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229 Cards in this Set
- Front
- Back
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how many total vertebrae are there
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33
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how many cervical vertebrae are there
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7
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how many thoracic vertebrae are there
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12
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how many lumbar vertebrae
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5
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how many sacral vertebrae are there
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5
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how many coccygeal vertebrae are there
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4
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what vertebrae is not fused posteriorly
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S5
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what is the most prominent spinous process
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T1
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what vertebrae corresponds to the iliac crest
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L4
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what are interlaminar foramen
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spaces formed b/t the spinous processes
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what shape are interlaminar foramen
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triangular shaped
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flexing does what to the interlaminar foramen
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slides the articular processes upward enlarging the foramen
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what vertebrae are convex anteriorly
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*cervical
*lumbar |
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what vertebrae are convex posteriorly
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*thoracic
*sacral |
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spinal curves have a significant impact on what in regards to spinals
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sig impact on the spread of local anesthetics
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in supine position what are the "high" points of the spine
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*cervical C5
*lumbar L5 |
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in supine position what are the "low" points of the spine
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*thoracic T5
*sacral S2 |
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if a solution is hyperbaric how will it "fall"
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to low points
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with what type of solution do you not want to sit the pt up because the solution will continue to rise
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HYPObaric
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where is the ligamentum flavum
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just outside the epidural space
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in what order doing a spinal so you encounter the following: interspinous ligament, ligamentum flavum and supraspinous ligament
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*supraspinous ligament (1st)
*interspinous ligament (2nd) *ligamentum flavum (3rd) |
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the ligamentum flavum is shaped how
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v-shaped
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where is the ligamentum flavum the thickest
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midline
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how thick is the ligamentum flavum in adults and at what location
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*3-5 mm
*interspace of L2-3 |
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where is the ligamentum flavum farthest from the meninges
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midline
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what type of insertion of an epidural needle with the ligamentum flavum is LEAST likely to result in unintended meningeal puncture AKA "wet tap"
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midline insertion
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what are the ligaments that are NOT penetrated during spinal or epidural anesthesia
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anterior and posterior longitudinal ligaments
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where are the anterior and posterior longitudinal ligaments
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they run along the ant and post surfaces of the vertebral bodies
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what do the anterior and posterior longitudinal ligaments do
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provide stablilization
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what approach is BEST for an epidural
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midline approach
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what is the outermost thickest of the meninges
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dura mater
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what type of space exists b/t dura and arachnoid
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potential space
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what is the space called b/t the dura and arachnoid
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subdural space
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how many subdural injections are seen in epidurals
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less than 1%
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how many subdural injections are seen with subarachnoid blocks
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up to 10%
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what meninge is a delicate, avascular membrane
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arachnoid mater
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what meninge is the primary barrier to movement of drug from epidural space to spinal cord
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arachnoid mater
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the subarachnoid space b/t arachnoid and pia mater contains what
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CSF
(it is contiguous with cranial CSF) |
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how is the CSF divided (located)
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*1/2 in cranial vault
*1/2 in spinal column |
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where is the "end goal" for a spinal
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subarachnoid
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what happen to a block if the block ends up subdural
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it will be STRONGER
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what meninge is closely adhrent to the spinal cord
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pia mater
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how is the pia mater connected to arachnoid
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by trabeculae
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what meninge is fenestrated
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pia mater
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at the tip of the spinal cord the pia mater does what
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becomes the filum terminale anchoring the cord to sacrum
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where does the conus medularis end in most people
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L1-L2
(want to go below that with spinal) |
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what is the "typical" spot for a spinal
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L3-L4
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what is important to know about the epidural space
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the lateral aspect is very vascular
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in the 1st trimester as a fetus where is the spinal cord
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it extends entire length of vertebral column
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in the term newborn where does the spinal cord end
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L3
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in 60% of adults the spinal cord ends where
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L1
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in 30% of adults the spinal cord ends where
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L2
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in 10% of adults the spinal cord ends where
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L3
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how many pairs of spinal nerves are there
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31
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the anterior spinal nerve is motor or sensory
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MOTOR
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the posterior spinal nerve is motor or sensory
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SENSORY
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what is a dermatone
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skin area innervated by a given spinal nerve
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what is the cauda equina
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spinal nerves which extend BEYOND the end of the spinal cord
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what dermatone corresponds to the nipples
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T4
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what dermatone corresponds to the xiphoid process
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T6
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what dermatone corresponds to the umbilicus
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T10
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what do the two posterior spinal arteries do
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supply the DORSAL SENSORY portion of the cord
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the two posterior spinal arteries have extensive collateral supply from what
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*subclavian
*intercostals |
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the single anterior spinal artery originates from what
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the vertebral artery
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what does the single anterior spinal artery do
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supplies the VENTRAL MOTOR portion of the cord
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what is the artery of adamkiewicz
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the largest anastomotic link of anterior spinal artery
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where does the artery of adamkiewicz come from
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the aorta
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where does the artery of adamkiewicz enter
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the LEFT side at the L1 vertebral foramen
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what does the artery of adamkiewicz do
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it is crucial to blood supply of the lower 2/3 of anterior cord
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what would be a sign of anterior spinal artery syndrome
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bilateral lower extremity motor weakness
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there are extensive venous plexus located where in spinal cord
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primarily in the lateral epidural space
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where does the venous supply of the spinal cord drain
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into the azygous vein and then vena cava
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an increased abdominal pressure or a mass compressing the vena cava can do what to the venous plexus
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dilate it
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what can occur if the venous plexus of the spinal cord is dilated
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*increases probability of puncturing a vein during epidural placement
*increases spread of local anesthestic d/t decreased effective volume of epidural space |
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what sensory level is needed for a hemorroidectomy
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S2-S5
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what sensory level is needed for foot surgery
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L2-L3
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what sensory level is needed for lower extremity surgery
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L1-L3
(inguinal ligament) |
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what sensory level is needed for hip sx, TURP or vaginal delivery
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T10
(umbilicus) |
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what sensory level is needed for lower abd sx or appendenctomy
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T5-T7
(xiphoid) |
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what sensory level is needed for upper abd sx or C-section
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T4
(nipple) |
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what is the likely site of action for a spinal
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nerve roots
(not spinal cord itself) |
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how does an epidural work on the spinal nerves
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blocks them laterally
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what is a differential block
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increasing concentration of local anesthetic will usually produce a blockade from autonomic to sensory to motor
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what sense is blocked FIRST in a differential block
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*autonomic
*preganglionic sympathetics |
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what fibers are blocked FIRST in a differential block
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B fibers
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what sense is blocked SECOND in a differential block
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*sensory
*pain, temp |
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what fibers are blocked SECOND in a differential block
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small A fibers
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what sense if blocked LAST in a differential block
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*motor
*large motor |
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what fibers are blocked LAST in a differential block
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*large A fibers
*C fibers |
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a sympathetic block is what level compared to a sensory block
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2-6 levels ABOVE
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a MOTOR block is what level compared to a sensory block
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2-3 levels BELOW
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what is the causative factor for a differential block
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likely d/t decreasing concentrations of local anesthetic in CSF as a function of distance from the injection site
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what are the CV effects of a spinal
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*hypotension
*bradycardia |
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hypotension and bradycardia with a spinal are primarily d/t what
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blockade of sympathetic efferents
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hypotension and bradycardia with a spinal are related to what factor
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block height
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what are the risk factors for hypotension with a spinal
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*age > 50
*hypovolemia *concurrent GA *addition of phenylephrine to local anesthetic |
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what are the risk factors for bradycardia with a spinal
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*age < 50
*asa 1 *beta blockade |
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why would an ASA classification of 1 be at greater risk for bradycardia with a spinal
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stronger parasympathetic drive
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hypotension with a spinal is d/t what
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both arterial and venodilation
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what plays a bigger role in hypotension with a spinal arterial dilation or venodilation
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venodilation
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what is the primary cause of decreased cardiac output with a high spinal
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decreased preload
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bradycardia with a spinal is d/t what
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blockade of cardioaccelerator fibers at T1-T4
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with a spinal decreased preload causes what to occur
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cardiac stretch receptors to reflexively SLOW heart rate
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what is the treatment for hemodynamic changes with a spinal
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*prehydration
*vasopressor |
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what amt of prehydration has been shown to reduce hypotension in some studies
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500-1500 ml of crystalloid
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what vasopressor should be given to treat hemodynamic changes with a spinal
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ephedrine 5-10 mg boluses
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what type of vasopressor agent is preferred to treat the hemodynamic changes associated with a spinal
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alpha + beta
(rather than just alpha) |
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when should the hemodymamic changes of hypotension and bradycardia be treated with a spinal
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*25-30% drop in BP from baseline
*HR < 50-60 |
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what is the magnitude of respiratory effects seen from a spinal
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MINIMAL
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what with respiration can be compromised with a high block
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accessory muscles of respiration
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what would cause a pt to complain of dyspnea with spinal
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lack of senstion of the chest wall moving
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rare episodes of resp arrest with spinals are d/t what
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hypoperfusion of brainstem resp centers
(NOT phrenic paralysis) |
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rare episodes of resp arrest with spinals respond to what
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improvement of cardiac output and/or blood pressure
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what does a sympathectomy do
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produces unopposed PS activity
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what are the signs of sympathectomy
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*increased secretions
*relaxation of the sphinctors *increased parastalsis *constriction of the bowel |
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nausea/vomiting with a spinal is associated with what factors
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*hypotension
*block height greater than T5 *opioids *hx of motion sickness |
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what are the renal effects of spinal and epidurals
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may see urinary retention following spinal or epidural anesthetics
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spinal and epidural anesthesia do what to the surgical stress response
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INHIBIT it
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by what mechanism do spinal and epidural anesthesia alter the surgical stress reponse
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d/t blockade of efferent sensory input
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the greatest effect of altering surgical stress response with spinals and epidurals are seen when
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with lower extremity and lower abd sx
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what are the styles of spinal needles
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*cutting
*pencil point |
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what type of needle produces fewer post spinal HA's
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small gauge pencil point needle
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what are the advantages of a cutting needle for a spinal
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*sharper
*easier to get through skin *no introducer needed unless a very small needle is used |
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what are the advantages of a pencil point needle
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*decreased post spinal HA
*better tactile feel |
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what is EXTREMELY important for successfully placing a spinal block
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POSITIONING
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with a HYPERbaric solution how should be ot be positioned with lateral decubitis position
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operative side DOWN
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with a HYPObaric solution how should the pt be positioned with lateral decubitis position
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operative side UP
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what should the pt look like in a lateral decubitis position for a block
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*knees flexed
*shoulders rounded *lower back bowed out |
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what maneuver in positioning is the key to seperating the spaces
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bowing out the lower back
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the sitting position for spinals is useful in what type of pt
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*morbidly obese
*difficult anatomy |
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what positon for spinals is useful when a low level is desired such as in perineal sx
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sitting position
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with a sitting position for a spinal if a higher level of block is required what should be done
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immediately after injection place pt in supine position
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what should the pt look like in a sitting position for a block
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*feet resting on stool
*keeping lower back bowed out to minimize lumbar lordosis |
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what position for a spinal is useful for rectal or perineal procedures
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PRONE
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what may be required to obtain CSF with a prone jacknife position for a spinal
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gentle aspiration on needle as CSF won't flow uphill
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what position for spinals is used for caudal epidural placement in adults
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PRONE
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for skin and sub-q analgesia the needle should be placed no higher that what vertebrae
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L2-L3
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where should the needle be placed for sub-q and skin analgesia with a spinal
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L3-4 or L4-5
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how do you perform skin/sub-q analgesia for a spinal
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*start near bottom of chosen interspace create a skin wheal of 1% lidocaine with a 25 g or smaller needle
*2nd inject to a depth of 1-2" in direction of anticipated spinal needle travel |
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what do sylets do
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prevent plugging of needle and carrying tissue into the epidural or subarachnoid space
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what size are introducers typically
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18 g 1 1/2 inches
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what is the function of an introducer
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prevents smaller needle and pencil point from bending or getting misdirected
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the introducer can reach what landmark in some people
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subarchnoid space
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how is the needle introduced in a midline approach
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*midline
*nearer the bottom of interspace *with a 10-15 degree cephalad angle |
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where should the introducer be anchored in a midline approach
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interspinous ligament
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what are the goals for holding the needle with a spinal
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*absoute control of needle depth
*tactile sensation of diff tissues & perforation of the dura |
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what is felt upon puncturing the dura with a spinal esp with a pencil point needle
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distinct "pop"
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if there is contact with the bone upon performing a spinal what could be possible causes
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*too steep an angle
*directed caudad *started in the wrong place |
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what should be done to correct the problem if there is contact with bone upon performing a spinal
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pull needle back to sub-q tissue and redirect
(otherwise needle may bend and won't reliably redirect) |
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what is the paramedian approach useful for
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pts who are unable to reduce their lumbar lordosis
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what type of pt would a paramedian approach be vaulable in
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*some elderly males
*fusion *bit much sedation on board *pain (i.e. hip fx) |
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what is the taylor approach with a spinal
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paramedian approach at L5-S1
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what is the typical paresthesia that the pt experiences with spinals
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transient pain "shooting" into buttocks or down leg
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what can be the cause of paresthesias with spinal
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*needle likely deviated from midline
*paramedian approach needs angle adjustment |
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what should be done regarding injecting into a paresthesia with a spinal
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NEVER inject into one
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what should be done if a paresthesia is encountered during a spinal
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pull the needle back to sub-q and redirect in the OPPOSITE direction of side which produced the paresthesia
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when performing a spinal when you feel the "pop" of puncturing the dura what should be done
|
*advance the needle slightly (1-2mm)
*remove the stylet *anchor the needle on pts back *attach syringe with local anesthetic *aspirate for CSF gently |
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when injecting the local for a spinal if CSF aspirates freely how long should the local be injected
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5-10 sec
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what is done regarding post-block positioning for spinal
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immediately position pt to acheive desired block height
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when after a block should you begin to assess development of block
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within 1-2 min
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after what amt of time does repositioning NOT affect block height much
|
5 min
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how can you tell the sympathetic level of a block on a pt
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run the back of you hand up the pt and where they begin to sweat is sympathetic level
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where is a sensory block on a pt with a spinal in relation to the sympathetic block
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2-4 levels BELOW
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what is the primary determinant of duration of a spinal block
|
drug selection
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what are the SHORT acting drugs used for spinals
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*procaine
*lidocaine *mepivacaine *chloroprocaine |
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what are the longer acting drugs used in spinals
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*tetracaine
*bupivacaine *ropivacaine *levobupivacaine |
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what is the dosage for procaine for spinals
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50-150 mg
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what local anesthetic for spinals has more frequent nausea
|
procaine
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what local anesthetic for spinals has a higher failure rate
|
procaine
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what local anesthetic for spinals has a slower recovery
|
procaine
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what local anesthetic for spinals has decreased incidence of TNS
|
*procaine
*mepivacaine |
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what is the dosage for lidocaine in spinals
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60-70 mg
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with lidocaine TNS develops most frequently after what
|
outpatient sx in lithotomy and knee arthroscopy positions
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what can be done to minimize risk of TNS with lidocaine
|
*limit dosage to 60-70 mg
*reduce concentration from 5% to 2.5% or less |
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what is the dosage of mepivacaine for spinals
|
30-60 mg
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what local anesthetic used in spinals is slightly longer acting than lidocaine
|
mepivacaine
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what is the dosage for chloroprocaine in spinals
|
40-60 mg
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what local anesthetic used for spinals provides excellent analgesia with little or no incidence of TNS
|
chloroprocaine
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with which local anesthetic used for spinals should you NOT add epi to
|
chloroprocaine
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what is the dosage for tetracaine with a spinal
|
12-15 mg
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what is the longest acting spinal anesthetic when a vasoconstrictor is added
|
tetracaine
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what can occur with tetracaine when a local anesthetic is added to it for a spinal
|
can increase the incidence of TNS
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what is the dosage of bupivacaine for a spinal
|
12-15 mg
|
|
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what are the solution types for bupivacaine
|
*hyperbaric 0.5% and 0.75% prepackaged in dextrose
*isobaric 0.5% and 0.75% plain |
|
|
how is tetracaine packaged
|
*niphanoid crystals 20 mg
*1% solution |
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how do you reconsitute the tetracaine crystals
|
*2 ml sterile water for 1% solution
*mix w/ equal volume D10 producing a hyperbaric 5mg/ml solution |
|
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what is the dose of epi used with a local anesthetic for a spinal
|
0.1-0.2 mg
(MAX 0.5 mg) |
|
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what is the dose of phenylephrine used with a local anesthetic for a spinal
|
2-5 mg
|
|
|
with lidocaine addition of vasoconstrictors may do what
|
increase neurotoxicity
|
|
|
with chloroprocaine addition of epi may do what
|
produce flu-like symptoms
|
|
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with tetracaine the addition of epi or phenylephrine may do what
|
increase incidence of TNS
|
|
|
what is the dosage of clonidine for a spinal
|
75-150 mcg
|
|
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what does clonidine do in a spinal
|
*increases duration and quality of block
*inhibition of nocioceptive afferents *may exacerbate hypotension |
|
|
what do narcotics do in a spinal block
|
mimic endogenous enkephalins at the dorsal horn
|
|
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what is the dosage of fentanyl for a spinal
|
12.5-25 mcg
|
|
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what is the dosage of morphine for a spinal
|
0.1-0.5 mg
|
|
|
what effects can morphine have with a spinal
|
*may produce pain relief up to 18-24 hrs
*may produce resp depression |
|
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what does neostigmine do in a spinal
|
release of NO in spinal cord prolongs and intensifies analgesia
|
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what are the CONTROLLABLE factors affecting a block height
|
*dose
*site of injection along neuaxis *baracity of LA solution *posture of pt |
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what are the UNCONTROLLABLE factors affecting a block height
|
*volume of CSF
*density of CSF |
|
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what factors are probably UNRELATED to height of spinal cord block
|
*added vasoconstrictor
*coughing, straining or bearing down *barbotage *rate of injection (except hyperbaric) *needle bevel *gender *weight |
|
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what factors other than drug dose and baracity really make a difference in block height
|
*CSF volume
*pt position *age |
|
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what factor accounts for ~80% of varability in block height with a spinal
|
CSF volume
|
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what is the onset to peak block height with lidocaine
|
10-15min
|
|
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what is the onset to peak block height with mepivacaine
|
10-15 min
|
|
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what is the onset to peak block height with tetracaine
|
20+ min
|
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what is the onset to peak block height with bupivacaine
|
20+ min
|
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what is the only ABSOLUTE contraindication to regional anesthesia
|
pt refusal
|
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what is the location of a post dural puncture HA
|
frontal, occiptal or both
|
|
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what is the nature of a post dural puncture HA
|
dull or throbbing
|
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what is the key feature of a post dural puncture HA
|
it is POSTURAL
|
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when does a post dural puncture usually occur
|
12-48 hrs following puncture
|
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what is the mechanism of a post dural puncture HA
|
loss of CSF through hole in dura causes the brain to be displaced downward causing traction on sensitive structures
|
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what are the risk factors for post dural puncture HA
|
*cutting needles
*needle size *age *pregnancy v female gender *prev hx of PDP HA |
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what age group is the risk for post dural puncuture HA low
|
children
|
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what age group does the risk for post dural puncture HA increase
|
puberty
|
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|
what are factors that do NOT increase the incidence of post dural puncture HA
|
*continuous spinals
*timing of ambulation |
|
|
what should be done following a blood patch
|
*bed rest
*no lifting x 24 hrs *force po caffeine containing fluids |
|
|
what are normal things to be expected after a blood patch
|
*low grade fever
*mild backache |
|
|
what are things that the pt should return to the ER immediately if experience after a blood patch
|
*high fever
*severe backache *new neurologic s/s (incontinence, numbness, worsening of HA) |
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what are the complications of a spinal
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*backache
*hearing loss *total spinal *neurologic injury |
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a total spinal block can result in
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*profound hypotension & bradycardia from sympathetic block
*possible resp arrest |
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what is the management for a total spinal
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*CV support (vasopressors, fluids, atropine)
*resp support (ventilation, oxygention) |
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what are the most common neurologic injuries associated with a spinal
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*limited motor weakness
*persistent paresthesias |
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what are the possible etiologies for neurologic injury with a spinal
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*direct needle trauma
*spinal cord ischemia *inadvertent injection of neurotoxic substance or bacteria *epidural hematoma |
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combined spinal-epidural anesthesia is most commonly used when
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obstetrics
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what are spinal-epidural combinations useful for
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*obstetrics
*sx which is of uncertain duration *post-op pain management |
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1 mg/ml is what concentration
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1:1000
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10 mg/ml is what concentration
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1:100 or 1%
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