Spinal- Epidural

Question 1

A characteristic hallmark symptom of a PDPH is ______ (situation: position)

Answer 1

A postural headache that is relieved by laying down

Question 2

A PDPH is most likely to occur ______ (within what time frame)

Answer 2

within several hours of the first or second postoperative day.

Question 3

A solution is considered ______ (baricity) if it has a specific gravity < 0.999.

Answer 3

Hypobaric < 0.999

Question 4

A solution is considered ______ (baricity) if it has a specific gravity > 1.015

Answer 4

Hyperbaric > 1.015

Question 5

Adding epinephrine to prolong the effects of a spinal anesthetic will have the greatest effect with _____ (tetra, lido, bupiv), less with_____ and minimal effect with ______.

Answer 5

Tetracaine

Lidocaine

Bupivacaine

Question 6

An epidural catheter should ideally be advanced _______ (depth) into the epidural space. Describe the risks associated with being outside of this window:

Answer 6

An epidural catheter should ideally be advanced 3-5cm into the epidural space. Describe the risks associated with being outside of this window:

< 3cm associated with increased risk of dislodgement/failed epidural > 5cm more likely to advance into an epidural vein or track along a spinal root and not have a midline placement

Question 7

Aside from PDPH, the only other type of headache which has a positional component is caused by ______.

Answer 7

Pneumocephalus

Question 8

A backache is more likely to occur with ________ (what type of central neuraxial technique).

Answer 8

Epidural cathether placement than with spinal blocks

Question 9

Blood patches for PDPH should be placed ______ (at what level) because blood has been shown to spread in a predominantly cephalad direction in the epidural space.

Answer 9

at or below the level of the lowest initial needle insertion

Question 10

Cauda equina syndrome is persistent paralysis of the nerves of the cauda equina, resulting in ________, _________ (what 2 problems). Its occurrence is associated with the use of _________ (what 3 things).

Answer 10

Cauda equina syndrome is persistent paralysis of the nerves of the cauda equina, resulting in ________, _________ (what 2 problems). Its occurrence is associated with the use of _________ (what 3 things).

lower extremity weakness and/or bowel/bladder dysfunction

microcatheters, small needles, and hyperbaric 5% lidocaine

Question 11

Central neuraxial anesthesia is contraindicated in patients with moderate to severe aortic valve stenosis because__________ (their stroke volume is ‘fixed’) to make up for the reduction in afterload, which can lead to impaired coronary perfusion (patients are dependent on afterload to maintain coronary perfusion)

Answer 11

Central neuraxial anesthesia is contraindicated in patients with moderate to severe aortic valve stenosis because__________ (their stroke volume is ‘fixed’) to make up for the reduction in afterload, which can lead to impaired coronary perfusion (patients are dependent on afterload to maintain coronary perfusion)

They are unable to increase cardiac output

Question 12

Central neuraxial anesthetics can lead to urinary retention because of blockade of _______ nerve roots inhibiting urinary function and weakening of the ______ muscle.

Answer 12

Central neuraxial anesthetics can lead to urinary retention because of the blockade of S2-S4 nerve roots inhibiting urinary function and weakening of the detrusor muscle

Question 13

Central neuraxial anesthetics primarily work at the spinal roots________ (what area), but have secondary sites of action at _________ (what 2 areas}.

Answer 13

Central neuraxial anesthetics primarily work at the spinal roots _______(what area), but have secondary sites of action at _________ (what 2 areas}.

the spinal roots

the spinal cord and brain

Question 14

Complications from central neuraxial anesthesia can include:

Answer 14

1) PDPH
2) urinary retention
3) backache
4) TNS or cauda equina syndrome
5) Nerve injury

Question 15

Conservative treatment options for a PDPH include:

1

2

3

4

PDPH will typically resolve on its own within ______.

Answer 15

1) Fluids
2) caffeine
3) NSAIDs
4) rest

a week.

Question 16

CSF specific gravity is ________ .

Answer 16

CSF specific gravity is 1.004 - 1.009

Question 17

Describe the blood supply to the anterior and posterior portions of the spinal cord.

Answer 17

Anterior 2/3 of the spinal cord is supplied by the anterior spinal artery.

Posterior 1/3 of the spinal cord is supplied by the 2 posterior spinal arteries

Question 18

Describe the concept of a differential blockade, and how this relates to dermatome levels.

Answer 18

As the LA spreads out within the spinal column, the concentration of the drug molecules reduces. At the most concentrated areas, all 3 types of nerve fibers (motor, sensory, sympathetic) are blocked. Sensory blockade typically extends 2 dermatomes above where motor blockade ends, and a sympathetic blockade is typically 2 dermatomes above where sensory blockade ends (but can be 4-6 above)

Question 19

Describe the difference between Touhy and Weiss epidural needles.

Answer 19

Touhy needles have a 30-degree angle, Weiss needles have a 15-degree angle

Question 20

Describe the differences in angulation between cervical, thoracic, and lumbar spinal processes.

Answer 20

Cervical and thoracic are acutely angled in a caudal direction & overlap. Lumbar spinous processes are bigger, shorter, and are less angled

Question 21

Describe the differences in nerve fiber blockade for 0.5% vs 0.25% or 0.125% bupivacaine.

Answer 21

Lower concentrations will reduce a-delta (sharp pain) but not block dull achy pain (c-fibers)

Question 22

Describe the drug and its various concentrations that can be used for an epidural as well as the effects seen at those concentrations.

Bupivacaine

1

2

3

Answer 22

1) 0.5% if needing surgical anesthesia
2) 0.25% if needing analgesia (strong analgesic block)
3) 0.125% if needing sensory > motor block (post-op pain relief)

This medication is typically run at 5-10 mL/hr

Question 23

General cutoff points for performing central neuraxial anesthesia in an anticoagulated pt or a patient with coagulopathies are:

Answer 23

1) PLT count < 100,000

2) PT or aPTT 2x normal values or higher

Question 24

How is a total spinal most likely to occur?

Answer 24

An epidural dose is inadvertently injected intrathecally.

Question 25

How might spread of local anesthetic with epidural catheters change in the elderly, as it relates to dermatomes?

Answer 25

Spread in the epidural space may be 3-4 dermatomes greater than in younger patients. Because of this, a volume of 1 mL per segment with lumbar epidurals is recommended for elderly patients

Question 26

If an epidural abscess does occur, the goal of treatment is ______________ (what treatment method and within what time frame?)

Answer 26

If an epidural abscess does occur, the goal of treatment is rapid decompression within 8 hours of symptom onset (what treatment method and within what time frame?)

Question 27

Immediate complications of placing a spinal block can include:

Answer 27

1) {{c1::total spinal}}
2) {{c1::cardiac arrest}}
3) {{c1::failed spinal}}
4) {{c1::GI complications}}
5) {{c1::IV injection/local toxicity}}

Question 28

In order to minimize the risk of an epidural abscess, epidural catheters should ideally be removed after ________.

Answer 28

In order to minimize the risk of an epidural abscess, epidural catheters should ideally be removed after 96 hours.

Question 29

Josh’s ‘recipe’ for obstetric epidurals is:

Answer 29

0.2% ropivacaine with 2mcg/mL fentanyl run at 8-10mL/hr and 4mL boluses every 30 minutes.

Question 30

Label the 5 different ligaments found along the spinal vertebrae.

Answer 30

Question 31

Meningitis can occur after placement of a central neuraxial anesthetic due to:

1

2

3

Answer 31

1) {{c1::contaminated equipment}}
2) {{c1::glass particles}}
3) {{c1::coring of tissue}}

Question 32

Morphine _____ mg can be given with epidurals. Doses _____ mg have the highest incidences of respiratory depression.

Answer 32

Morphine 3 mg can be given with epidurals. Doses > 3 mg have the highest incidences of respiratory depression.

Question 33

Nausea and vomiting are associated with central neuraxial anesthesia because of the unopposed parasympathetic activity leading to increased peristalsis. Other contributing factors may be hypoxemia and hypotension. Because of this cause, _____ (What drug) may lessen the N/V experienced

Answer 33

Nausea and vomiting are associated with central neuraxial anesthesia because of the unopposed parasympathetic activity leading to increased peristalsis. Other contributing factors may be hypoxemia and hypotension. Because of this cause, Atropine may lessen the N/V experienced

Question 34

The occurrence of a Transient neurological syndrome is associated with use of_________ (what 2 things}

Answer 34

5% lidocaine or chloroprocaine

Question 35

PDPH is less likely after spinal blocks if a 25g or smaller size needle is used. Additionally, ________ (what type of} needles are less likely to cause PDPH compared to ________ (type of needle).

Answer 35

pencil-tip

cutting-tip needles

Question 36

Relative contraindications to performing central neuraxial anesthesia include:

Answer 36

1) {{c1::previous spine surgery}}
2) {{c1::’other’ neurological issues such as back/lower extremity pain or spina bifida}}
3) {{c1::aortic stenosis}}
4) {{c1::hypovolemia}}
5) {{c1::thromboprophylaxis / coagulopathies}}
6) {{c1::infection}}

Question 37

Ropivacaine {{c1::0.2}}% can be used in an epidural as an analgesic block (for what effect}

Answer 37

Ropivacaine 0.2 % can be used in an epidural as an analgesic block as an analgesic block

Question 38

Solutions are made hyperbaric by adding dextrose and hypobaric by adding ______ water

Answer 38

Solutions are made hyperbaric by adding dextrose and hypobaric by adding sterile water

Question 39

Some of the theoretical benefits to central neuraxial anesthesia include:

Answer 39

1) {{c1::narcotic sparing}}

2) {{c1::blunted stress response}}

3) {{c1::decreased blood loss in certain populations}}

4) {{c1::can do cases awake}}

5) {{c1::less overall medication use -> decreased N/V and more alert at the end}}

6) {{c1::avoid airway manipulation & the associated drugs}}

Question 40

Sympathetic innervation of ________ (what region of the body) exits from the spinal column at the level of _______.

Answer 40

Sympathetic innervation of the GI tract (what region of the body) exits from the spinal column at the level of T5-L2.

Question 41

Sympathetic nerve fibers exit from the spinal column at the levels of _____.

Answer 41

Sympathetic nerve fibers exit from the spinal column at the levels of T5- L1

Question 42

Symptoms of a total spinal include:

1

2

3

4

Answer 42

1) {{c1::restlessness}}
2) {{c1::hypotension}}
3) {{c1::bradycardia}}
4) {{c1::apnea}}

Question 43

The one absolutely absolute contraindication to performing central neuraxial anesthesia is ______.

Other ‘absolute’ contraindications include: (two)

Answer 43

The one absolutely absolute contraindication to performing central neuraxial anesthesia is ______ .

patient refusal.

Other ‘absolute’ contraindications include:

1) localized sepsis

2) increased ICP

Question 44

The 3 primary types of pencil-tip needles are:

1

2

3

Answer 44

The 3 primary types of pencil-tip needles are:

1) {{c2::Sprotte}}

2) {{c2::Pencan}}

3) {{c2::Whitacre}}

Question 45

The Artery of Adamkiewicz is of importance because it can be damaged during ____________, leading to _________.

Answer 45

The Artery of Adamkiewicz is of importance because it can be damaged during abdominal aortic procedures, leading to lumbar spinal ischemia.

Question 46

The average AP distance of the epidural space is approximately 5 mm. This space contains:

1

2

3

4

Answer 46

The average AP distance of the epidural space is approximately 5 mm. This space contains:

1) {{c1::blood vessels}}

2) {{c1::fat}}

3) {{c1::lymphatics}}

4) {{c1::nerve roots}}

Question 47

The gold standard of treatment for a PDPH is ________, which has a 90% success rate. If failed, done again 90% of those that failed are a success. An alternative but effective treatment option is a __________.

Answer 47

The gold standard of treatment for a PDPH is blood patch, which has a 90% success rate. If failed, done again 90% of those that failed are a success. An alternative but effective treatment option is a sphenopalatine ganglion block.