Spinals and Epidurals - Quiz 6 Flashcards
Label 1-9 of the Vertebra
- Spinous Process
- Transverse Process
- Vertebral Arch Lamina
- Pedicle
- Body
- Head of Rib
- Superior Articular Process
- Vertbral Foramen
- Spinal Cord
Which part of the vertebra allows for the passage of nerves?
Lateral Notches
What angle should the needle be when placing in Cervical & Thoracic Vertebrae?
Cephalad Angle
What makes Lumbar Vertebrae easier to place needles?
Larger with Less Overlap & Larger Gaps
Label 1 - 15 of the Sacral Vertebra
- Sacral Canal
- Superior Sacral Notch
- Auricular Surface
- Sacral Tuberosity
- Posterior Sacral Foramina
- Sacral Hiatus
- Sacroccocygeal Notch
- Apex of Coccyx
- Transverse Process of Coccyx
- Cornua of Sacrum & Coccyx
- Inferolateral Angle
- Lateral Crest
- Intermediate Crest
- Median Crest
- Superior Articular Facet
What was the 3 Intervertebral Ligaments from Superficial to Deep?
Supraspinous Ligament
Intraspinous Ligament
Ligamentum Flavum
Which Intervertebral Ligament is strong, connects the apices of the spinous processes, and is the major ligament of Cervical and Upper Thoracic Regions?
Supraspinous Ligament
Which Intervertebral Ligament is Absent or Poor Quality in the Cervical Region and Thin, especially in the Lumbar?
Intraspinous Ligament
Which Intervertebral Ligament is the Strongest and looks like a contiguous ligament?
Ligamentum Flavum
The Ligamentum Flavum is _____ on the lateral edge, ______ midline, like a V
The Ligamentum Flavum is THIN on the lateral edge, THICK midline, like a V
At the L2 - L3 level, the Ligamentum Flavum measures _______ thick
At the L2 - L3 level, the Ligamentum Flavum measures 3 - 5 mm thick
Which Ligaments of the Spine covers the Anterior & Posterior parts of the Vertebra?
Anterior & Posterior Longitudinal Ligaments
Where is the Epidural Space located?
Between Ligamentum Flavum & Dura Mater
Where does the Epidural Space Originate and End?
From Base of Cranium to Sacral Sulcus
How far is the Epidural Space from the Skin?
Varies - From 2.5 - 8 cm
Average is about 5 cm from Skin
How far does the Spinal Cord extend for Adults & Kids?
Adults: Medulla to L2
Kids: Medulla to L3
Which Layer of the Spinal Cord contains CSF?
Arachnoid Mater
How are the 31 Pairs of Spinal Nerves distributed?
8 Cervical
12 Thoracic
5 Lumbar
1 Coccygeal
Where do Thoracic Nerves run along in relation to the Ribs?
Inferior Margin of Rib
Slide 18 - Levels
How far along the Spinal Cord is the Brachial Plexus?
C4 - T1
How far along the Spinal Cord is the Lumbar & Sacral Plexus?
L2 - S3
How far along the Spinal Cord is the Cauda Equina?
L1 - S5
Which part of the Spinal Cord is the entering Sensory Root and which is the outgoing Motor Root?
Dorsal - Entering Sensory
Ventral - Outgoing Motor
What is the Laminae II called?
Substanca Gelatinosa - Where IV & Neuraxial Opioids work
What are the Afferent & Ventral Tracts of Grey Matter?
Afferent: I - VI
Ventral: VII - IX
Which part of the highly organized White Matter is exclusively Ascending Sensory Fiber Tracts?
Dorsal White Matter
What do the Lateral & Ventral White Matter do?
Descending Motor Tract
Ascend to Brain
Reflex - Start and End w/in Spinal Cord
Where are the Sensory/Afferent Receptors location?
Epidermis & Dermis: Pain & Temp
Dermis: Pressure, Touch, Vibration, Proprioception
What are the 2 Classifications of Sensory Receptors?
Extroceptors - Near Suface of Skin
&
Proprioceptors - Deeper than Skin Surface
How do peripheral sensory signals travel to the Thalamus with the Dorsal Medial Lemniscus tract?
Dorsal Root –> Cross over Medulla (1st to 2nd Order) –> Goes up Medial Lemiscus Tract via Brainstem (2nd Order) –> Thalamus (3rd Order Neuron)
How do peripheral sensory signals travel to the Thalamus with the Anterolateral Pathway?
Dorsal Horn –> Laminae I, IV, V, VI –> Crossover at Anterior Commissure –> Anterolateral White Columns –> Associated Tract (Spinothalmic) –> Thalamus –> Interpretation in Brain
What are the differences b/t the Dorsal Medial Lemnisucus versus the Anterolateral System?
Dorsal Medial Lemniscus: Large, Myelinated, High Spacial Orientation with a 30-110 m/sec conduction speed - Descrete Senses
Anterolateral: Small, Myelinated, Low Spacial Orientation with a 40 m/sec conduction speed - Broad Senses
What kind of sensations does the Dorsal Medial Lemniscal system transmit?
Touch
Vibrations
Skin Movement
Joint Position
Fine Pressure
What kind of sensations does the Anterolateral system transmit?
Pain
Thermal
Crude Touch
Tickle
Itch
Sexual
Where do Preganglionic B Fibers Originate and Exit?
Originates in Tnermediolateral Gray Horn T1 - L2/L3
&
Exits via Ventral Nerve Root - Whtie Rami Cummincans
What does stimulation of the SNS fiber in the Superior Cervical Ganglia cause?
Midrasis - Pupil Dilation
&
Blood Vessel Constriction in Head
What happens when the Superior Cervical Ganglia, Central SNS, or Paravertebral Ganglia is damaged?
Horners Syndrome:
Miosis - Small Pupil
Ptosis
Anhydrosis - No Sweat
What are the 4 Stages of Pain Transmssion?
- Tranduction
- Transmission
- Modulation
- Perception
How do motor signals travel through the Corticospinal Tract?
Precentral Gyrus –> Crosses Medulla –> Form Pyramids –> Leave Spinal Cord or Enter Ventral Horn to Synapse w/ Lower Motor Neurons
What happens if damage occurs to the Neurons of the Corticospinal Tract that have inhibitory effects on the Lower Motor Neurons?
Hyperreflexia & Spasticity
What happens with Upper Motor Neuron Paralysis?
Hyperreflexia d/t Impeded Suppressor fibers
What happens when Lower Motor Neurons are damaged?
Flaccid Paralysis
How are Cutting Epidural/Spinal needles placed?
Longitudinal
What is the purpose of the Stylet regarding Epidural/Spinal Needles?
Prevents introduction of Dermal Cells, leading to Dermoid Spinal Cord Tumor
What are absolute contraindications to Spinals?
Patient Refuse
Lack of Cooperation
Coagulopathy
Infection at Site
Hypovolemia
Neuro Disease
Increased ICP
What factors affect the Uptake & Spread regarding Spinals?
Local Anesthetic Concentration
Nerve Surface Area
Lipid Content of Nerve
Blood Flow to Nerve
What factors affect distribution regarding Spinals?
Baricity
Position
Dose
What factors affect the Level regarding Spinals?
Baricity
Position
Dose
Site of Injection
Age
Speed of Injection
Volume
Concentration
Which Local Anesthetics are Isobaric & Hyperbaric?
Tetracaine
Lidocaine
Bupivacaine
What kind of Baricity does Tetracaine & Lidocaine have?
Hypobaric
Isobaric
Hyperbaric
What are the main cardiovascular side affects of Spinals?
Hypotension & Bradycardia - treat w/ Fluids or Vasopressors
What are the GI effects from Spinals?
T6 - L2 Sympathetic Innervation
↑Secretions
Relaxed Sphincters
Bowel Constriction
N/V
What is the LA Spinal dose suggestion for Lidocaine?
25-50 mg (25-100 mg)
What is the recommended LA Spinal dose for Tetracaine & Bupivacaine?
5 - 20 mg
What baricity should the LA be if the patient is getting a Spinal in the prone position?
Iso or Hypobaric
What are the different approaches for placing a Spinal?
Median
Maramedian
Taylor
What should be done if bone is felt when placing a Spinal?
Withdraw both needle & stylet to skin & Redirect
What should be done if the patient experiences paresthesia during Spinal placement?
Stop Advancing, Remove Stylet, Check for CSF
What is a Paramedian approach good for when placing a Spinal?
Calcified Intraspinous Ligaments or Difficult Positioning
How is the needle inserted with a Paramedian approach?
1 cm Lateral & 1 cm Inferior to Space w/ a Medial & Cephelad angle
Which ligament is first to give resistance with a Paramedian Spinal approach?
Ligamentum Flavum
What are the complications r/t Spinals?
Cauda Equina Syndrome
Arachnoiditis
Meningitis
PDPH
Hematoma
High Spinal
CV Collapse
With PDPHm the headache is worse when when the patient is ________, and gets relief when the patient is _________
With PDPH the headache is worse when when the patient is UPRIGHT, and gets relief when the patient is SUPINE
How are PDPHs treated?
Epidural Blood Patch - Mainstay
Fluids
Caffeine
Bedrest
Pain Meds
Sumatriptan
Spinal Hematomas are considered an ________, and requires immediate Neuro Consult & MRI
Spinal Hematomas are considered an EMERGENCY, and requires immediate Neuro Consult & MRI
What are absolute contraindications for Epidurals?
Patient Refuse
Hypovolemia
Increased ICP
Infection at Site
What are the effects of an Epidural below T4?
Vasomotor Tone Effected
↓Venous Return & CO
What are the effects of Epidurals Above T4?
Cardiac Sympathetic Fibers Effected
Profound HYPOtension & Bradycardia
What factors affect Epidural Coverage?
** VOLUME **
Site
Concentration
Age
Height
Pregnancy
Obesity
Regarding Epidurals, what is the volume needed for each level of block?
1 - 2mL per level
Regarding Epidurals, the Lumbar gets more spread ________, while the Thoracic gets and _____ spread
Regarding Epidurals, the Lumbar gets more spread CEPHALAD, while the Thoracic gets and EVEN spread
Pregnant & Obese patients require a ________ dose for an Epidural d/t Vein Engorgement & Increased Fat Tissue
Pregnant & Obese patients require a DECREASED dose for an Epidural d/t Vein Engorgement & Increased Fat Tissue
When should each Epidurally injected Local Anesthetic be redosed?
- Chloroprocaine
- Lidocaine
- Mepivacaine
- Bupivacaine
- Ropivacaine
- Chloroprocaine: 45 min
- Lidocaine: 60 min
- Mepivacaine: 90 min
- Bupivacaine: 120 min
- Ropivacaine: 120 min
How is the Epidural Space identified with the Loss of Resistance technique?
Once in the Intraspinous Ligament, advance syringe slowly while tapping or placing continuous pressure until LOR.
How is the Epidural Space identified with the Hanging Drop technique?
Once in Intraspinous Ligament, place syringe with a lil fluid in the hub and advanced until drop sucks into needle
What are the complications of an Epidural?
Hypotension
Unilateral Block
Inadequate Block
Back Pain
PDPH
Subdural/Subarachnoid Injection
Meningitis
Arachnoiditis
Nerve Injury
What should be done if there is a Unilateral Block from an Epidural?
Pull Catheter Back
Unaffected side Down
Redose
Replace
What should be done if there is an Inadequate Epidural Block?
Raise Head
Redose w/ Higher Concentration
Add Fentanyl
A Subdural Epidural Injection will elicit a response after _________ and can lead to a High Spinal
`A Subdural Epidural Injection will elicit a response after 10 - 15 minutes and can lead to a High Spinal
A Subarachnoid Epidural Injection leads to a ________
A Subarachnoid Epidural Injection leads to a FAST HIGH SPINAL
What are signs of Meningitis from an Epidural?
Non-Positional Headache
Fever
Lethargy
Confusion
Nuchal Rigidity
What should be done if Meningitis is suspected?
Head CT
Lumbar Puncture
Neuro Consult
Antibiotics
How long should anticoagulants such as Warfarin be discontinued before placing an Epidural/Spinal?
4 - 5 Days
&
PT/INR < 1.5
How should Heparin be managed regarding Epidurals/Spinals?
Sub Q: Hold until after Block
IV: Hold 1 Hour after Block & Remove 2-4 Hours after last Dose
How long should Herbal supplements that cause bleeding be held before Epidurals/Spinals?
5 - 7 Days
When should Ticlopidin & Clopidogrel be discontinued for Epidurals/Spinals?
Ticlopidine: 14 days
Clopidogrel: 7 days
When should Abciximab be discontinued for Epidurals/Spinals?
Avoid Epidural/Spinal if patient is on Abciximab
How should LMWH/Lovenox be mangaged regarding Epidurals/Spinals?
Place Block 10-12 Hrs after last dose
24 hrs if High Dose
