Term
| What surgical procedure is decompressive involving complete removal of the lamina in a piecemeal fashion using rongeurs? |
|
Definition
|
|
Term
| What surgical procedure uses a technique to decompress the nerve root by opening the foramen via partial facet removal? |
|
Definition
|
|
Term
| What are two names for the procedure where there is removal of all or part of a vertebral body for anterior decompression? |
|
Definition
*Vertebrectomy
*Corpectomy |
|
|
Term
| Why are spinal stabilizations and fusions done? |
|
Definition
| *To provide stability for the unstable spine |
|
|
Term
| What is the procedure called where a herniated disc is removed? |
|
Definition
|
|
Term
| List common mechanisms of spinal nerve compression |
|
Definition
*Disc herniation
*Bone compression
*Spinal instability
*Spinal stenosis
*Neoplasm
*Hematoma
*Abcess |
|
|
Term
| What is it called when nerve roots are compressed leading to symptoms at the dermatome level? |
|
Definition
|
|
Term
| What are symptoms of a radiculopathy? |
|
Definition
*Symptoms at the dermotomal level of nerve root compression:
*Normal motor function to weak
*Pain
*Numbness
*Decreased reflexes |
|
|
Term
| What is it called where the spinal cord is compressed itself and symptoms are caudal to the involved area? |
|
Definition
|
|
Term
| What are symptoms of a myelopathy? |
|
Definition
*Symptoms are caudal to the involved area:
*Motor function is normal or weak
*May be spastic
*Pain
*numbness
*Increased Reflexes |
|
|
Term
| What four factors should always be discussed with the neurosurgeon for safe management? |
|
Definition
*Intubation
*Positioning
*Choice of Muscle Relaxant
*Blood pressure control |
|
|
Term
| How should the patient with cervical radiculopathy be intubated? |
|
Definition
| *Asleed intubation unless airway exam contraindicates |
|
|
Term
| How should the patient with cervical myelopathy be intubated? |
|
Definition
*Possible risk for cord ischemia with neck extention during laryngoscopy
*Stabilize spine |
|
|
Term
| Can complications occur with intubation in patients who have thoracic or lumbar radiculopathy/myelopathy? |
|
Definition
| *Intubation is unlikely to cause problems |
|
|
Term
| Are complications common when positioning patients with cervical radiculopathy? |
|
Definition
| *Permanent problems are rare |
|
|
Term
| Are complications common with positioning for patients with cervical myelopathy? |
|
Definition
| *Extreme care used. Especially with cervial stenosis. |
|
|
Term
| Are complications common with thoracic or lumbar radiculopathy/myelopathy patients during positioning? |
|
Definition
| *Problematic only with very unstable spine. |
|
|
Term
| What are radiculopathy and myelopathy patients at risk for with succinylcholine use? |
|
Definition
*Hyperkalemia
*Rarely happens
*Occurs when the presenting sypmtoms are unstable or long-term. |
|
|
Term
| Where should the anesthetist maintain the myelopathic patient's blood pressure? |
|
Definition
*Maintain BP at or above normal
*Hypotension in the myelopathic patient may cause spinal cord ischemia |
|
|
Term
| What should not be used if a spinal surgery patient has malignancy? |
|
Definition
|
|
Term
| What should be thoroughly documented preoperatively in the spinal patient? |
|
Definition
| *Document all neurological findings |
|
|
Term
| What possible problems may be present in the spinal patient who is also suffering from metasatic disease? |
|
Definition
*Debilitated state preop. Recent chemo/radiation, Frequently Dehydrated.
*Pulmonary status may be affected by tumor, chemo, or radiation
*Prone to infection. Multiple drug therapies. May be tolerant to narcotics
*Possible cardiac involvement |
|
|
Term
| What airway considerations should the anesthetist think about with the spine patient? |
|
Definition
*May have limited ROM
*Suspect difficult airway with rheumatoid arthritis patients
*Evaluate for presence of any pulmonary impairment
*Document c-collar if present |
|
|
Term
| How can ischemic optic neuropathy be avoided? |
|
Definition
*Avoid:
-Pressure on globes
-Anemia
-Hypotension |
|
|
Term
| What are some important considerations for prone positioning? |
|
Definition
| *Be certain chest excursion is unimpeded and there is no compression of abdomen, breasts, and genitals |
|
|
Term
| Do not extubate patients undergoing a _______ spine procedure deep |
|
Definition
|
|
Term
| The presence of a _________ should be documented if present and extubated after it is on. |
|
Definition
|
|
Term
| What is the median age and usual gender for SCI patients? |
|
Definition
*Median age 26
*80% are male |
|
|
Term
| How do SCI usually result? |
|
Definition
*40% MVA
*25% acts of violence (GSW #1)
*22% due to falls
*7% due to sports injuries |
|
|
Term
| When is the higest mortality for the SCI patient? |
|
Definition
|
|
Term
| What is the most common cause of death for both acute and chronic SCI patients? |
|
Definition
|
|
Term
| What are frequent pulmonary complications experienced by SCI patients? |
|
Definition
*Pneumonia
*Pulmonary Emboli
*Septicemia |
|
|
Term
| Where is the most common area for SC injury? |
|
Definition
*50% of all injury are cervial
*Specifically C5
*Followed by C4, C6, T12, & L1 |
|
|
Term
| Why is the cervical spine most vulnerable? What type of injury is most common? |
|
Definition
*C-spine is most vulnerable because it is so mobile
*Flexion injury is the most common |
|
|
Term
| 60% of SCI in kids are in the ___________. |
|
Definition
|
|
Term
| What deems the spinal cord "unstable" |
|
Definition
*Spine is divided into 3 columns; anterior, middle, and posterior
*If 2 of the 3 columns are disrupted, the spine is considered unstable. |
|
|
Term
| How is the SC lesion named? |
|
Definition
| *The most distal uninvolved segment of the cord determines the naem of the injury |
|
|
Term
| List different types of spinal cord injury |
|
Definition
*Dislocation
*Subluxation
*Extention
*Flexion
*Compression
*Rotation
*Penetrating |
|
|
Term
| What is a complete spinal injury? |
|
Definition
| *Total loss of function below the level of teh lesion |
|
|
Term
| What is an incomplete spinal cord lesion? |
|
Definition
*Partial preservation of neurologic function more than one level below the site of injury
(Significant becuse the patient may have neurologic improvement) |
|
|
Term
| What can be described as a primary injury in the SCI patient? |
|
Definition
*Fracture, disruption of discs, ligaments, or the soft tissue around the spinal column.
*Injury to soft tissues and vessels causes hemorrhage into the gray matter.
*Ischemia, edema and microthrombi are formed
*Alterations in autonomic tone occur, causing hypotension and cord ischemia
*Calcium influx occus causing inflammation and edema of the cord. |
|
|
Term
| What can secondary injury be described as in the SCI patient? |
|
Definition
*Necrosis of teh injured areas takes place and damage spreads into the white matter
*Over time the necrotic areas are replaced by fibrotic tissue causing a functional transection
*Autoregulation exists within the cord and is impaired for up to 24 hours after injury
*Flow becomes pressure passive
*The spinal cord blood flow responds to changes in CO2 & O2, just like the CBF. |
|
|
Term
| What is it called when necrotic areas of the spine are replaced by fibrotic tissue? |
|
Definition
| *a Functional transection |
|
|
Term
| What is the definition of spinal shock? |
|
Definition
| *Loss of all sensory, motor, and reflex function below the level of injury |
|
|
Term
| What are the hallmark clinical manifestations of spinal shock? |
|
Definition
*Hypotension
*Bradycardia |
|
|
Term
| What are other S&S of spinal shock besides the 2 hallmark symptoms? |
|
Definition
*Flaccid paralysis
*Poikilothermnia
*Decreased PVR
*Paralytic Ileus
*Loss of visceral and somatic sensation
*Retention of feces and urine |
|
|
Term
| When does spinal shock develop and how long does it last? |
|
Definition
*Begins immediately after injury
*Commonly lasts for days to weeks
*Average duration is 3-10 days |
|
|
Term
| What injuries have a higer incidence of spinal shock? |
|
Definition
| *Most sever injuries above the level of T6 |
|
|
Term
| What cause the physiologic effects of spinal shock? |
|
Definition
*Caused by the disruption of sympathetic outflow from higher CNS centers
*Loss of the cardioaccelerator fibers (T1-T4) and loss of vasoconstrictor tone.
*Vasodilation causes pooling of blood in teh periphery, unopposed parasympathetic tone, and bradycardia |
|
|
Term
| When does bradycardia peak with spinal shock? |
|
Definition
|
|
Term
| When does spinal shock typically resolve? |
|
Definition
|
|
Term
| What can happen during suctioning and laryngoscopy to the patient with spinal shock? How can this be blunted? |
|
Definition
*Vagal stimulation which may lead to cardiac arrest.
*By administration of 100% O2 |
|
|
Term
| Why do SCI patients have sensitivity to volume changes? |
|
Definition
*No ability to make compensatory changes in heart rate, contractility, or vascular tone
*If a high c-spine patient is hypovolemic, they wil not become tachycardic or vasoconstrict to compensate.
*Will be hypotensive leading to ischemic events |
|
|
Term
| Why are spinal shock patients easily volume overloaded? |
|
Definition
*Catecholamine surge occurs at time of injury leading to impaired LV function and pulmonary capillary permeability.
*Fluid bolus can cause pulmonary edema
*Treat hemodynamic instability with direct acting vasoconstrictors and inotropes. |
|
|
Term
| The end of spinal shock is signaled by......... |
|
Definition
*The return of spinal & tendon reflexes
*May progress to spacticity |
|
|
Term
| What is the first reflex to return after the resolution of spinal shock? |
|
Definition
| *The bulbovavernous reflex |
|
|
Term
| What are two different names for autonomic hyperreflexia? |
|
Definition
*Autonomic Dysreflexia
*Mass Reflex |
|
|
Term
| What is the definition of Autonomic Dysreflexia? |
|
Definition
| *Generalized, uncontrolled Sympathetic discharge below the level of the injury which occurs in response to noxious stimuli |
|
|
Term
| Incidence of autonomic hyperreflexia is reported to occur in up to 85% of patients with a level of _______ or higher. |
|
Definition
*T6
*Unlikely to occur when injury is below T10. |
|
|
Term
| What is the mechanism that causes autonomic hyperreflexia? |
|
Definition
| *Noxious stimulus (bowel, bladder, pressure) below the level of injury causes afferent impulses to enter the spinal cord. They are blocked at the level of injury. |
|
|
Term
| What do the afferent impulses resulting from autonomic dysreflexia cause? |
|
Definition
*Sympathetic activity via preganglionic fiber
*Vasoconstriction occurs below the injury
*Resultant Hypertension |
|
|
Term
| What does hypertension from autonomic dysreflexia stimulate? |
|
Definition
| *Carotid sinus baroreceptor, causing a decrease in efferent sympathetic impulses. |
|
|
Term
| What predominates above the level of the injury during autonomic hyperreflexia? |
|
Definition
*Parasympathetic Tone
*Efferent impulses are blocked at level of injury |
|
|
Term
| Describe what happens above and below the SCI durin autonomic hyperreflexia |
|
Definition
*Bradycardia and vasodilation above
*Hypertension below the level of injury
-This area is isolated from the higher CNS control
-Continued sympathetic dominiance |
|
|
Term
| What can cause autonomic hyperreflexia? |
|
Definition
*Distension of hollow viscus (bladder, bowel)
*Cutaneous stimulation (head or cold)
*Infection; such as decubiti, pyelonephritis
*Surgical stimulation or pain
*Uterine contractions
*Pressure |
|
|
Term
| What are signs and symptoms of autonomic hyperreflexia? |
|
Definition
*Hypertension and bradycardia
*Above: Vasodilation- flushing of face & neck, nasal congestion, headache, blurred vision, nausea, arrhythmias
*Below: Vasoconstriction- pallor, sweating, piloerection |
|
|
Term
| What are some major complications of autonomic hyperreflexia? |
|
Definition
*Intracranial bleed/SAH
*Retinal hemorrhage
*Seizure
*Pulmonary Edema
*MI
*Treatment must be instituted immediately! |
|
|
Term
| How should the anesthetist manage autonomic hyperreflexia? |
|
Definition
*remove the stimulus
*deepen the anesthesia |
|
|
Term
| What drug therapies should be utilized for the autonomic hyperreflexia patient? |
|
Definition
*Direct vasodilators preffered. (Nipride, Hydralazine)
*Alpha Blockers Work
*Centrally acting agents will NOT work
*Clonidien might/Aldomet wont work |
|
|
Term
| How can autonomic hyperreflexia be prevented? |
|
Definition
*Maintain sufficient anesthetic depth
*Regional anesthesia excellent alternative
*Treat HTN aggressively
*Assess likelihood during preop eval. |
|
|
Term
| What is the goal of medical management of SCI patients? |
|
Definition
| *To prevent secondary injury |
|
|
Term
| What is the focus of SCI management (6 areas) |
|
Definition
1.Immobilize the spine, medically stabilize
2.Maintain spinal cord blood flow. Oxygenate and
ventilate. Correct hypotension.
3. Corticosteroid Therapy
4. NGT to decompress stomach due to paralytic ileus
5. Foley to decompress the bladder
6. Maintain body temperature |
|
|
Term
| What are the guidelines for corticosteriod therapy and the dosage? |
|
Definition
*NASCIS showed hi-dose steroid given within 2 hours of injury for 24 hours provides the best outcome.
-If given within 3-8 hours post-injury, 48 hour duration.
*Dosage: Methylprednisone 30mg/kg bolus; 5.4mg/kg/hr to be given over 24-48 hours.
*Bolus is given over 15 minutes, infusion starts 45 minutes later. |
|
|
Term
| Respiratory insufficiency is the leading cause of M&M in the SCI patient. What is this due to? |
|
Definition
*D/t muscle paralysis
*Diaphragm (C3,4,5) is critical
*Injury C4 and above: no diaphragm function
*C6 & below: Diaphragm intact
-Ventilation still impaired
-Loss of scalenes, intercostals, abdominals |
|
|
Term
| What respiratory parameters are affected by SCI? |
|
Definition
*VT
*IRV
*ERV
*FRC
*ALL REDUCED
*RV increased |
|
|
Term
| What does imparied alveolar ventilation cause? |
|
Definition
*Hypoventilation
*Hypercarbia
*D/t inability to generate a cough leading to retained secretions and hypoxemia
*C5 or higher levels will need intubation and ventilation acutely |
|
|
Term
| What CV problems should be ruled out with an acute SCI patient? |
|
Definition
*R/O other injuries: thoracic, abdominal, long bone fractures, cardiac contusions or tamponade, vascular
*EKG to check for contusion, MI
*May have postural hypotension |
|
|
Term
| Why can pathologic fractures occur in the SCI patient? |
|
Definition
*Occur due to disuse osteoporosis
*Careful positioning- spasticity or contractures impeded positioning |
|
|
Term
| What electrolyte abnormality happens 1-12 weeks post injury in the SCI patient? How long can this last? |
|
Definition
*Hypercalcemia
*Can last up to one year
*Commn in young males |
|
|
Term
| Why does hypercalcemia occur in the SCI patient? |
|
Definition
*CA is released from denervated inactive muscle adn demineralized bone
*Ventricular arrhythmias can result |
|
|
Term
| Why can hyperkalemia result after use of Succinylcholine in the SCI patient? |
|
Definition
*Denervation injury causes proliferation of cholinergic receptors in extrajunctional area of muscle
*receptors begin to proliferate as early as 48 hours post injury. |
|
|
Term
| How is ARF typically developed in a SCI patient? |
|
Definition
*From hypotension, dehydration, and sepsis
*From recurrent UTIs, pyelonephritis and renal calculi
*avoid drugs metabolized by the kidneys |
|
|
Term
| Why is temperature regulation disrupted in the SCI patient? What is that called? |
|
Definition
*Poikilothermic
*Disrupted sympathetic pathway to the hypothalamus is the cause.
*Loss of vasoconstriction in teh periphery below injury
*Must monitor temperature intraop and use all warmers. |
|
|
Term
| Why is there a high incidence of gastric ulcers in the SCI patient? |
|
Definition
| *High incidence of Gi bleeding and gastric ulcers d/t high vagal tone and steriods |
|
|
Term
| List contributing factors that a SCI patient has for a VTE. What can be done to help prevent? |
|
Definition
*Immobilization
*no PVR
*No muscle tone
*Use low dose heparin, rotobeds, ted hose, and compression stockings |
|
|
Term
| What level will result in Quadriplegia? |
|
Definition
|
|
Term
| How far can edema extend in SCI and in what time frame? |
|
Definition
| *Edema formation extends 2 levels above the level of injury within 48 hours and subsides over next few days. |
|
|
Term
| How should the c-spine injury patient be intubated? |
|
Definition
*Under controlled circumstances, an awake intubation is preferred after good topicalization and possible sedation.
**In EMERGENCIES, in normal-appearing airway, a RSI with in-line manual stabilization is prefered over an uncooperative patient who may harm themselves further during awake attempts. Give anticholinergic if time permits. |
|
|
Term
| What are some alternatives to DVL that can be utilized in the SCI patient? |
|
Definition
*Blind nasotracheal
*Fiberoptic assisted
*Cricothyrotomy
*Retrograde intubation |
|
|
Term
| True or False: If the surgery is below the level of the lesion, the patient may not need anesthesia. |
|
Definition
| *True- beware of some patchy sensory sparing, may be prone to autonomic dysreflexia. If so ansethetize. |
|
|
Term
| What is the prefered anesthetic technique for the SCI patient but may be technically difficult and difficult to assess? |
|
Definition
|
|
Term
| A slow induction should be performed on a SCI patient. State why and what medication can be given preop. |
|
Definition
*Unpredictable sympathetic function especially T7 and up.
*Pre-op anticholinergic important to blunt low HR |
|
|
Term
| Who may need post op ventilation in the SCI patient population? |
|
Definition
*Determined by the location of the lesion
*Elderly patient
*Vital capacity <15ml/kg
*NIF <~20cm H20 |
|
|
Term
| What are some SCI specific concerns about extubation? |
|
Definition
*Cautiously delay in most instances
*Even in a patient with no neuro deficit but with a high spine lesion
*Postop edema of teh cord may impair pulmonary reserve
*If you remove the ETT too early, residual anesthetic effects may depress respirations
**Remember: Reintubation may be extremely difficult and dangerous**
*C7 or higher be careful about extubation!! |
|
|
Term
| What is the purpose of spinal cord monitoring? |
|
Definition
| *To detect compromised cord intraoperatively to improve neurologic outcome |
|
|
Term
| What induction drugs are ok and which should be avoided in SCI patient? |
|
Definition
*Ketamine good if no head injury
*Etomidate, Versed ok
*Use Thiopental with caution, decrease dose
*Avoid Succinylcholine
**Give drugs slowly and wait for expected response |
|
|
Term
| What intraoperative drugs should be used with caution, which are helpful in the SCI patient? |
|
Definition
*May not tolerate inhalation agents
*Narcotics and N2O good
*NDMRs are useful |
|
|
Term
| How may the SCI patient respond to NDMRs? |
|
Definition
*May appear resistant to them d/t increase of receptors
*May have skeletal muscle spacticity
*Will help with ventilation since spontaneous ventilation may be inadequate. |
|
|
Term
| What predisposes SCI patients to hypothermia/poikilothermia? |
|
Definition
*Chronic vasodilation and loss of normal reflex cutaneous vasoconstriction.
*Especially in patients with injury above T1 |
|
|
Term
| What methods can be used for spinal cord monitoring? |
|
Definition
*SSEP's
*Wakeup test
*MEP's |
|
|
Term
| What should the anesthetist keep in mind when only monitoring SSEPs for SCI patient? |
|
Definition
| *That only sensory pathways are being monitored and that there is potential for motor damage. |
|
|
Term
| What are some intraop factors that can affect spinal cord monitoring? |
|
Definition
*Hypothermia
*ischemia
*Hypo/hypercarbia
*Hypotension
*HTN
*Anesthetics |
|
|
Term
| What are the guidelines for volatile anesthetic use for intraop spinal cord monitoring? |
|
Definition
| *Volatile agents safe to use 0.75% MAC with 50% N20 ok. N20 frowned upon by techs. |
|
|
Term
| What is the preferred mode of anesthesia for spinal cord monitoring? |
|
Definition
*IV agents preferred, continuous infusions rather than boluses
*NDMR are helpful but might use EMGs also |
|
|
Term
| How should intraoperative hemodynamic changes be treated in the SCI patient with spinal cord monitoring? |
|
Definition
| *Treat with vasoactive drugs not anesthetic agents if adequate depth of anesthesia has been achieved. |
|
|
Term
| What should happen if SSEP recordings deteriorate intraop? |
|
Definition
*Surgeon will remove wires, fixation rods, etc
*Anesthesia will correct any abnormalities
*DO A WAKE UP TEST
*Abandon the operation |
|
|
Term
| What is the gold standard of intraop spinal cord monitoring? |
|
Definition
|
|
Term
| What should be done preop if a wake up test is to be performed? |
|
Definition
*Patient teaching:
-Tell the patient they will be awakened; will be asked to move their hands and feet; WILL NOT BE PAINFUL; once they move, they go back to sleep. |
|
|
Term
| How many minutes are ideal to know before a wake up test? |
|
Definition
|
|
Term
| How should the anesthetist alter their anesthetic management once notified that a wake up test is to be performed? |
|
Definition
*No more boluses of narcotics/NDMRs
*Turn off narcotic infusion 20 minutes before wakeup
*D/C volatile agent after 20 minutes has elapsed
*Reverse with half of calculated reversal dose
*When spontaneous respiration returns, d/c N2O
*Patient usually responds w/in 5 minutes
*if no response titrate narcan or more reversal
*after patient moves, anesthetize them |
|
|
Term
| What are some hazards that can occur with the wake up test in a SCI patient? |
|
Definition
*Extubation
*VAE
*Dislocate rods or wires
*IVs or lines dislodged |
|
|
Term
| In what group are wake up tests usually not performed? |
|
Definition
*Young children
*Mentally challenged |
|
|
