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Regional Flashcards

1
Q

Termination of
- Spinal cord (conus medullaris)
- Dural sac

In neonate

A

L2/3 for conus medullaris
Cauda equina + filum terminal remains
Dural sac terminates at S3/S4

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2
Q

PECS 1 block target nerves

A

Between pec major and minor
Targeting lateral and medial pectoral nerves

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3
Q

PECS 2 block target nerves

A

B/w pec minor + serratus anterior
Blocks lateral cutaneous spinal nerves + long thoracic nerve +/- intercostal nerves

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4
Q

Which ligament do you pierce to reach the paravertebral space?

A

costotransverse ligament

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5
Q

Location of serrates plane block

A

aim between lat dorsi serratus anterior at the mid axillary line

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6
Q

Location of the
- Anterior thoracolumbar fascia (TLF)
- Middle TLF
- Posterior TLF

A

anterior TLF anterior to quadratus lumborum, posterior to kidney

Middle TLF posterior to QL, lateral to erector spinae

Posterior TLF superficial to erector spinae

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7
Q

Location of TAP block

A

Between IOM and TA, lateral abdomen, probe immediately caudal to costal margin

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8
Q

Location of rectus sheath block

A

Through the oblique muscles laterally, aiming medially under the rectus abdominis
Lateral to the superior epigastric artery branch

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9
Q

Which part of brachial plexus does long thoracic nerve come off?

What does it innervate?

A

At the C5,6,7 roots

Serratus anterior (motor nerve)

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10
Q

Where does dorsal scapular nerve come off? what does it supply?

A

C4,C5 roots

motor supply for rhomboid, levator scapula

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11
Q

origin of the supraclavicular nerve?

A

C3/C4

Sensory supply to skin of the upper chest

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12
Q

Where are lateral and medial pectoral nerves come off?

A

Lateral pectoral nerve comes off lateral cord

Medial pectoral nerve comes off medial cord

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13
Q

Supply of
- Medial brachial cutaneous nerve
- Medial ante-brachial cutaneous nerve?

Where do they come off?

A

Both nerves come of medial cord.

Medial brachial cutaneous nerve supplies the medial surface of the arm, along with intercostal brachial (tourniquet)

Medial ante-brachial cutaneous nerve supplies medial surface of both arm and forearm, extending to wrist.

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14
Q

Where does intercosto-brachial nerve originate?

A

T2 intercostal nerve

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15
Q

Which part of the upper limb does a interscalene block frequently miss?

A

C8-T1 roots - not good for distal surgery - does not cover medial surface

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16
Q

Specific risks of interscalene block?

A

Phrenic nerve palsy
Horner’s syndrome
RLN palsy
Dorsal scapular nerve
Vertebral artery puncture
Pneumothorax

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17
Q

Location of
- Interscalene block target
- supraclav nerve
- Long thoracic nerve
- Dorsal scapular nerve

A

Block target is between C5 and C6 nerve roots (looking for the traffic light sign), between the anterior and middle scalene muscles

Three nerves surround the middle scalene
Supraclav = superficial to MS
long thoracic within the MS
dorsal scap posterior to MS

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18
Q

Describe the surrounding features of the IJV

A

IJV situated within the carotid sheath, containing carotid artery, vagus nerve

Carotid sheath lies deep the SCM, anterior to anterior scalene. Phrenic nerve can be found between SCM and anterior scalene

Thyroid, trachea, oesophagus medial to IJV

Sympathetic trunk medial and deep to carotid sheath (closer to vertebral body)

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19
Q

Where is intermediate cervical plexus block performed?

A

Similar probe placement as interscalene block
Identify spinal transverse processes.
Block performed at C4/C5
Identify posterior border of SCM, target plane between levator scapulae muscle + SCM
- Middle scalene is anterior to levator Scap

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20
Q

Which nerves does a cervical plexus block achieve?

A

Neck area divided into four quadrants
- Greater auricular nerve: ear region, upper portion of SCM
- Lesser occipital nerve: lateral scalp
- Transverse cervical nerve: anterior neck, lower SCM
- Supraclavicular nerve: lateral neck, skin above clavicle

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21
Q

Interscalene nerve block misses?

A

Suprascapular nerve
Can get sparring of the very inferior trunk (ulnar)

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22
Q

Describe the surrounding structures of supraclavicular nerve bundle

A

Needle approaches lateral to medial

Medial: subclavian artery, anterior scalene, subclavian vein

Lateral: middle scalene

Superficial: omohyoid, platysmus

Deep: 1st rib, pleura

SCM medial to omohyoid.

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23
Q

Supply of the musculocutaneous nerve?

A

sensory supply via lateral cutaneous nerve to the lateral forearm

Motor supply to biceps, coracobrachialis, brachialis

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24
Q

Describe the surrounding structures of the axillary artery, relevant for a axillary brachial plexus block

A

3 nerves surround the artery - ulnar posterior, radial deep, medial anterior

Corocobrachialis anterior to bundle, within it is musculocutaneous nerve, biceps further anterior

Axillary vein posterior to ulnar nerve

Conjoint tendon of lat dorsi and teres major diagonally, anterior -> posterior

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25
Femoral triangle border?
inguinal canal adductor Magnus medial sartorius lateral
26
Osteotome of the proximal femur
medial surface - obturator nerve sacral plexus - greater trochanter Femoral nerve for the rest
27
Hip joint capsule innervation?
Posterior capsule by sacral plexus nerves (superior gluteal + musculo articulares) Anterior capsule into 4 quadrants - Femoral nerve main supply - Obturator nerve inferior quadrants - Accessory obturator nerve medial quadrants
28
Where are the sensory branches of the hip capsule nerves consistently found? (target of PENG block)
Between anterior inferior iliac spine (AIIS) and iliopubic eminence of the superior rami These nerves are FN, ON, AON
29
PENG block structures
Target plane between AIIS, along superior pubic ramus, and iliopubic eminence Look for iliopsoas tendon within iliacus, aim needle just deep to it FV, FA, FN lie superficial to iliacus.
30
Muscular structures that can be visualised during a infra-inguinal FI block?
satorius lateral, iliacus deep Pectineus medial and deep to femoral vein
31
Describe the trajectory of the fascia iliaca
Separates femoral vein and artery from pectineus medially Runs between femoral artery and femoral nerve, then deep to satorius and superficial to iliacus
32
Neural supply for the anterior knee capsule ?
nerve to the vests medialis Saphenous nerve
33
Neural supply for the posterior knee capsule?
Branches of obturator nerve (medial part of the distal femur) Tibial nerve and CPN
34
Describe the surrounding anatomy of an adductor canal block
Target is the saphenous nerve, which is lateral to the femoral artery and vein Satorius lies superior, adductor longus medial, vastus medialis lateral Note NVM above the vastus-adductor membrane, need to find this to avoid neuropraxia
35
Describe the surrounding anatomy for a popliteal sciatic block
Needle approach lateral to medial, with probe on the posterior knee surface. Biceps femoris lateral. Semimembranosis medial Skin -> neural bundle (CPN and TN) -> pop vein -> pop artery
36
Motor nerves for the ankle/foot?
deep peroneal for anterior leg compartment (dorsiflexion) tibial nerve for posterior compartment
37
Plantar osteotome supply? ankle
Mainly tibial nerve Sural lateral ankle
38
Dorsum osteotome? ankle
Mainly deep peroneal, sural nerve lateral ankle
39
Sensory supply to plantar surface ankle ?
Tibial nerve mainly Saphenous nerve mid medial surface sural nerve lateral surface
40
Sensory supply to dorsal surface ankle?
Superficial peroneal mainly Saphenous medial foot around the sole sural lateral small patch deep peroneal 1st webber space
41
Describe tibial nerve ankle block
identify medial malleolus aim between achilles tendon, posterior to the posterior tibial artery advance needle to hit tibia in a posterior to anterior direction, hit tibia, withdrawal few mm, inject
42
Describe saphenous nerve block
Identify medial malleolus Nerve located anterior to the MM Just lateral to great saphenous vein SC block just superior to MM, lateral to GSV
43
Describe superficial peroneal block
ring block from anterior tibial ridge to lateral malleolus If US guidance, go 10cm up the ankle and identify nerve between EDL and peroneus
44
Describe deep peroneal nerve block
Lateral to tibialis anterior, medial to anterior tibial artery Inject lateral to TA, hit bone, withdrawal few mm, inject
45
Describe sural nerve block
Field block lateral malleolus to achilles tendon Located anterior to small saphenous vein
46
7 nerves of scalp block
supraorbital supratrochlear zygomaticotemporal auriculotemporal greater auricular lesser occipital greater occipital
47
Location of supraorbital block
just above the supraorbital notch
48
location of supratrochlear block
just medial to the supraorbital nerve site, above the eyebrow line
49
Location of zygomaticotemporal block?
Deep and superificial block at the lateral edge of zygomatic arch Deep - hit bone then inject Superficial - on the way out, aiming more laterally.
50
Location of auriculotemporal block?
1cm anterior to the auditory meatus, immediately posterior to the superficial temporal artery
51
Line drawn from occipital protuberance to mastoid Alone this line, which blocks can be performed?
Lateral third - lesser occipital nerve (posterior border of SCM) Medial third - greater occipital nerve
52
Greater auricular nerve block location?
2cm posterior to the auricle at the level of the tragus
53
Spinal tracts for motor control?
Later corticospinal tract Anterior corticospinal tract - truncal stability Cross at level of brain stem
54
Brown Seckar Syndrome pattern at T8
Ipsilateral loss of sensory and motor - Motor pattern: lower motor neuron at the level (flaccid paresis), spastic paresis below as upper motor neuron loss. Contralateral loss of pain and temperature - starts a few levels below (i.e T8 injury = T10 loss)
55
Spinal cord segmental supply
Aorta -> segmental -> dorsal branch -> epidural and spinal arteries. Radicular medullary branch (main branch of concern) joins the ASA and PSA.
56
Damage to flow of Artery of Adamkewtiz (syndrome)
Anterior spinal syndrome - Flaccid paresis at the level of damage. - Spastic paresis below - Loss of pain 2 levels below (tracts of Ls are spared) - Sparring of the dorsal column (proprioception not affected) - SNS loss due to lateral horn cells.
57
Venous supply to the epidural space
Anterior and posterior epidural plexus Draining laterally ----> azygous
58
Spinal level of dural sac termination?
S2 in neonate. Doesn't tend to change in adults. L1/2 - Conus, L4/5 - Tuffier's line
59
Major terminal branches of posterior cord?
Axillary nerve C5,6 Radial nerve C5 - T1 Subscapular nerve (for rotator cuff muscle)
60
Median nerve course
Lateral to axillary artery, then medial to brachial / radial artery Middle of the forearm -> under the carpel tunnel into the hand.
61
Ulnar nerve course
Between axillary artery and vein Groove on the back of medial epicondyle Medial to ulnar artery at the wrist Cross the flexor retinaculum
62
Radial nerve course
direct continuation of the posterior cord Between heads of triceps Superficial branch - purely sensory Travels through the snuff box
63
Measures to reduce nerve injury - Equipment - Technique - LA - Patient factor - Surfical factor
Equipment: blunt needle, US, nerve stim, injection pressure monitor Technique: awake, slow injection, feel the resistance, visualise on US LA - lower LA dose, lower volume Patient - note comorbidities (T2DM, BMI, smoker), caution in anticoagulation Surgical - optimal positioning while numb, minimise tourniquet.
64
Which upper limb block is considered deep?
infraclavicular block
65
Interscalene block - how can one tell the spinal process level?
C7 only has posterior tubercle visible. C6 above will have double hump - anterior and posterior tubercles.
66
Deposit location of superficial cervical plexus block?
5-10ml LA between the posterior edge of SCM and MSM.
67
Describe the superior trunk block
Trace interscalene a bit more distal Reliably block the supra scapular nerve Reason to do this is phrenic nerve being further away
68
Specific complications of supraclavicular block>
pneumothorax Ulnar sparing Damage to subclavian artery Phrenic nerve palsy Dorsal scapular artery or transverse cervical artery injury
69
Describe infraclavicular block
hand behind head to move clavicle superior Linear probe just medial to coracoid process to identify axillary artery 10cm short bevelled needle IP cephalic to caudal
70
Specific risks of infraclavicular block
Pneumothorax Axillary artery injury 3% phrenic nerve block
71
Which cords give rise to which terminal nerves?
Meidal cord - median / ulnar Posterior - radial, axillary Lateral - median, musculocutaneous
72
Testing upper limb distal nerves
Median nerve - thumb opposition Ulnar - spread fingers against resistance Radial - wrist extension MCN - elbow flexion
73
Describe digital nerve block
Each digit by 4x digital nerves (2x palmar, 2x dorsal) Inject the web space dorsum Palmar surface, inject midpoint at the base of the digit.
74
Which division of the femoral nerve gives rise to the saphenous nerve?
Posterior
75
Which nerves need to be blocked for the skin incision component of hip arthroplasty
LFCN + skin infiltration to the superior component
76
Surrounding structures of suprainguinal FI block
Bowtie - AIIS deep to it, iliopsoas overlying Caudad - satorius muscle Internal olblique cephalad, with deep circumflex iliac artery sometimes visible. Local spread under the fascia iliaca, superficial to the iliopsoas muscle, pushing the internal oblique away
77
Optimal location for adductor canal block
At the point when adductor Magnus and adductor longus both visible - AM, when more proximal, is in close proximity to sartorius. - Lower down, AL takes over.
78
muscles surrounding the pop-sci nerve
Laterally, biceps femoris Medially, semi-tendonosus superficial, and semi-membranosus deep Vein immediately deep to nerve bundle, then artery. pop-sci block, needle goes lateral to medial, through the semi-tendenosus muscle
79
What are the three hyoid muscles?
MSG Mylohyoid Stylohyoid Geniohyoid
80
Abductors of vocal cord?
Posterior cricoarytenoids, supplied by RLN
81
Which muscle does the RLN not supply?
Cricothyroid (tensor), Supplied by external SLN
82
Which nerves are you numbing for AFOI in the nasal cavity
Greater and lesser Palatine (from M2) Olfactory bulb -> anterior ethmoid (C1) for nares and anterior third of nasal septum
83
Course of subclavian vein
Continuation of axillary vein, commences at the lateral border of the first rib Travels posterior to the clavicle Anterior scalene muscle posteriorly separating it from the subclavian artery Travels over the superior surface of the first rib, forming a slight groove, then joins the internal jugular vein to form the brachiocephalic
84
Which coronary artery supplies the - AV node? - SA Node?
AV node by whichever branch supplies the PDA (85% RCA, 15% LAD) SA node - 60% RCA, 40% Cx
85
Segments of right middle lobe?
Medial and lateral segments
86
Orientation of the right lung - where would you find each lobe on lateral CXR
Most of the anterior chest wall by upper lobe Most of the posterior chest wall by lower lobe Right middle lobe anterior and inferior
87
Segments of the upper right lobe?
Apical, anterior and posterior segments
88
Segments of the lingual lobe?
part of left lung, upper lobe division Superior and inferior segments

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