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Advanced Anes. Spring 21 > Spinal & Epidural Anesthesia > Flashcards

Spinal & Epidural Anesthesia Flashcards

1
Q

Spinal Cord - general

A
  • cord is approx 25 cm shorter than vertebral canal
  • enlarged @ C5-7 (brachial plexus) & L2-3 (lumbar & sacral plexus)
  • extends from medulla oblongata to L2 (adult) or L3 (peds)
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2
Q

Cauda Equina

A
  • long roots of lumbar and sacral nerves

- extends from L1-S5

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3
Q

Intervertebral Foramina

A
  • superiorly and inferiorly larger
  • lateral notches
  • allow for passage of nerves
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4
Q

What forms the facet joint?

A

superior and inferior articular surfaces and lateral notches

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5
Q

Regional Variation: Cervical & Thoracic

A

-spinous processes are more angled - need more cephalad angle for needle

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6
Q

Regional Variation: Lumar

A

-larger vertabra, less overlap and larger gaps

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7
Q

Regional Variation: Sacrum

A
  • fused section of vertebra

- sacral hiatus- lamina of last vertebra is incomplete, bridged by ligaments

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8
Q

Caudal Block Landmarks

A

PSIS
SC
SH
TC

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9
Q

Abnormal Curvatures

A

scoliosis - lateral
kyphosis - posterior
lordosis - anterior

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10
Q

3 Ligaments

A

Supraspinous (superficial)
Intraspinous
Ligamentum Flavum (deep)

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11
Q

Ligamentum Flavum

A

-thickest, “V shaped”

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12
Q

Epidural Space: location, origination and end

A

lies between ligamentum flavum and dura mater

-contiguous from base of cranium to sacral sulcus

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13
Q

Epidural Space: distance from skin

A
  • varies with level, loosely correlated with weight

- midline, lumbar approach = 2.5-8cm, average 5 cm

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14
Q

Epidural Space: Contents

A
  • veins (valveless, engorge during pregnancy), fat, lymph, segmental arteries and nerve roots
  • potential space is largest lumbar >thoracic>cervical
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15
Q

Spinal Cord: Layers

A

Dura Mater
Arachnoid Mater (holds CSF)
Pia Mater

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16
Q

Spinal Nerves

A 
31 pairs 
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
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17
Q

Thoracic nerves & CT placement

A

-thoracic nerves run along inferior margin of rib, so place a chest tube at superior aspect of rib

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18
Q

Level and vertebra

A

-cervical correlate with vertebra below, after T1, correlates with vertebrae above

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19
Q

Dorsal

A

entering sensory root

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20
Q

Ventral

A

outgoing motor root

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21
Q

H-shaped central gray region…

A

neuronal cell bodies and unmyelinated fibers, surrounded by white matter (fiber tracts)

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22
Q

Grey Matter

A

subdivided into 12 laminae of rexed
I-VI = afferent tracts (receive sensory info)
VII - IX = ventral tracts - motor neurons, interneurons involved in motor functions

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23
Q

Lamina II

A

substanca gelatinosa

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24
Q

White Matter

A
  • organized
  • dorsal white - almost exclusively ascending sensory
  • lateral & ventral white - descending motor tracts, most cross over at some point
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25
What can the lateral and ventral white matter do?
- ascend to the brain | - associate trat originate and terminate entirely within spinal cord (reflexes)
26
Sensory Pathways
afferent (ascend) | -transmit pain & temp (epidermis), pressure, touch, vibratory, proprioception (dermis)
27
2 Classifications of receptors
1 - extroceptors (near surface of skin and oral mucosa) | 2 - proprioceptors (deeper skin layers, joint capsules, ligaments, tendons, muscles and periostium)
28
2 Main Sensory Tracts
Dorsal Column - Medial Lemniscus | Anterolateral Pathway
29
Dorsal Column - Medial Lemniscus
- carries signals upwards towards the medulla in dorsal column tract - crosses over at medulla - carried through brainstem to thalamus in medial lemniscus tract
30
Anterolateral Pathway
- originates in dorsal horn to laminae I, IV, V, VI where they synapse - immediately cross over in anterior commissure to anterior and lateral white columns - go to brainstem or thalamus
31
Dorsal Column Medial Lemniscus - characteristics
fibers: large, myelinated conduction speed: 30-110 m/sec spatial orientation: high with respect to origin -discrete types of mechanoreceptive sensations
32
Anterolateral system
fibers: small, myelinated conduction speed: few - 40 m/sec spatial orientation: low with respect to origin -broad spectrum of sensory modalities - pain, warmth, cold, crude touch
33
SNS
- preganglionic neurons (b fibers, small) originate: intermediolateral gray horn btwn T1-L2/3 - exit spinal cord via ventral nerve root - white rami communicans
34
Cervical Ganglia
-divided into superior, medial and inferior ganglia
35
Cervical Ganglia: SNS stim of superior...
mydriasis (contract radial muscle of eye) relaxation of ciliary muscle constriction of blood vessels of head
36
Damage to superior cervical ganglia, central SNS damage or injury to other paravertebral ganglia..
miosis (small pupil), ptosis (droopy lid), anhydrosis (no sweat) aka horner's syndrome
37
Inferior cervical ganglia fuses with ___ to form the _____
inferior cervical ganglia fuses with the first thoracic to form the stellate ganglia (C5-6)
38
Pain and temp pathway
some fibers in dorsal horn give off branches that synapse with internuncial neurons - synapse with ventral horn -part of reflex response to pain
39
Dermatomes
T4 - nipple line T 6-7 - xiphoid process T 10 - belly button
40
Motor Pathways
motor/efferent (exit) - info from brain to voluntary muscles, smooth and cardiac muscles and some glands
41
Corticospinal tract
- supplies voluntary muscles of the trunk and extremities | - originates in large, upper motor neurons located in PREcentral gyrus
42
Damage to corticospinal tract neurons
-located antrior to precentral gyrus | damage = lower motor neurons can overfire (hyperreflexia) or fire simultaneously (spasticity)
43
Upper motor neuron paralysis
reflexes intact, suppressor fibers impeded, hyperreflexia occurs
44
Damage to lower motor neurons
produce flaccid type paralysis
45
Which two disease processes effect the corticospinal tract?
cerebral palsy and ALS
46
Pro's of spinal anesthesia
less adverse in-hospital outcomes, less NV, urinary retention, less opioids, less hospital length of stay -more mental alertness, long term pain control (epidural)
47
Uptake & Spread from subarachnoid space
- concentration of LA in CSF - surface area of nerve tissue exposed - lipid content of nerve tissue - blood flow
48
Distribution
baricity, position, dose
49
Spinal Anesthesia Physiologic changes
- liver - no change if MAP maintainted - CV - sympathectomy (block height) - hypotension and bradycardia - venodilation >arterial dilation GI- SNS innervation from T6-12 - increased secretions, sphincters relax, bowel constricts
50
Spinal - prone position
- can use of pt in this position for surgery | - iso or hypobaric
51
Process
``` ID iliac crests (L4-5 clean skin drape ID level to block local (use as finder) approach - median, paramedian, taylor ```
52
Parethesia
- stop advancing | - remove stylet and check for CSF
53
PDPH
- up to 25% incidence - relief when supine tx: fluids, caffeine, bed rest, analgesics, sumatriptan - can take 1-6 wks to resolve epidural blood patch 1-2 times
54
1st sign of CV collapse following spinal...
bradycardia
55
Epidural
level L2-4, can use adult levels after age 8
56
Epidural below T4
vasomotor tone controlled by T5-L1 | decreased venous return and subsequent decrease CO
57
Epidural above T4
T1-4 cardiac sympathetic fibers | profound hypotension and brady
58
Concentration
lower - sensory | higher - may get motor
59
Key factor,,
volume adults: 1-2 mL for each level to be blocked lumbar gets more spread cephalad than caudal thoracic even spread up and down -position is not considered a factor
60
Does age effect epidural dose?
yes, increased age = decreased dose
61
Epidural height
``` <5'2" = used 1 mL per level >5'2" = increase by 0.1 mL for each 2" ```
62
Epidural: Pregnancy and Obesity
decrease dose, epidural veins engorged
63
Epidural: Subdural injection
-delayed high spinal
64
Epidural: Subarachnoid injection
-immediate high spinal

Advanced Anes. Spring 21 (7 decks)

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