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Anesthesia Principles II > Spinal Anesthesia > Flashcards

Spinal Anesthesia Flashcards

1
Q

How many vertebrae are there? How many in each section?

A

33 total

7 Cervical
12 thoracic
5 lumbar
5 sacral
4 coccygeal

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2
Q

how many facet joints between each vertebrae? and What kind of joints are they?

A

2, synovial joints

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3
Q

Another name for C1?

A

Atlas

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4
Q

another name for C2?

A

axis

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5
Q

motion of atlanto-axial joint?

A

side to side movement

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6
Q

Are facet joints a synovial filled cavity?

A

yes

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7
Q

where do spinal nerves exit?

A

from intervertebral foramen and sacral foramen

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8
Q

Adult spinal cord runs from what to what?

A

foramen magnum to L1-L2

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9
Q

where does spinal cord end in child?

A

L3

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10
Q

how many spinal nerves?

A

31 pairs

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11
Q

do bulbous portions of the spinal cord have more gray or white matter?

A

gray matter

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12
Q

where is cervical enlargment?

A

C1-C4

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13
Q

where is lumbar enlargement?

A

L2-S3

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14
Q

what is cervical enlargement responsible for?

A

anterior motor, upper limb muscles

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15
Q

what is lumbar enlargement responsible for?

A

lower limb muscles

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16
Q

Pia mater

A

thin delicate vascular membrane that covers the spinal cord.

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17
Q

how far lateral does pia mater go?

A

as far as intervertebral foramen

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18
Q

does the pia mater have projections that connect it to the arachnoid mater and dura mater?

A

yes

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19
Q

is arachnoid mater vascular?

A

no

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20
Q

where does subarachnoid space/arachoid mater end?

A

filum terminale

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21
Q

what structure does the duramater become continuous with?

A

epinerium as it passes through intervertebral foramen

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22
Q

when do you feel a pop with the spinal needle?

A

when it passes through the dura mater

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23
Q

where is the subdural space?

A

potential space between duramater and arachnoid mater

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24
Q

what can happen with injection into subdural space?

A

delayed block for 10-25min

also risk of VERY DANGEROUS high block

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25
Q

what neurons are located in anterior gray horn of spinal cord?

A

motor neurons

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26
Q

which tracts are located in the lateral gray horn?

A

corticospinal tracts

T1-L2 sympathetic motor neurons

S2-S4 parasympathetic pre and post ganglionic splenic, descending colon

cranial parasympathetic fibers deerived from fivers of the vagus nerve

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27
Q

where do cranial parasympathetic fibers enter the abdomen?

A

jointly with the esophagus and lie outside the subarachnoid space.

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28
Q

what do cranial parasympathetic fibers supply?

A

viscera

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29
Q

are cranial parasympathetic fibers affected very much by SAB/epidurals?

A

no, little affected

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30
Q

what can happen during surgery when retractors are on the mesentary? And how do you prevent this?

A

pt can have N/V, bradycardia, hypotension, and pain from the cranial parasympathetic fibers.

surgeon can block vagus nerve as it enters the abdomen. Or you can add GETA

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31
Q

what is contained in the posterior gray column?

A

substania gelationosa

nucleus proprius

nucleus dorsalis

visceral afferent nucleus

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32
Q

Tell me about the substania gelatinosa

A

afferents from dorsal roots syanpse here. Contain pain, temp, and crude touch via spinothalamic track

opioid receptors are here in dorsal horn

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33
Q

what do neuraxial opioids do?

A

inhibit release of excitatory neurotransmitters like substance P and glutamate and inhibit afferent neural transmission to the brain from peripheral nerves

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34
Q

tell me about the nucleus proprius

A

ascending pathway for general sensation, pain, temp, and tactile sensation

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35
Q

tell me about the nucleus dosralis

A

only in cervical and lower lumbar

project to cerebellum for proprioception

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36
Q

tell me about the visceral afferent nuclues

A

receives visceral information

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37
Q

Name everything indicated

A

from the top in clockwise fashion:

posterior gray horn
lateral gray horn
anterior gray horn
anterior nerve root
spinal nerve trunk
anterior ramus
posterior ramus
spinal ganglion
posterior nerve root

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38
Q

Posterior primary rami have how many branches?

A

2

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39
Q

what are the two branches of pos. primary rami?

A

lateral (motor) to muscle

medial (sensory) to skin

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40
Q

anterior primary rami can organize into how many different plexi? What are they?

A

4

cervical plexus C1-C4
brachial plexus C5-T1
lumbosacral plexus L1-S4
coccygeal plexus S4-S5 + 1st coccygeal

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41
Q

external portion of spinal cord is white or gray matter?

A

white. it is white because of myelin

42
Q

what form the “tracts” in the spinal cord?

A

the clusters of axons in the external white matter

43
Q

what is myelin made out of?

A

lipid/protein

44
Q

What are the three ascending (sensory) pathways?

A

tract of lissauer
posterior white columsn
Ant./Post. spinocerebellar tracts

45
Q

what does tract of lissauer do? why is it unique?

A

it is part of the pain pathway.

different from others becasue it has sensation that jumps 1-2 vertebral levels, then cross at the spinothalamic tract and then enter the posterior gray horn

46
Q

what make up the posterior white columns? what do they do?

A

fascicularis gracilis (legs)
fascicularis cunetus (arms)

touch, discriminate, touch, vibration, conscious muscle joint sense, proprioception

47
Q

what do ant./post. spinocerebellar tracts do?

A

carry proprioception info to the cerebellum

48
Q

what are the descending pathways?

A

lateral/anterior corticospinal tracts

reticulospinal tracts

vestibulospinal tracts

rubrospinal tracts

49
Q

what do lat/ant corticospinal tracts do?

A

gross motor movement and fine motor, voluntary

50
Q

what do reticulospinal tracts do?

A

awake and voluntary movement, reflexes

51
Q

what does vestibulospinal tract do?

A

balance traverse teh inner ear and cerebelllum by this tract

fasilitate extensor muscles and inhibit flexor muscles to maintain balance

52
Q

what do rubrospinal tracts do?

A

alpha motor neurons facilitate flexor muscles

53
Q

Are these ascending or descending tracts?

A

ascending with sensory information to the brain

54
Q

are these ascending or descending tracts?

A

descending carrying commands to motor neurons

55
Q

ventral roots are motor or sensory?

A

motor

56
Q

Name the four sections

A

from top to bottom

somatic sensory nuclei
visceral sensory nucleui
autonomic efferent nuclei
somatic motor nuclei

57
Q

Name the highlighted areas from top to bottom.

A

substania gelatinosa

nucleus proprius

dorsal nucleus

intermediolateral nucleus

motor neurons of the anterior horn

58
Q

what is the principal site of action for SAB?

A

nerve roots

59
Q

what do you get with blockade of dorsal roots?

A

somatic/visceral
sensory

60
Q

what do you get with blockade of ventral root?

A

motor
autonomic

61
Q

What supplies blood to post. spinal cord?

A

posterior spinal arteries 1/3 of post. spinal cord

radicular arteries other 2/3 of spinal cord

62
Q

what arteries supply the posterior spinal arteries?

A

derived from cerebral arterial system with rich supply of collateral flow from the subclavian, intercostal lumbar, and sacral arteries.

63
Q

what supplies blood to anterior spinal cord?

A

a singular ant. spinal artery 2/3 of cord

single, segmental branch of radiuclar artery called the artery of adamkiewicz or arteria radiuclaris magna: nearly all of the flow to lower thoracic and lumbar segments.

64
Q

what is anterior spinal artery derived from and what contributes to it?

A

derived from both vertebral arteries and transverse down cord in ant. median fissure.

contributions from radicular arteries.

65
Q

where does ant. spinal artery become extremely small? why is this importnat?

A

mid to lower thoraic region. Can be a problem if the radicular arteries are occluded

66
Q

tell me more about admakiewicz artery

A

supplies lower 2/3 of ant. spinal cord.

damage, ischemia, hypoperfusion or occlusion to this artery can cause anterior spinal artery syndrome.

67
Q

what is anterior spinal artery syndrome?

A

flaccid paralysis and variable loss of sensation of pain and temp at and below the level of injury. proprioception and light touch are preserved.

68
Q

when does ant. spinal artery syndrome occur?

A

this is a rare syndrome but most common in aortic surgery with prolonged cross clamping or direct injury.

69
Q

what are other factors that play a role in ant. spinal artery syndrome?

A

atherosclerosis, prolonged hypotension, and embolic issues

70
Q

what occurs with disruption of teh cord at the corticospinal tract?

A

MOTOR PARALYSIS

71
Q

when do you loose pain and temp at and below injury?

A

disruption of spinothalamic tract

proprioception and vibratory sensation retained because of intact dorsal columns

post cord can remain intact. sensory fascicularis gracilis intact as well as proprioception. partial complex injury.

72
Q

ALL is widest at top or bottom?

A

bottom. so more likely to have cervical disc herniation forward.

“ACDF”

73
Q

PLL is widest at top or bottom?

A

top, so more likely to have lumbar disc herniation posteriorly

“lumbar lami and disectomy”

74
Q

where is the supraspinous ligament the thickest and most broad?

A

lumbar region

75
Q

where is ligamentum flavum most think and most thin?

A

most thin in cervical region, most thick in lumbar region.

76
Q

what structures does ligamentum flavum attach too? And blend with?

A

attach to ant. inf. aspect of lamina below

latterally with the joint capsule betwen articular processes

posteriorly with inerspinous ligament

77
Q

what vessels can be found within the ligamentum flavum?

A

small vessells from the vertebral plexuses (blood tinge in the syringe)

78
Q

although rare, the ligamentum flavum sometimes does not totally fuse in the middle. Where does this most offeten occure? (still rare) Why is this importnat?

A

L1-L2

won’t feel loss of resistance when accessing the epidural space

79
Q

how far is ligamentum flavum normally from spinous process in lumbar region?

A

3-4cm

80
Q

what does the needle feel like when in the ligamentum flavum?

A

dense/elastic feeling and needle becomes engaged in the tissue

81
Q

disc height can become smaller in old age, how would this affect spinals or epidurals?

A

makes the interspace smaller

82
Q

what can happen to the ligamentum flavum in old age?

A

it can become calcified

83
Q

where is epidural space located?

A

between the periosteal lining of the canal and the dura.

extends from base of skill to the sacral hiatus (S4)

84
Q

what limits the epidural space on each side?

A

PLL anteriorly

ligamentum flavum and vertebral pedicles posteriorly

intervertebral foramen laterally

85
Q

describe the distance between the ligamentum flavum and dura matter

A

smallest, 3-4mm, where cord is present, so upper lumbar thoracic and cervical,

biggest, 5-7mm, after L2

86
Q

how far from skin to epidural space?

A

usually 4-5cm, can be anywhere from 2-9cm so be careful

87
Q

pressure in epidural space?

A

slightly negative -1 to -7 cmH20 except in sacral area.

88
Q

widest and narrowest parts of epidural space?

A

narrowest at C5 1-1.5mm
widest at L2 5-6mm

89
Q

where is CSF made?

A

choroid plexus in the ventricles of the brain. mostly in the 2 lateral ventricles but the 3rd ventricle also contributes

90
Q

where is CSF absorbed?

A

arachnoid villi

91
Q

how much CSF produced per day?

A

21ml/hr or 500ml a day.

92
Q

how much CSF present at one time?

A

about 150ml

30-80ml in spinal subarchnoid space, but it can be much more which would cause a spinal to fail from being too dilute.

93
Q

what is CSF made of?

A

ultrafiltrate of blood, contains trace amounts of protein and glucose

94
Q

specific gravity of CSF?

A

1.003-1.009 and is isobaric

95
Q

where does spinal anesthesia work?

A

ant and post nerve roots, and to a lesser extent on the spinal cord itself.

96
Q

what do dorsal rami supply?

A

skin and muscles of the back

97
Q

how are dermatomes in the face organized?

A

by ophthalmic, maxillary, and mandibular divisions of the trigeminal nerve

98
Q

dermatome level of clavicle?

A

C4

99
Q

dermatome level of little finger?

A

C8

100
Q

dermatome level of nipple?

A

T4

101
Q

dermatome level of xiphoid, lower rib cage

A

T6-T8

102
Q

dermatome level of umbilicus?

A

T10

Anesthesia Principles II (14 decks)

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