Q

Where does the sciatic nerve arise from?

A

L4-L5 and S1-S3

Divides io tibial nerve and peroneal nerve

133
Q

Where is a popliteal block performed?

A

Sciatic nerve in the proximal popliteal fossa

134
Q

5 nerves innervate the foot. How can you tell if they are sensory or sensory + motor

A

3 sensory start with just S

2 Mixed sensory and motor do not start with S

Femoral = Saphenous

Sciatic =
1.Deep peroneal
2. Superficial peroneal
3. Sural
4. Posterior tibial

135
Q

Ankle innervation

136
Q

Where is the Sural N blocked?

137
Q

Where is the Deep Peroneal N blocked?

138
Q

Where is the superficial peroneal n blocked?

139
Q

Where is the saphenous nerve blocked?

140
Q

At the level of the ankle, which nerve is not next to a vascular structure ?

A

Superficial peroneal nerve

141
Q

What’s the difference between PECS1 and PECS2 block?

A

PECS1 - inject between pec major and minor

PECS2 - inject between pec major and minor THEN between pec minor and serratus anterior

142
Q

Where do intercostals arise from?

A

Ventral rami of the thoracic spine nerves T1-T11

Each nerve travels beneath the rib

143
Q

Describe the distribution of anesthesia paravertebral block

A

Only covers one dermatome level

Must be performed at each level desired

144
Q

What are the boundaries of the paravertebral space?

A

Anterior - Parietal pleura

Medial - Vertebral body and intravertebral foramen

Posterior - Transverse process and superior costotransverse ligament

145
Q

Indications for a paravertebral block?

A

Thoracic
Breast
Chloey
Herniorrhaphy
Appendectomy
Rib fractures
Flail Chest
Blunt Trauma
Vertebral fractures
Herpes zoster

146
Q

What is an erector spinae block?

A

Targets dorsal and ventral rami of the thoracolumbar nerves. Can have significant craniocaudal spread

147
Q

What is the triangle of Petit?

A

Helps with TAP block

Posterior border - Latissimus dorsi

Anterior border - External oblique

Inferior border - Iliac crest

Inside the triangle - internal oblique

148
Q

Goal of TAP block?

A

Place block between internal oblique and transverse abdominis muscles

These nerves from T6-L1 innervate the IO and TA muscles

149
Q

Indications for a rectus sheath block?

A

Needs midline incision

Umbilical hernia repair

C Section

Laparoscopic tubal ligation

150
Q

Describe the thoracolumbar fascia

151
Q

Where is the thoracolumbar fascia block injected?

A

QL1- LA injected lateral to the QLM

QL2 - LA injected posterior to the QLM

QL3 - LA injected anterior to the QLM

152
Q

Dosage for adult and child caudal anesthetic

Blocks (4 decks)

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