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Spinal Cord Flashcards

1
Q

What is scoliosis? What are the causes of scoliosis?

A

Lateral rotation of the spine > 10° with vertebral rotation.
Causes:
congenital
idiopathic
neuromuscular

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1
Q

What are the effects of thoracic spine scoliosis?

A
  • ↓ Chest wall compliance
  • Restrictive lung disease
  • ↓ exercise tolerance

Get PFTs!

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2
Q

What EKG/cardiac findings might one suspect to find on a scoliosis patient? (Select all that apply)

a. RVH
b. RAE
c. LVH
d. Bi-atrial enlargement

A

a & b

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3
Q

The increased pulmonary vascular resistance of chronic, significant scoliosis can lead to ___ _______.

A

cor pulmonale

Enlarged RV due to lung disease.
-may progress to Right heart failure

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4
Q

What muscles would you expect to be effected from a C5 injury?

A
  • Partial diaphragmatic paralaysis
  • Deltoids
  • Biceps
  • Brachialis
  • Brachio-radialis
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5
Q

What are the hemodynamic consequences of injuries T5 and higher? What is the treatment for these symptoms?

A

Physiologic Sympathectomy
- ↓BP
- ↓HR
Tx: midodrine

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6
Q

Autonomic Hyperreflexia is most often seen with cord transection above the ____ level.

A

T5/T6

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7
Q

What s/s are seen with autonomic hyperreflexia below the injury? Above injury?

A

Below Injury
- Cutaneous vasoconstriction
- Severe, transient HTN
- Bradycardia
- Dysrhythmias
Above Injury
-Cutaneous vasodilation

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8
Q

What is the basic pathophysiology of Autonomic Dysreflexia?

A

Below injury: intact Sympathetic nerves below injury release Norepi in response to stimuli (bladder distention, bowel stimuli etc.)
-This l/t vasoconstriction and increased BP
Above Injury: baroreceptors in aortic arch and carotid sinus sense HTN and trigger parasympathetic nervous system response.
-this l/t bradycardia and vasodilation (ineffecient to counteract HTN)
Communication disruptions between spinal cord and brain

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9
Q

What are the most common causes of Autonomic Dysreflexia?

A
  1. Distended bladder/bowel
  2. Noxious stimuli (think surgical pain)
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10
Q

What is the treatment for Autonomic Dysreflexia?

A
  1. Removal of stimulus
  2. Deepen anesthetic
  3. Direct-acting Vasodilators
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11
Q

Injury to C3-C5 results in….

A

Diaphragmatic respiratory failure

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12
Q

Is respiratory function affected by injury to C5-C7?

A

Yes; impairment of abdominal and intercostal respiratory support

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13
Q

Why is there an increased risk of pulmonary infection with cervical spine injuries?

A
  • Inability to cough/ clear secretions
  • Atelectasis
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14
Q

What is poikilothermia?

A

Inability to maintain constant core temp

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15
Q

What is the pathophysiology of poikilothermia?

A
  • SNS disruption
  • Temperature sensation disruption
  • Inability to vasoconstrict below spinal cord injury
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16
Q

Spinal deformities are associated with _______ respiratory patterns, often necessitating PFT’s and an ABG. Describe the respiratory volume changes seen with this pattern?

A

Restrictive
↓ all lung vol.
-same or ↓ IRV
-↓ Vt
-↓ERV
-↓RV
-↓TLC/VC/IC/FRC

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17
Q

Flaccidity in which two muscles would indicate possible cervical spine fracture?

A
  • Deltoids
  • Biceps
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18
Q

What is the greatest risk with a cervical surgery sitting position?

A

VAE (Venous Air Embolism)

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19
Q

An anterior approach for a thoracic spine procedure requires what position and equipment?

A
  • Lateral position with bag
  • Double Lumen ETT or bronchial blocker

May have to drop lung for access.

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20
Q

A posterior approach for a thoracic spine procedure requires what position and equipment?

A
  • Prone with arms tucked or 90° abduction
  • Single lumen ETT.
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21
Q

What are the three causes of postoperative vision loss secondary to prone positioning? What is the incidence of POVL?

A
  • Ischemic Optic Neuropathy (ION)
  • Retinal artery/vein occlusion
  • Cortical brain ischemia (l/t stroke/CVA if not addressed early)
    Post op visual loss: incidence less than or equal to 1%
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22
Q

T/F. Ischemic optic neuropathy occurrence requires direct pressure placed on the eyes?

A

False. Can occur without direct pressure.

*Occurs due to ↓ blood flow or O₂ delivery.

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23
Q

What are risk factors for ION?

A
  • Male
  • Obesity
  • Wilson Frame Use
  • > 6 hour surgery
  • ↓ colloid usage (crystalloid leaves intravascular space rapidly)
  • Blood loss > 1000 mL (EBL 30 mL/Kg increases risk as well)
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24
What is the typical onset of ION?
24 - 48 hours
25
What are the symptoms of ION?
Bilateral - Painless vision loss - Non-reactive pupils - No light perception
26
What are the treatments for ION?
- Acetazolamide (Diamond) a diuretic (↓ intraocular pressure) - Corticosteroids -Diuretics - Hyperbaric O₂ -Increase BP or Hgb
27
What are the respiratory effects of prone positioning?
↓ FRC ↓ pulmonary compliance *Due to ↑ intrabdominal pressures → ↑ intrathoracic pressures*.
28
Does venous return increase or decrease in prone positioning?
decrease
29
Which of the following positioning devices is the most stable?
Mayfield Tongs
30
What cardiac consequences are there to prone positioning? Why?
- ↓ preload - ↓ CO - ↓ BP *Due to pooling of blood in extremities and compression of abdominal contents and muscles*.
31
What neurological consequences occur due to extreme head rotation in prone positioning?
↓ cerebral venous drainage and ↓ CBF
32
What risk factors are there for increased blood loss during spinal surgery?
- Number of vertebrae being operated on - > 50 yo - Obesity - Tumor surgery (vascular) - ↑ intrabdominal pressure - Transpedicular osteotomy
33
When is autologous blood donation utilized? When is autologous blood donation contraindicated in spinal surgery?
**autologous donation when anticipated EBL 500-1000 mL** - Significant cardiac disease - Infection
34
What is the push dose of TXA for spinal surgery?
- 10 mg/kg IV
35
What is the infusion dose of TXA? How long is the infusion utilized?
2 mg/kg/hr d/c drip at end of surgery
36
What is the push dose of aminocaproic acid (Amicar)? Infusion dose?
Bolus dose: 100 mg/kg IV Infusion: 10 - 15 mg/kg/hr (d/c at end of surgery)
37
Somatosensory Evoked Potentials (SSEPs) are associated with what spinal column and sensations?
**SSEP (Afferent): Periphery to CNS** Dorsal column pathways - Proprioception - Vibration
38
Motor Evoked Potentials (MEPs) are associated with what spinal column and sensations?
MEP (Efferent): CNS to periphery Anterior/ Motor Column
39
During spinal surgery, electromyogram (EMG) is used to monitor for what during pedicle screw placement and nerve decompression?
Monitor for **nerve root injury**.
40
What is an SSEP? Can paralytics be used if assessing SSEP?
Impulse from a peripheral nerve that is measured centrally. Patient can be paralyzed as impulse is from periphery to CNS
41
What are Motor Evoked Potentials (MEPs)? Can paralytics be used if assessing MEP?
Impulse triggered in the brain (centrally) and monitored in specific muscle groups. Short-acting paralytic for induction only.
42
What are possible adverse effects associated with MEPs?
- Cognitive defects - Seizures (contraindicated for hx of seizures) - Intraoperative awareness - Scalp burns - Cardiac arrythmias - Bite injuries (bite block necessary)
43
In what patients should MEPs be avoided?
- Patients w/ active seizures - Patients w/ vascular clips in brain - Patients w/ cochlear implants
44
Differentiate amplitude and latency in regards to neurophysiologic monitoring.
Amplitude: signal strength Latency: time for signal to travel through spinal cord.
45
What physiologic factors commonly can affect amplitude and latency of neurophysiologic monitoring?
- Hypothermia - Hypotension - Hypocarbia - Anemia - **VAAs**
46
How do VAAs affect neurophysiologic agents? What MAC is suitable for neuromonitoring?
Dose dependent (suppression at 0.5-1.5 MAC) - ↓ amplitude - ↑ latency Suitable dose of VAA: 0.5 MAC **no Nitrous during MEP**
47
Out of the following drugs, which affects our MEPs the most? - Opioids - Midazolam - Ketamine - Propofol
Propofol **depresses MEPs**. *The others have little effect on MEPs*.
48
How much does muscle relaxant requirement increase when using MEPs?
Trick question. **No muscle relaxants after intubation.**
49
What type of nerve block might be used for spinal surgery?
Erector Spinae block
50
During what surgery is venous air embolism at its greatest risk of happening?
Laminectomies - Large amount of exposed bone - Surgical site above the heart
51
What are some s/s of VAE?
- Unexplained ↓BP - ↑ EtN₂ - ↓ EtCO₂
52
For patients >60 years old, what is the most common spinal issue?
Spinal stenosis
53
What are some symptoms of adult scoliosis?
Back pain caused by arthritis and disc degeneration -misalignment l/t nerve compression Spinal stenosis (nerve impingement) -pain worse with standing/walking Radiculopathy/sciatica (nerve root impingement)
54
What are the respiratory side effects of thoracic scoliosis?
Chronic hypoxemia secondary to V/Q mismatch Increased PVR Possible Pulmonary HTN
55
What is the consequence of injuries above T1-T4
Bradycardia since T1-T4 are cardiac accelerators
56
What is the efficacy of anticholinergics for injuries above T1-T4?
While anticholinergics decrease parasympathetic outflow; they do not address the SNS disruption and therefore are inadequate for treatment of bradycardia for injury above T1-T4
57
What is the primary medication to treat bradycardia for injury above T1-T4
Epinephrine: Direct acting beta 1/beta 2 -this is required for bradycardia d/t sympathectomy of injury at this level
58
Anesthesia options for spinal surgery
GETA most common -plan must consider need for Neuromonitoring (SSEP, MEP, EMG) VAA vs TIVA Muscle relaxation: succinylcholine **only with stable spinal cord** -fasciculations are not safe for unstable spinal cord
59
What is the indication for double lumen ETT or bronchial blocker for spine surgery?
Typically used for anterior thoracic surgery. Lung deflated to improve visualization and instrumentation
60
How is proper double lumen tube chosen
Right sided tube for Left lung deflation and vice versa
61
What is the insertion process of double lumen tube
*Tube inserted with angle tip pointing upward (toward trachea) *Once bronchial cuff passes cords, tube is turned 90 degrees toward desired side **right sided tube turned right** *Advance until resistance is met Blue bronchial cuff should be just below carina (inflated under fiberoptic visualization)
62
In posterior cervical spine cases what can be supplemented prior to placement of Mayfield pins
If unsure on depth, give 50-100mg of propofol. This is a very stimulating portion of the positioning.
63
What is important to understand regarding an anterior/posterior (360 degree) lumbar surgery
The anterior approach will be in supine position. -this portion will require laparotomy to retract aorta and major vessels in the anterior cavity in order to expose spine
64
What medication class may be useful for prone position
Anti-sialogogue preop
65
What are some airway management techniques for prone position surgery?
Add corrugated adapter to decrease ETT kinking/pressure injury Assess for bilateral lung sounds after positioning **Airway edema** -assess orbital/circumoral/face edema throughout procedure (strong indicators for airway edema)
66
What are the disadvantages of using the Wilson Frame?
Increased risk of ION Decreased abdominal excursion Diaphragm compression (↓ FRC/VT/VC)
67
What fluid management can help prevent ION?
After 3 liters of crystalloids, use colloids -crystalloids stay intravascular for 20-40 mins Colloids maintain intravascular oncotic pressure
68
In regards to post op visual loss (POVL) differentiate between the two types of retinal artery occlusion?
Central retinal artery occlusion l/t decreased blood supply to entire retine Retinal arterial branch: decreased blood supply to part of retina
69
How is bleeding from epidural veins affected in prone position?
Increased bleeding from epidural veins is seen in prone position.
70
What is cell saver
Cell saver is a device that filters the patients blood and allows the perfusionist to transfuse the filtered blood. They are also able to run ABGs
71
Describe the technique of intraoperative hemodilution for spine surgery and blood loss?
Removal of 450-500 mL of blood after induction Maintain normovolemia with crystalloid/colloid *intentional HoTN **not common d/t risk of end-organ ischemia**
72
During corrective surgery, and after completion of instrumentation, a patient may be waken up to assess gross motor movements of extremities. What are the possible complications of this?
Inadvertent extubation Air embolism Violent movement (movement of instrumentation)
73
What are interventions for acute changes in amplitude/latency?
D/C surgery Get BP to normal or within 20% Decrease or d/c volatiles

Advanced Exam 1 (4 decks)

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