Spinal & Epidural Part 1 ( Tubog) Exam 1 Flashcards
Which areas are specifically mentioned as relevant for surgical procedures involving a neuraxial anesthesia? (Select 3)
a. Lower abdomen
b. Perineum
c. Lower extremities
d. Upper extremities
a. Lower abdomen
b. Perineum
c. Lower extremities
Slide 5
Which types of surgery could involve Neuraxial Anesthesia? (Select 3)
a. Orthopedic surgery
b. Vascular surgery on the legs
c. Thoracic surgery (adjunct to GETA)
d. Neurosurgery
a. Orthopedic surgery
b. Vascular surgery on the legs
c. Thoracic surgery (adjunct to GETA)
Slide 5
Which of the following statements are true about the advantages of neuraxial anesthesia? (Select 3)
a. It reduces the need for narcotics
b. It increases postoperative ileus
c. It reduces thromboembolic events
d. It reduces respiratory complications
e. It increases PONV
f. It increases Bleeding
a. It reduces the need for narcotics
c. It reduces thromboembolic events
d. It reduces respiratory complications
also
reduces Postoperative ileus
reduces PONV
reduces Bleeding
Slide 6
Which of the following benefits of neuraxial anesthesia are associated with mental alertness post-surgery?
a. Great mental alertness
b. Increased confusion
c. Sedation
d. Improved cognitive function
a. Great mental alertness
Slide 7
Which of the following are benefits related to patient comfort and recovery? (Select 2)
a. Less urinary retention
b. Longer PACU recovery time
c. Increased stress response from surgery
d. Quicker to eat, void, and ambulate
a. Less urinary retention
d. Quicker to eat, void, and ambulate
Slide 7
Which benefits of neuraxial anesthesia are highlighted in terms of reducing surgical stress? (Select 2)
a. Great mental alertness
b. Preemptive anesthesia/analgesia
c. Blunts stress response from surgery
d. Increased urinary retention
b. Preemptive anesthesia/analgesia
c. Blunts stress response from surgery
Slide 7
Which benefits related to discharge times are mentioned? (Select 2)
a. Longer hospital stays
b. Quicker PACU discharge times
c. Delayed discharge from recovery
d. Avoid unexpected overnight admission
b. Quicker PACU discharge times
d. Avoid unexpected overnight admission from complications of general anesthesia
Slide 7
Which of the following are considered deformities of the spinal column that serve as relative contraindications for neuraxial anesthesia? (Select 3)
a. Spinal stenosis
b. Kyphoscoliosis
c. Ankylosing spondylitis
d. Herniated disc
a. Spinal stenosis
b. Kyphoscoliosis
c. Ankylosing spondylitis
Slide 8
What preexisting diseases of the spinal cord are listed as relative contraindications for neuraxial anesthesia? (Select 2)
a. Multiple Sclerosis
b. Post polio syndrome
c. Spinal stenosis
d. Ankylosing spondylitis
a. Multiple Sclerosis
b. Post polio syndrome
Neuraxial anesthesia exacerbates a progressive, degenerating disease
Slide 8
Which of the following conditions are relative contraindications for neuraxial anesthesia? (Select 2)
a. Chronic headache
b. Chronic backache
c. Epidural failed after 2 attempts
d. Back strain to lumbar area
a. Chronic headache
b. Chronic backache
How many attempts at performing SAB/Epidural is the limit?
a. One attempt
b. Two attempts
c. Three attempts
d. Four attempts
c. Three attempts
Slide 8
Which of the following are absolute contraindications for neuraxial anesthesia as mentioned in the image? (Select 3)
a. Coagulopathy
b. Patient refusal
c. Evidence of dermal site infection
d. History of mild hypertension
a. Coagulopathy
b. Patient refusal
c. Evidence of dermal site infection
Slide 9
Which conditions are considered absolute contraindications for neuraxial anesthesia due to coagulation issues? (Select 4)
a. INR > 1.5
b. Platelets > 150,000
c. Known coagulation disorder
d. Taking anticoagulants
e. Platelets < 100,000
f. PT of 14 seconds
a. INR > 1.5
c. Known coagulation disorder
d. Taking anticoagulants
e. Platelets < 100,000
Slide 9
What is the significance of “Nagelhout x 2” in the context of neuraxial anesthesia?
a. It refers to the use of two different anesthetic agents
b. It indicates the need to consider PT, aPTT, and bleeding time
c. It suggests doubling the dosage of anticoagulants
d. It is a measure of anesthesia depth
b. It indicates the need to consider PT, aPTT, and bleeding time
Slide 9
What is the normal range for Prothrombin Time (PT) ?
a. 10 to 12 seconds
b. 12 to 14 seconds
c. 14 to 16 seconds
d. 16 to 18 seconds
b. 12 to 14 seconds
Slide 9
What is the normal range for International Normalized Ratio (INR)?
a. 0.5 to 0.8
b. 0.8 to 1.1
c. 1.1 to 1.4
d. 1.4 to 1.7
b. 0.8 to 1.1
Slide 9
What is the normal range for Activated Partial Thromboplastin Time (aPTT)?
a. 20 to 25 seconds
b. 25 to 32 seconds
c. 30 to 35 seconds
d. 32 to 38 seconds
b. 25 to 32 seconds
Slide 9
What is the normal bleeding time range provided in the image?
a. 1 to 3 minutes
b. 3 to 5 minutes
c. 3 to 7 minutes
d. 5 to 7 minutes
c. 3 to 7 minutes
Slide 9
What is the normal range for platelet count?
- a. 100,000 - 200,000 mm³
- b. 150,000 - 300,000 mm³
- c. 200,000 - 350,000 mm³
- d. 250,000 - 400,000 mm³
- b. 150,000 - 300,000 mm³
Slide 9
Which of the following is NOT listed as an absolute contraindication?
A. Severe or critical valvular heart disease
B. Operation duration longer than local anesthetic
C. Decreased intracranial pressure (ICP)
D. Severe congestive heart failure (CHF)
E. Idiopathic Hypertrophic Subaortic Stenosis
C. Decreased intracranial pressure (ICP)
Increased ICP is an absolute contraindication
Slide 10
Severe or critical valvular heart disease is indicated by aortic stenosis and mitral stenosis with a valve area of less than ____ cm².
A. 1
B. 2
C. 2.5
D. 1.5
A. 1cm².
*Aortic Stenosis =/< 1.0 cm². or MS < 1.0 cm².
Slide 10
True or False
Severe Congestive Heart Failure (CHF) is considered an absolute contraindication if the ejection fraction (EF) is less than 30-40% and Preload dependent.
True
Slide 10
Match the following symptoms with their corresponding average survival times after onset in adults with valvular aortic stenosis:
1. Angina
2. Syncope
3. Failure
A. 2 years
B. 3 years
C. 5 years
Angina - C. 5 years
Syncope - B. 3 years
Failure - A. 2 years
Slide 10
Which of the following is/are NOT part of the “Death Spiral” diagram?
Select 2
A. Ischemic contractile dysfunction
B. Increased ischemia
C. Increased cardiac output
D. Worsening hypotension
E. Hypertension causes MI
C. Increased cardiac output
E. Hypertension causes MI
Match the characteristics with the appropriate type of anesthesia (Spinal or Epidural):
A. Rapid onset
B. Slow onset
C. Higher than expected spread
D. As expected spread
E. Dense nature of block
F. Segmental nature of block
G. Dense motor block
H. Minimal motor block
I. Likely hypotension
J. Less likely hypotension
A - Rapid onset (Spinal)
B - Slow onset (Epidural)
C - Higher than expected spread (Spinal)
D - As expected spread (Epidural)
E - Dense nature of block (Spinal)
F - Segmental nature of block (Epidural)
G - Dense motor block (Spinal)
H - Minimal motor block (Epidural)
I - Likely hypotension (Spinal)
J - Less likely hypotension (Epidural)
Slide 11
Match the following characteristics with the appropriate type of anesthesia (Spinal or Epidural):
A. Quick onset (5 min)
B. Slow onset (10-15 min)
C. Limited and fixed duration
D. Unlimited duration
E. Placement at any level
F. Placement level at L3-4, L4-5, L5-S1
G. Dose-based (mg) dosing of local anesthetic
H. Volume-based dosing of local anesthetic
I. Gravity influence on position
J. Gravity influence on baricity
A. Quick onset (5 min) - SPINAL
B. Slow onset (10-15 min) - EPIDURAL
C. Limited and fixed duration - SPINAL
D. Unlimited duration - EPIDURAL
E. Placement at any level - EPIDURAL
F. Placement level at L3-4, L4-5, L5-S1 - SPINAL
G. Dose-based (mg) dosing of local anesthetic - SPINAL
H. Volume-based dosing of local anesthetic - EPIDURAL
I. Gravity influence on position - EPIDURAL
J. Gravity influence on baricity - SPINAL
Slide 12
Match the number of vertebrae to their corresponding spinal sections:
A. Cervical vertebrae
B. Thoracic vertebrae
C. Lumbar vertebrae
D. Sacrum
E. Coccyx
- 12
- 7
- 5
- 4-fused
- 5-fused
A. Cervical vertebrae - 7
B. Thoracic vertebrae - 12
C. Lumbar vertebrae - 5
D. Sacrum - 5 (fused)
E. Coccyx - 4 (fused)
Slide 14
Match each condition with picture shown below.
A. Scoliosis
B. Lordosis
C. Kyphosis
D. Normal curvature
1 - D. Normal Curvature
2 - A. Scoliosis
3 - C. Kyphosis
4 - B. Lordosis
Slide 14
Which part of the vertebra is known as the anterior segment?
A. Lamina
B. Pedicle
C. Vertebral body
D. Spinous process
C. Vertebral body
Slide 15
Which part of the vertebra is known as the posterior segment?
A. Lamina
B. Vertebral arch
C. Vertebral body
D. Spinous process
B. Vertebral arch
Slide 15
Which structure links the anterior and posterior segments of the vertebra?
A. Spinous process and pedicle
B. Transverse process and body
C. Lamina and pedicle
D. Superior articular process
C. Lamina and pedicle
Slide 15
What does the vertebral foramen house?
A. Intervertebral disks, epidural space, and nerve roots
B. Spinal cord, nerve roots, and the epidural space
C. Ligaments, nerve roots, and epidural space
D. Muscles, ligaments and epidural space
B. Spinal cord, nerve roots, and the epidural space
Slide 15
What direction do the transverse processes stick out?
A. Medial
B. Lateral
C. Anterior
D. Posterior
B. Lateral (to the sides)
Slide 16
Which process sticks out towards the back (posterior)?
A. Transverse process
B. Spinous process
C. Superior articular process
D. Inferior articular process
B. Spinous process
Slide 16
True or False
The transverse processes and spinous processes help stabilize and support the spine by providing attachment points for muscles.
True
Slide 16
What is the spinous process used as a landmark for?
A. Finding the vertebral foramen
B. Identifying the vertebral body
C. Locating the middle line of the back
D. Determining the length of the spine
C. Locating the middle line of the back
Slide 16
How do the spinous processes of the cervical and thoracic vertebrae differ from those of the lumbar vertebrae?
A. They tilt upward.
B. They tilt downward.
C. They stick out directly backwards.
D. They are shorter.
B. They tilt downward.
Lumbar spinous processes stick out directly backwards
Slide 17
What approach is required for needle insertion in cervical and thoracic vertebrae due to the orientation of their spinous processes?
A. Caudal approach
B. Posterior approach
C. Lateral approach
D. Cephalad approach
D. Cephalad approach
Slide 17
What is the primary function of intervertebral discs?
A. They form the vertebral foramen.
B. They act as shock absorbers between vertebrae.
C. They protect the spinal cord.
D. They allow spinal nerves to exit the spine.
B. They act as shock absorbers between vertebrae.
Slide 18
Where are intervertebral foramina located?
A. Between the intervertebral discs and vertebral body.
B. Between the vertebrae where spinal nerves exit the spine.
C. On the anterior side of the vertebrae.
D. Inside the vertebral foramen.
B. Between the vertebrae where spinal nerves exit the spine.
Slide 18
True or False
The anterior side of the foramen is formed by the vertebral body and the intervertebral disc.
True
Slide 18
What forms the posterior side of each intervertebral foramen?
A. Vertebral body
B. Intervertebral disc
C. Facet joints
D. Nucleus pulposus
C. Facet joints
Slide 18
What can cause the foramina to become smaller and potentially press on spinal nerves?
A. Growth of the vertebral body
B. Degeneration of intervertebral discs
C. Enlargement of the nucleus pulposus
D. Increase in spinal fluid
B. Degeneration of intervertebral discs
This narrowing can press on the spinal nerves, potentially causing pain, numbness, or weakness
Slide 18
True or False:
A facet joint is formed by the connection of the inferior articular process of one vertebra with the superior articular process of the vertebra below it
True
Slide 19
What is the primary function of facet joints in the spine?
A. To absorb shock
B. To provide attachment points for muscles
C. To protect the spinal cord
D. To guide and limit the spine’s movement
D. To guide and limit the spine’s movement
keeping the back’s motions controlled
Slide 19
What can happen if a facet joint gets injured?
A. It can press on nearby spinal nerves
B. It can fuse with adjacent vertebrae
C. It can cause vertebral dislocation
D. It can lead to increased flexibility
A. It can press on nearby spinal nerves
Slide 19
Pressure from an injured facet joint can cause pain and muscle spasms in the area of skin served by that nerve, which is referred to as a ____.
A. Myotome
B. Dermatome
C. Fascia
D. Tendon
B. Dermatome
Slide 19
Which vertebral level corresponds with the superior aspect of the iliac crest?
A. L3
B. L4
C. L5
D. S1
B. L4
Slide 20
The posterior superior iliac spine aligns with which vertebral level?
A. L2
B. L4
C. S1
D. S2
D. S2
Slide 20
Which statements about the Intercristal Line (Tuffier’s Line) are true? (select 3)
A. It runs across the top edges of the hip bones (iliac crests).
B. It matches the L5 vertebra.
C. It helps identify the correct spaces between vertebrae for inserting spinal anesthesia needles.
D. The space above this line aligns with the L4 - L5 vertebrae.
E. In infants up to one year, the Intercristal Line corresponds with the L5 - S1 intervertebral space.
A. It runs across the top edges of the hip bones (iliac crests).
C. It helps identify the correct spaces between vertebrae for inserting spinal anesthesia needles.
E. In infants up to one year, the Intercristal Line corresponds with the L5 - S1 intervertebral space.
The space above this line aligns with the L3 - L4 vertebrae.
The space below this line aligns with the L4 - L5 vertebrae.
Slide 20
Which of the following statements about the sacrum are true?
Select 2
A. The sacrum is a triangular-shaped section of fused vertebrae.
B. The lamina of S5 is incomplete and bridged by ligaments.
C. The sacral hiatus is located at the top of the sacrum.
D. The sacral cornu acts as an access point for caudal anesthesia.
E. The sacral hiatus is a projection of the articular processes.
A. The sacrum is a triangular-shaped section of fused vertebrae.
B. The lamina of S5 is incomplete and bridged by ligaments.
Slide 22
What anatomical features are associated with the sacral hiatus? (select 4)
A. It is located at the base of the sacrum.
B. It aligns with the S5 vertebra.
C. It aligns with the S4 vertebra
D. It is covered by the sacrococcygeal ligament.
E. It acts as an access point for caudal anesthesia.
F. It is a bony projection on the sacrum.
A. It is located at the base of the sacrum.
B. It aligns with the S5 vertebra.
D. It is covered by the sacrococcygeal ligament.
E. It acts as an access point for caudal anesthesia.
Slide 22
Which statements correctly describe the sacral cornu? (select 3)
A. They are the “horns” or bony protuberances on the sacrum.
B. They guard the area of the sacral hiatus.
C. They are part of the coccyx.
D. They serve as landmarks for caudal anesthesia.
E. They form the dorsal sacral foramina.
A. They are the “horns” or bony protuberances on the sacrum.
B. They guard the area of the sacral hiatus.
D. They serve as landmarks for caudal anesthesia.
Slide 22
Where does the spinal cord originate rostrally?
A. Conus medullaris
B. Medulla oblongata
C. Cauda equina
D. Cerebral cortex
B. Medulla oblongata
Slide 23
In adults, between which vertebrae does the conus medullaris typically end?
A. T12 and L1
B. L1 and L2
C. L2 and L3
D. L3 and L4
B. L1 and L2
L1 in most textbooks
Slide 23
In infants, where does the conus medullaris end?
A. L1
B. L2
C. L3
D. S1
C. L3
Slide 23
What is the cauda equina and where does it orginate? (select2)
A. The terminal part of the spinal cord
B. A bundle of spinal nerves extending from the conus medullaris
C. The cervical enlargement of the spinal cord
D. T12 to L3
E. L1 to L5
F. L2 to S5 and the coccygeal nerve
G. S1 to S5 and the coccygeal nerve
B. A bundle of spinal nerves extending from the conus medullaris
F. L2 to S5 and the coccygeal nerve
Slide 23
At what vertebral level does the dural sac end in adults?
A. S1
B. S2
C. S3
D. S4
B. S2
below S2 is not a Spinal block because there is no CSF
Slide 24
At what vertebral level does the dural sac end in infants?
A. S1
B. S2
C. S3
D. S4
C. S3
Slide 24
Which of the following statements about the filum terminale are true? (select 3)
A. The filum terminale is a continuation of the pia mater.
B. It extends from the conus medullaris to the tailbone (coccyx).
C. Its main function is to anchor the spinal cord to the coccyx.
D. The external filum terminale extends from the conus medullaris to the dural sac.
E. The internal filum terminale starts from the dural sac and extends into the sacrum.
A. The filum terminale is a continuation of the pia mater.
B. It extends from the conus medullaris to the tailbone (coccyx).
C. Its main function is to anchor the spinal cord to the coccyx.
Slide 24
The internal filum terminale: (select 2)
A. Begins at the conus medullaris.
B. Extends to the dural sac.
C. Starts from the dural sac and extends into the sacrum.
D. Is a continuation of the arachnoid mater.
A. Begins at the conus medullaris.
B. Extends to the dural sac.
L1 to S2
Slide 24
The external filum terminale: (select 2)
A. Begins at the conus medullaris.
B. Extends into the sacrum.
C. Starts from the dural sac.
D. Is part of the cauda equina.
B. Extends into the sacrum.
C. Starts from the dural sac.
Slide 24
Which statements describe the posterior spinal arteries? (select 4)
A. They are paired arteries.
B. They supply the motor portion of the spinal cord
C. They supply the anterior two-thirds of the spinal cord.
D. They supply the sensory portion of the spinal cord.
E. They emerge from the cranial vault.
F. They originate from the vertebral artery.
A. They are paired arteries.
D. They supply the sensory portion of the spinal cord.
Afferent, Ascending
E. They emerge from the cranial vault.
F. They originate from the vertebral artery.
Slide 25
Which statements about the anterior spinal artery are true? (select 3)
A. It originates from the vertebral artery.
B. It supplies the anterior one-third of the spinal cord.
C. It supplies the front (motor) portion of the spinal cord.
D. It is paired with another anterior spinal artery.
E. It supplies the anterior two-thirds of the spinal cord.
A. It originates from the vertebral artery.
C. It supplies the front (motor) portion of the spinal cord.
Efferent, Descending
E. It supplies the anterior two-thirds of the spinal cord.
Slide 25
True or False
The anterior spinal artery is more vulnerable to ischemia due to having fewer protective links compared to the posterior spinal arteries.
True
posterior spinal arteries are paired and have many connections (collateral anastomotic links) from the subclavian and intercostal arteries.
These connections help protect the sensory part of the spinal cord from ischemia.
Slide 25
Which symptoms can result from anterior spinal artery syndrome? (select 3)
A. Motor paralysis
B. Loss of pain sensation below the affected area
C. Increased reflexes
D. Enhanced coordination
E. Sensory loss in the posterior columns
F. Loss of temperature sensation below affected area
A. Motor paralysis
B. Loss of pain and temperature sensation below the affected area
F. Loss of temperature sensation below affected area
Slide 26
What are possible causes of ischemia in the anterior spinal artery? (select 4)
A. Low blood pressure (profound hypotension)
B. Mechanical blockage
C. Blood vessel disease (vasculopathy)
D. Bleeding (hemorrhage)
E. Enhanced blood flow
A. Low blood pressure (profound hypotension)
B. Mechanical blockage
C. Blood vessel disease (vasculopathy)
D. Bleeding (hemorrhage)
Slide 26
What critical connections help supply the anterior spinal artery? (select 2)
A. Intercostal arteries
B. Iliac arteries
C. Basilar artery
D. Subclavian artery
E. Vertebral artery
A. Intercostal arteries
B. Iliac arteries
Slide 26
Which statements about the artery of Adamkiewicz are true? (select 3)
A. It supplies blood to the lower two-thirds of the spinal cord.
B. It usually arises from the aorta between the T9 and L2 regions.
C. It is a crucial connection for the upper third of the spinal cord.
D. Damage to this artery can lead to anterior spinal artery syndrome.
E. It has no significant role in spinal cord blood supply.
A. It supplies blood to the lower two-thirds of the spinal cord.
B. It usually arises from the aorta between the T9 and L2 regions.
D. Damage to this artery can lead to anterior spinal artery syndrome.
Slide 26
Which statements about the supraspinous ligament are correct? (select 3)
A. It runs along the back.
B. It connects the tips of the spinous processes.
C. It is located between the spinous processes.
D. It forms the sidewalls of the space outside the spinal cord (epidural space).
E. It runs from the upper back down to the lower back.
A. It runs along the back.
B. It connects the tips of the spinous processes
E. It runs from the upper back down to the lower back.
Slide 27
Which statements describe the interspinous ligament? (select 2)
A. It runs along the back.
B. It is located between the spinous processes.
C. It provides stability by joining adjacent vertebrae.
D. It connects the tips of the spinous processes.
E. It forms the sidewalls of the epidural space.
B. It is located between the spinous processes.
C. It provides stability by joining adjacent vertebrae.
Slide 27
Which statements about the ligamentum flavum are true? (select 3)
A. It is particularly thick in the lower back.
B. It forms the sidewalls of the epidural space.
C. Piercing this ligament indicates entry into the epidural space.
D. It runs along the back of the vertebral bodies inside the spinal column.
E. It connects the tips of the spinous processes.
A. It is particularly thick in the lower back.
B. It forms the sidewalls of the epidural space.
C. Piercing this ligament indicates entry into the epidural space.
Slide 27
Which ligaments are attached to the intervertebral discs and helps to bind the vertebrae together? (select 2)
A. Posterior longitudinal ligament
B. Anterior longitudinal ligament
C. Supraspinous ligament
D. Ligamentum flavum
A. Posterior longitudinal ligament
Runs along the back side of the vertebral bodies inside the spinal column
B. Anterior longitudinal ligament
Attached to the front of the vertebral bodies
Slide 27
Which ligaments should be avoided when placing a needle for spinal or epidural anesthesia? (select 2)
A. Anterior longitudinal ligament
B. Posterior longitudinal ligament
C. Supraspinous ligament
D. Interspinous ligament
E. Ligamentum flavum
A. Anterior longitudinal ligament
B. Posterior longitudinal ligament
Slide 27
Match the following steps with the corresponding approach:
Approach:
A. Midline approach
B. Paramedian approach
Steps:
- Skin → Subcutaneous fat → Supraspinous ligament → Interspinous ligament → Ligamentum flavum → Dura mater → Subdural space → Arachnoid mater → Subarachnoid space
- Skin → Subcutaneous fat → Ligamentum flavum → Dura mater → Subdural space → Arachnoid mater → Subarachnoid space
- Typically involves positioning the needle directly in the midline of the spine
- Involves angling the needle 15 degrees off midline
- Needle is positioned 1 cm to the side (lateral) and 1 cm below (inferior) the interspace
- Procedure can be performed while the patient is sitting, lying on their side, or face down
A. Midline Approach
1. Skin → Subcutaneous fat → Supraspinous ligament → Interspinous ligament → Ligamentum flavum → Dura mater → Subdural space → Arachnoid mater → Subarachnoid space
- Typically involves positioning the needle directly in the midline of the spine
B. Paramedian Approach
2. Skin → Subcutaneous fat → Ligamentum flavum → Dura mater → Subdural space → Arachnoid mater → Subarachnoid space
- Involves angling the needle 15 degrees off midline
- Needle is positioned 1 cm to the side (lateral) and 1 cm below (inferior) the interspace
- Procedure can be performed while the patient is sitting, lying on their side, or face down
Slide 28
