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Advanced Anesthesia Test#2 > Spinal anatomy > Flashcards

Spinal anatomy Flashcards

1
Q

Arterial Blood Supply to the Spinal Cord:

➢ Longitudinal arteries include: up and down

A
  • A single anterior spinal artery
  • Paired posterior spinal arteries
  • Paired posterior lateral spinal arteries
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2
Q

Arterial Blood Supply to the Spinal Cord:

➢ Transverse arteries include: across

A
  • Cervical radicular artery
  • Thoracic radicular artery
  • Radicularis magna (Artery of adamkowicz)
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3
Q

The ______ spinal arteries and the______ spinal arteries supply blood to the posterior aspect of the spinal cord.

A

posterior

posteriolateral

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4
Q

The _____ spinal artery supplies blood to the anterior aspect of the spinal cord.

A

anterior

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5
Q

dura damage - maneuver we do to make sure repair is adequate

A

we hand ventilate and hold a positive pressure breath at 30-35cm H20 which decreases venous return and puts more blood into venous system throughout the body including the epidural venous plexus and puts pressure on the dura and they can see if there is leaking of CSF at that time.

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6
Q

positioning - increased pressure on abdomen –>

A

decreases venous return and increases venous engorgement all over body. Surgeons will damage some of these veins. The greater amt of venous engorgement = greater amount of bleeding

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7
Q

VENTRAL DECUBITUS (PRONE) POSITIONING- Circulatory:

A

Due to pressure on the abdomen, venous engorgement of the_epidural_ vessels can occur which can lead to increased _bleeding___.

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8
Q 
VENTRAL DECUBITUS (PRONE) POSITIONING-
➢	If the head is turned to one side,
A
  • then decreases in intracranial arterial flow and venous drainage can occur.
  • Potential for brachial plexus inj. Facial and oralpharygeal edema since head is usually lower than back
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9
Q

VENTRAL DECUBITUS (PRONE) POSITIONING- Circulatory:

A

decrease in stroke volume and cardiac index.

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10
Q

VENTRAL DECUBITUS (PRONE) POSITIONING- Respiratory:

A

➢ Decreased chest excursion. Peak pressures will be increased
➢ Abdominal contents displace the diaphragm __cephalad

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11
Q

VENTRAL DECUBITUS (PRONE) POSITIONING- Abdominal Compression:

A

If intra-abdominal pressure exceeds venous pressure, blood return from the lower extremities can be _obstructed and static__ and increase the risk of a PE.

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12
Q

VENTRAL DECUBITUS (PRONE) POSITIONING- Thoracic Outlet Syndrome:

A

➢ Compression of the _brachial plexus and/or subclavian artery_between the 1st rib and clavicle.
➢ If patients develop parasthesias and/or decreased radial pulses when arms are extended above the head, then arms should be maintained in side lying position.

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13
Q

VENTRAL DECUBITUS (PRONE) POSITIONING- The anesthetist must ensure that the following pressure points are padded:

A 
•	Fingers and wrists 
•	Elbows 
•	Iliac crests 
•	Knees 
•	Feet and toes 
- Breasts, testicles and penis 
- Eyes, ears, and nose must be free for compression and checked every _15_ minutes. And documented 
- Head and neck must be in neutral position
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14
Q

Ischemic optic neuropathy is associated with; (ION)

A

. Ocular compression (pressure on eyes will decrease perfusion to optic nerve)

  1. Decreased BP overtime – causing ischemia of optic nerve
  2. Anemia
  3. Microemboli – cutting bone, using bone grafts, glue or cement for repair of vertebra
  4. Edema of optic nerve – when they get too much blood or fluid they develop edema in airway, and optic nerve decreasing perfusion to optic nerve
  5. Length of surgery- longer the surgery, the greater the possibility – no control over this
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15
Q

Relton frame:

A

used for spinal surgery. There would be pressure on lateral aspects of chest so there would be chest excursion and iliac crests. Frame can be adjusted smaller or larger and allow chest and abdomen to hang free

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16
Q

The Wilson frame

A

minimal amt of pressure on chest and abdomen.

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17
Q

ANESTHETIC PROBLEMS ASSOCIATED WITH THE PRONE POSITION

- AIRWAY

A
  • Endotracheal tube kinking or dislodgement

- Airway edema

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18
Q

ANESTHETIC PROBLEMS ASSOCIATED WITH THE PRONE POSITION

- BLOOD VESSELS

A
  • Arterial or venous occlusion of the upper extremities
  • Kinking of femoral vein with hips severely flexed
  • Abdominal pressure increases epidural venous pressure
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19
Q

ANESTHETIC PROBLEMS ASSOCIATED WITH THE PRONE POSITION

- NERVES

A
  • Compression or stretch of the brachial plexus
  • Ulnar nerve compression
  • Peroneal nerve compression
  • Lateral cutaneous nerve trauma
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20
Q

ANESTHETIC PROBLEMS ASSOCIATED WITH THE PRONE POSITION

- HEAD AND NECK

A
  • Hyperextension/hyperflexion
  • Rotation causing brachial plexus injury
  • Eye damage
  • Soft tissue damage
  • Facial nerve palsy
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21
Q

ANTERIOR CERVICAL DISKECTOMY/FUSION

A

➢ symptomatic nerve root and spinal cord compression caused by herniated or degenerated discs or osteophytes, which protrude into the spinal canal.
➢ unstable conditions such as laxity in cervical ligaments, degenerative changes in cervical vertebrae or for traumatic injury.
➢ Cervical disc herniation usually occurs at C5 or C6.
➢ herniated cervical discs that impinge upon the spinal cord complain of neck pain that may radiate down one or both arms.
➢ weakness and muscle atrophy in the arms.

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22
Q

ANTERIOR CERVICAL DISKECTOMY/FUSION

Procedure:

A

Incision is made in the anterolateral neck. Can be done posterior as well. Dissection continues until the prevertebral fascia is exposed which is continuous with the anterior vertebral bodies and discs.

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23
Q

ANTERIOR CERVICAL DISKECTOMY/FUSION

- During dissection, care must be taken in order not to damage the:

A

1- Carotid or jugular veins
2- The esophagus
3- The cervical spinal cord
4- The trachea

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24
Q

ANTERIOR CERVICAL DISKECTOMY/FUSION
Preoperative Assessment:
Respiratory:

A
  • INTUBATION MUST BE PERFORMED WITH THE PATIENT’S HEAD AND NECK IN A NEUTRAL POSITION.
  • CERVICAL SPINE IMMOBILIZATION IS CRITICAL.
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25
Q

ANTERIOR CERVICAL DISKECTOMY/FUSION

Preparation

A 
➢	IV 16g X 1 
➢	EBL  little as 50cc – high as 500cc 
➢	Average surgical time  1-3 hours 
➢	Foley catheter -  majority of the time. 
➢	Warming measures
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26
Q

ANTERIOR CERVICAL DISKECTOMY/FUSION

Neurologic:

A

➢ Preoperative assessment of sensory and motor deficits is vital.
➢ MRI and CT scan can help differentiate between a herniated disc or a cyst/tumor

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27
Q

ANTERIOR CERVICAL DISKECTOMY/FUSION:

Cardiovascular:

A

➢ Spinal shock can occur as a result of cervical spine disruption and injury to the cord.
➢ A complete loss of sympathetic tone can result in ___very significant hypotension from peripheral vasodilatation and bradycardia.
➢ The inability to maintain body temperature as a result of vasodilation

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28
Q

Spinal shock
S&S
TX

A

decreased HR, decreased BP, cold, (vasodilation)

TX- vasopressors, volume, atropine

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29
Q

A patient, recently sustained a spinal cord injury, returns for debridement of an anterior thigh wound. Is succinylcholine contraindicated for this patient?

A

Yes- denervating inj

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30
Q

ANTERIOR CERVICAL DISKECTOMY/FUSION:

Airway obstruction can be caused by soft tissue obstruction, bleeding, edema and/or ________ nerve damage.

A

recurrent

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31
Q

Hematoma formation can compress major _______ and ______causing hemodynamic instability and respiratory compromise.

A

vasculature and trachea
EMERGENCY
DRAIN HEMATOMA

32
Q

VENOUS AIR EMBOLUS

A

➢ Venous air embolism is caused by the entrainment of air into a vein when the pressure within that vein becomes subatmospheric.
➢ Occurs when the open vein is above the level of the heart.
➢ Air collects in the junction between the superior vena cava and the right atrium. An airlock is formed which decreases blood flow through the right side of the heart.

33
Q

VAE

Sudden ________ can occur prior to signs of hypoxia.

A

hypotension

34
Q

Disadvantages of sitting position;

A

Blood pressure decreases
Sacral and pelvic pressure →
pain and skin breakdown

35
Q

MONITORS FOR THE DETECTION OF VENOUS AIR EMBOLISM

(most sensitive to least sensitive)

A

➢ TEE- transesophageal echocardiogram
➢ Precordial Doppler – position of precordial Doppler: right side of sternum btw 3rd and 6th rib – you would be able to hear turbulent blood flow
➢ Increased pulmonary art pressures
➢ Decreased ETCO2
➢ Mass spectrometer- see the presence of end tidal nitrogen bc nitrogen is present in the air

36
Q

Signs and Symptoms of Venous Air Embolus

A 
➢	Hypotension
➢	**mill wheel murmur***
➢	Decreased ETCO2 -  mass spec: increased ET nitrogen 
➢	Dysrhythmias 
➢	Desaturation
37
Q

Treatment of Venous Air Embolism***

A

➢ Notify surgeon and have him or her flood the field – hemodynamically compromising with little to no BP- call for help!!
➢ 100% O2 – turn off anesthetic
➢ Fluid bolus
➢ Vasopressors
➢ Place a CVC and attempt to aspirate the air out of the SVC and junction leading to right heart
➢ LLD position

38
Q

LUMBAR LAMINECTOMY

A

➢ Laminectomy (complete removal of the lamina) is performed to decompress the spinal nerve roots or the spinal cord.
➢ Compression is caused by a herniated intervertebral disc or by an osteophyte that protrudes into the spinal canal.
➢ decompress the cauda equina caused by degenerative disease, congenital stenosis, tumors and trauma.

39
Q

LUMBAR LAMINECTOMY

position

A

prone or maybe lateral

40
Q

LUMBAR LAMINECTOMY
Preoperative Assessment:
Neurologic:

A

sensory test and motor on lower extremities since it is in the lumbar region

41
Q

LUMBAR LAMINECTOMY

CV

A

For deliberate hypotension, an arterial line is needed to titrate medications.

42
Q

LUMBAR LAMINECTOMY

Respiratory:

A

The prone position may decrease the ability to adequately oxygenate the patient.

43
Q

LUMBAR LAMINECTOMY

Hematologic:

A

bleeding is a big issue,

44
Q

LUMBAR LAMINECTOMY

A

➢ Preoperative H/H.
➢ If multiple segments are to be decompressed, blood loss can be sizeable.
➢ If multiple segments are to be decompressed, autologous units may be available, cell saver can be used if the is no evidence of a tumor, and T&X 2 units.

45
Q

If a dural tear occurs, how do we check the repair

A

The integrity of the repair is tested by applying positive inspiratory pressure. 30cm H20 pressure holding to check if any CSF leaks out.

46
Q

Deliberate hypotensive technique MAP of—

A

continuous infusion of nitroprusside and/or esmolol to maintain MAP at _60_mm/Hg

47
Q

SPINAL RECONSTRUCTION AND FUSION

A

biggest of all spinal surgeries. Done for trauma, CA, scoliosis**
➢ Performed for patients with scoliosis involving a lateral curvature and rotation of the spine with associated rib cage deformity.
➢ Most likely cause of scoliosis is idiopathic in nature.

48
Q

SPINAL RECONSTRUCTION AND FUSION

Associated conditions include

A 
➢	Muscular dystrophy 
➢	Cerebral palsy 
➢	 Spinabifida – caution latex allergies, children will be cathed I &O throughout life. 
➢	Congenital heart disease
➢	Gastroesophageal reflux
➢	Dwarfing’s syndrome 
➢	Myasthenia gravis
49
Q

SPINAL RECONSTRUCTION AND FUSION
Preoperative Assessment
Respiratory:

A

➢ If VC > 70% of predicted, respiratory reserve is adequate.** maybe able to extubate
➢ If VC <40% of predicted, then postoperative ventilation is require
PFT test if available

50
Q

SPINAL RECONSTRUCTION AND FUSION

Severity of scoliosis is determined by determining the______ angle.

A

the greater the degree of the angle the more severe the resp changes are, not just in these capacities but in all the lung capacities.

51
Q

SPINAL RECONSTRUCTION AND FUSION

. Pts with scoliosis have ________lung dz

A

restrictive
– it is restrictive meaning it impedes on the amt of air that can go in that lung. So they will be chronically hypercarbic, breath shallow, RR will be high. *

52
Q

SPINAL RECONSTRUCTION AND FUSION

Hematologic:

A

➢ Use of autologous blood.
➢ Use of cell saver blood. 60-80% of blood can be salvaged via cell saver.
➢ Hemodilution can be used by removing blood preoperatively replacing with fluid.
➢ Be aware of preoperative H/H and a T&X for 2 units of PRBC’s must be available.

53
Q

SPINAL RECONSTRUCTION AND FUSION

_____ monitoring will be done throughout procedure

A

SSEP at minimum

decrease gases

54
Q

SPINAL RECONSTRUCTION AND FUSION

postop concerns

A

➢ Respiratory insufficiency- resp failure**
➢ Pneumothorax 1-5% of cases
➢ Dislodged instrumentation requiring reoperation
➢ Spinal cord injury
➢ Massive hemorrhage 1-5% of cases
➢ Venous air/fat embolism
➢ Hematoma formation

55
Q 
Bleeding risk classification:
class one - low chance of bleed
A

Discectomy
Laminectomy (1 level)
Tumor biopsy

56
Q 
Bleeding risk classification:
class 2
A

Laminectomy ( 2 levels)
Fusion (1 level)
Hardware removal

57
Q 
Bleeding risk classification:
class 3
A

Fusion ( 2 levels)
Instrument correction
Kyphosis correction

58
Q 
Bleeding risk classification:
class 4 - high chance of bleed
A

Combined AP fusion
Scoliosis
Tumor decompression
Infection/debridement

59
Q

SOMATOSENSORY EVOKED POTENTIAL MONITORING (SSEP)

A

➢ Sensory information passes through the posterior column of the spinal cord to the cerebral cortex.

60
Q

SSEP monitors the integrity of the _________ pathways in the dorsal cord.

A

sensory

61
Q

Motor evoked potentials (MEP’s) monitor the integrity of the ____ pathways in the ventral cord.

A

motor

62
Q

The______ or ________ horn receives and supplies sensory information to and from the brain.

A

posterior or dorsal

63
Q

The ______ or ______horn receives and supplies motor information to and from the brain.

A

anterior or ventral

64
Q

Wave Latency:

A

length, it is the time btw the application of the stimulus and the appearance of a cortical response.

65
Q

Wave Amplitude

A

size or intensity of a cortical response generated by a peripheral nerve stimulation.

66
Q

Wave Morphology:

A

general appearance.

67
Q

Changes in wave forms that are of concern:

A
  • Increased latency

* Decreased amplitude.

68
Q

If latency increases by ______and amplitude decreases by _____ then spinal cord integrity could be in jeopardy.

A

> 10% and

decreased by >50%

69
Q

These undesirable changes in SSEP wave form can occur due to:

A
  • Stretching or retracting of the spinal cord
  • Increased anesthesia
  • Decreased bp
  • Anemia
  • Equipment failure
70
Q

_______ monitors the integrity of the posterior ascending sensory pathway in the dorsal cord.

A

SSEP

71
Q

_______ monitors the integrity of the anterior descending motor pathway in the ventral cord

A

MEP

72
Q

Intraoperative changes in SSEP’s such as significant decreases in amplitude and/or increases in latency are considered indications of spinal cord __________.

A

ischemia

73
Q

Anesthetic agents that affect SSEP monitoring

A
  • inhalation anesthetic gases – iso, sevo, des have the greatest affect at increasing latency and decreasing amplitude.
  • N20 with inhalation agent will potentiate the effects on latency and amplitude
74
Q

All anesthetic agents, with the exception of___________, depress SSEP monitoring in a dose dependent manner.

A

ketamine and etomidate

75
Q

Recommendations include maintaining inhalation agent concentration at or below ____MAC.

A

1

76
Q

Other Factors That Can Effect SSEP Monitoring:

A
  • Anemia
  • Hypotension
  • Hypoxia
  • Significant hypothermia
  • OR table
  • Nerve stimulator
  • Electrocautery

Advanced Anesthesia Test#2 (4 decks)

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