BARASH HOUR: NEURO AXIAL BLOCK

MAY 6, 2020

1.) All of the following are true regarding the anatomy of the epidural space, except?
a.) The epidural space lies within the vertebral canal but outside the dural sac.
b.) Laterally, the epidural space extends to the pedicles where it communicates with the paravertebral space via the
intervertebral foramina.
c.) The remainder of the space consists of discontinuous, fat –filled pockets that open readily upon injection of air or
liquid.
d.) The cervical level contains no epidural fat.
e.) None of the above

2.) All of the following are true regarding the anatomy of the spinal cord, except?
a.) The vertebral column grows faster than the spinal cord and at birth the cord usually ends at the level of the second
lumbar vertebra.
b.) In adults the cord most often ends at around L1.
c.) The sympathetic nervous system arises from the intermediolateral grey matter of the T1 to L2 spinal cord segments
d.) The spinal nerves and their corresponding dermatomes are named for the foramina through which they exit the
vertebral column. In the cervical region, spinal nerves are named after the lower vertebrae (i.e., C5 exits between C4 and
C5). Elsewhere, the roots are named by the upper vertebrae (L2 emerges between L2 and L3)
e.) None of the above

3.) The following are the two most important factor that determines the spread and duration of subarachnoid
anesthesia:
a.) Baricity and Dose
b.) Dose and Density
c.) Baricity and Density
d.) Baricity and Volume
e.) None of the above

4.) All of the following patient variables does not affect the spread of the subarachnoid anesthesia, except?
a.) Height
b.) Weight
c.) BMI
d.) Vertebral column length
e.) None of the above

5.) True regarding adjuvants used in subarachnoid anesthesia , except?

a.) Lipid soluble opioids (fentanyl or sufentanil) can enhance intraoperative anesthesia and provide a few hours of
postoperative analgesia
b.) Epinephrine or phenylephrine may prolong the intrathecal block by inhibiting absorption of intrathecal local
anesthetics or by acting directly on spinal cord a-receptors.
c.) The α2-agonists clonidine and dexmedetomidine can only prolong the duration of subarachnoid anesthesia .
d.) None of the above

6.) In the spread of block in Epidural Anesthesia, lumbar injection spreads more caudad than cephalad whereas
thoracic blocks spreads more cephalad than cauda.
True or False
7.) False regarding the onset and duration of epidural anesthesia:
a.) Lidocaine produces relatively more motor block than sensory block.
b.) Sensory block usually outlasts motor block with mepivacaine, ropivacaine, and bupivacaine
c.) Bupivacaine and ropivacaine have the fastest onset and longest duration of action.
d.) Some sign of sensory block should be detectable at the dermatomal level of injection within 5 to 10 minutes. The full
extent of block usually develops within 20 to 30 minutes. Differences in onset time between local anesthetics are small
and rarely clinically significant.
e.) None of the above.

8.) The Bezold-Jarisch Reflex happens when there is a decrease in cardiac filling pressures resulting in vagally
mediated bradycardia, which usually involves which spinal level?
a.) T3-T6
b.) T2-T4
c.) T1-T3
d.) T1 – T4
e. None of the above

9.) True regarding the vasopressors that can be used during hypotension associated with neuroaxial anesthesia,
except?
a.) Phenylephrine increases systemic vascular resistance and decreases cardiac output.
b.) Ephedrine raises BP primarily by increasing stroke volume and cardiac output.
c.) Norepinephrine maintains heart rate and cardiac output.
d.) Vasopressin may be a treatment of last resort in severe hypovolemic hypotension or for patients taking medications
that impair the renin–angiotensin system.
e.) All are true.
10.) False regarding PDPH, except ?
a.) Most PDPH develop after 24-48 hours
b.) It resolves mostly after 3-5 days.
c.) The exact mechanism is still unknown.
d.) Severe PDPH can also cause neck, shoulder and back pain which may be relieved by lying down.
e.) None of the above.

ANSWERS
1.) All of the following are true regarding the anatomy of the epidural space, except?
a.) The epidural space lies within the vertebral canal but outside the dural sac.
b.) Laterally, the epidural space extends to the pedicles where it communicates with the paravertebral space via the
intervertebral foramina.
c.) The remainder of the space consists of discontinuous, fat –filled pockets that open readily upon injection of air or
liquid.
d.) The cervical level contains no epidural fat.
e.) None of the above
1.Answer: E 1368
The epidural space lies within the vertebral canal but outside the dural sac. It extends from the foramen magnum to
the sacral hiatus. The epidural space is bound anteriorly by the posterior longitudinal ligament and posteriorly by the
lamina and ligamentum flavum. Laterally the epidural space extends to the pedicles where it communicates with the
paravertebral space via the intervertebral foramina. The epidural space is often absent because the dural intermittently
abuts the bony and ligamentous structures of the spine. The remainder of the space consists of discontinuous, fat-filled
pockets that open readily upon injection of air or liquid.The cervical level contains no epidural fat. In the lumbar region,
fat in the anterior and posterior aspects of the epidural space forms multiple, metameric, discrete collections This fat
may play an important role in the kinetics of epidural medications.

A P

2.) All of the following are true regarding the anatomy of the spinal cord, except?
a.) The vertebral column grows faster than the spinal cord and at birth the cord usually ends at the level of the second
lumbar vertebra.
b.) In adults the cord most often ends at around L1.
c.) The sympathetic nervous system arises from the intermediolateral grey matter of the T1 to L2 spinal cord segments
d.) The spinal nerves and their corresponding dermatomes are named for the foramina through which they exit the
vertebral column. In the cervical region, spinal nerves are named after the lower vertebrae (i.e., C5 exits between C4 and
C5). Elsewhere, the roots are named by the upper vertebrae (L2 emerges between L2 and L3)
e.) None of the above

Answer: A.
In the first trimester fetus, the spinal cord extends to the end of the sacrum. The vertebral column grows faster than the
spinal cord and at birth the cord usually ends at the level of the third lumbar vertebra. In adults, the cord most often ends
at around L1. However, there is considerable interindividual variation. The cord ends at T12 in some but may extend to
L3 in up to 10% of adults. There are 31 pairs of spinal nerves, each with an anterior motor root and a posterior sensory
root. These nerve roots arise from individual spinal cord segments. Each posterior sensory root innervates a specific
dermatome (Fig. 35-9). The sympathetic nervous system arises from the intermediolateral grey matter of the T1 to L2
spinal cord segments. This grey matter contains the cell bodies of the preganglionic sympathetic neurons, which travel
with the corresponding spinal nerve through the intervertebral foramen. They then diverge and join the sympathetic
chain ganglia. The spinal nerves and their corresponding dermatomes are named for the foramina through which they
exit the vertebral column. In the cervical region, spinal nerves are named after the lower vertebrae (i.e., C5 exits between
C4 and C5). Elsewhere, the roots are named by the upper vertebrae (L2 emerges between L2 and L3).

3.) The following are the two most important factor that determines the spread and duration of subarachnoid
anesthesia:
a.) Baricity and Dose
b.) Dose and Density
c.) Baricity and Density
d.) Baricity and Volume
e.) None of the above

Answer: B 1386
Density and dose are the two most important factors that determine the spread and duration of subarachnoid anesthesia.
Density is the ratio of the mass of a substance to its volume. Baricity is the ratio of two densities; here, the density of
CSF and that of the injected local anesthetic. Currently used local anesthetics are made hyperbaric by mixing with
dextrose. Plain local anesthetic solutions are isobaric or slightly hypobaric. Table 35-2 offers suggestions for dose and
baricity when performing subarachnoid anesthesia for various surgeries

4.) All of the following patient variables does not affect the spread of the subarachnoid anesthesia, except?
a.) Height
b.) Weight
c.) BMI
d.) Vertebral column length
e.) None of the above

Answer: E. None of the above pg. 1386

Height, weight, body mass index, and vertebral column length have no clinically significant effect on the spread of
subarachnoid anesthesia. Increasing age is associated with slower onset and longer duration but no change in extent of
subarachnoid block.Both female gender and pregnancy increase motor block produced by intrathecal isobaric
bupivacaine.One small study reported that CSF volume correlated with the spread of subarachnoid anesthesia.Pregnant
patients will develop higher levels of sensory block than nonpregnant patients when given the same dose of intrathecal
local anesthetic. This enhanced sensitivity disappears shortly after delivery. In nonpregnant adults, increasing abdominal
girth correlates with increasing extent of sensory block after intrathecal injection of isobaric bupivacaine. Increases in
intra-abdominal and consequently epidural space pressure associated with both pregnancy and obesity may enhance
sensory spread by decreasing lumbar CSF volume.
5.) True regarding adjuvants used in subarachnoid anesthesia , except?
a.) Lipid soluble opioids (fentanyl or sufentanil) can enhance intraoperative anesthesia and provide a few hours of
postoperative analgesia
b.) Epinephrine or phenylephrine may prolong the intrathecal block by inhibiting absorption of intrathecal local
anesthetics or by acting directly on spinal cord a-receptors.
c.) The α2-agonists clonidine and dexmedetomidine can only prolong the duration of subarachnoid anesthesia .
d.) None of the above

Answer: C. 1388
Many drugs have been studied for their ability to prolong or improve subarachnoid anesthesia. Vasoconstrictors,
such as epinephrine or phenylephrine may prolong the intrathecal block by inhibiting absorption of intrathecal local
anesthetics or by acting directly on spinal cord α-receptors. Vasoconstrictors prolong the duration of intrathecal
tetracaine. They have no clinically significant effects on the duration of intrathecal lidocaine or bupivacaine. The α2-
agonists clonidine and dexmedetomidine prolong the duration of subarachnoid anesthesia and analgesia. Associated
bradycardia may require atropine. Larger doses of intrathecal clonidine also can cause hypotension and sedation.Lipid
soluble opioids (fentanyl or sufentanil) can enhance intraoperative anesthesia and provide a few hours of postoperative
analgesia. Small doses of fentanyl (5 to 10 μg) are as effective as larger doses and may produce less itching. Intrathecal
morphine can provide prolonged (12 to 24 hours) postoperative analgesia but side effects, including itching and nausea
and vomiting, are common and challenging to treat. Rarely, intrathecal morphine can produce delayed respiratory
depression.
6.) In the spread of block in Epidural Anesthesia, lumbar injection spreads more caudad than cephalad whereas
thoracic blocks spreads more cephalad than caudad.
True or False
Answer: False 1388
The extent of epidural block is proportional to the dose of local anesthetic injected. Mass of drug, not the volume
injected, mostly determines the extent of sensory block. However, the relationship is not linear. A smaller dose produces
a relatively greater spread (dermatomes/dose) than a larger dose. Site of injection has a major impact on the spread of
epidural block. Small doses of local anesthetic (5 to 10 mL) will produce a band of block around the injection site. Lumbar
injection spreads more cephalad than caudad, whereas upper thoracic drug blocks more dermatomes below than above
the injection site.

7.) False regarding the onset and duration of epidural anesthesia:

a.) Lidocaine produces relatively more motor block than sensory block.
b.) Sensory block usually outlasts motor block with mepivacaine, ropivacaine, and bupivacaine
c.) Bupivacaine and ropivacaine have the fastest onset and longest duration of action.
d.) Some sign of sensory block should be detectable at the dermatomal level of injection within 5 to 10 minutes. The full
extent of block usually develops within 20 to 30 minutes. Differences in onset time between local anesthetics are small
and rarely clinically significant.
e.) None of the above.

Answer: C. 1389
Onset and duration of epidural anesthesia depend largely on the choice of anesthetic (Table 35-4 ). Some sign of
sensory block should be detectable at the dermatomal level of injection within 5 to 10 minutes. The full extent of block
usually develops within 20 to 30 minutes. Differences in onset time between local anesthetics are small and rarely
clinically significant. 2-Chloroprocaine has the shortest duration followed by lidocaine and mepivacaine. The more potent
drugs, bupivacaine and ropivacaine have the slowest onset but the longest durations. Lidocaine produces relatively more
motor block than sensory block. Postoperative patients may have pain before the motor block has completely regressed.
Sensory block usually outlasts motor block with mepivacaine, ropivacaine, and bupivacaine.
8.) The Bezold-Jarisch Reflex happens when there is a decrease in cardiac filling pressures resulting in vagally
mediated bradycardia, which usually involves the cardiac accelarator fibers that originates from ?
a.) T3-T6
b.) T2-T4
c.) T1-T3
d.) T1 – T4
e. None of the above

Answer: D. 1393
Heart rate may increase, decrease, or remain unchanged. Thoracic levels of anesthesia can produce cardiac
sympathetic block (T1–T4). The resultant vagal predominance can decrease heart rate. A decrease in cardiac filling
pressures may also stimulate vagally mediated bradycardia via the Bezold– Jarisch reflex. This bradycardia is usually
benign, but can occasionally be profound. Cardiac arrest has been reported.

9.) True regarding the vasopressors that can be used during hypotension associated with neuroaxial anesthesia,
except?
a.) Phenylephrine increases systemic vascular resistance and decreases cardiac output.
b.) Ephedrine raises BP primarily by increasing stroke volume and cardiac output.
c.) Norepinephrine maintains heart rate and cardiac output.
d.) Vasopressin may be a treatment of last resort in severe hypovolemic hypotension or for patients taking medications
that impair the renin–angiotensin system.
e.) All are true.
Answer: E. 1393
Ephedrine and phenylephrine are the most commonly used vasopressors for hypotension associated with neuraxial
anesthesia. In parturients during cesarean section, ephedrine raises blood pressure primarily by increasing stroke
volume and cardiac output. Phenylephrine increases systemic vascular resistance and decreases cardiac output
.However, since cardiac output increases with induction of subarachnoid anesthesia, it usually remains above baseline
even after phenylephrine. Changes in heart rate parallel the changes in cardiac output. Ephedrine usually increases heart
rate, whereas phenylephrine causes a reflex slowing. Norepinephrine also can be used to prevent or treat maternal
hypotension associated with subarachnoid anesthesia. Unlike phenylephrine, norepinephrine maintains heart rate and
cardiac output.The clinical implications of these findings remain to be seen. Vasopressin may be a treatment of last resort
in severe hypovolemic hypotension or for patients taking medications that impair the renin–angiotensin system.
10.) False regarding PDPH, except?
a.) Most PDPH develop after 24-48 hours
b.) It resolves mostly after 3-5 days.
c.) The exact mechanism is still unknown.
d.) Severe PDPH can also cause neck, shoulder and back pain which may be relieved by lying down.
e.) None of the above.

Answer C. 1396
Most PDPHs develop 24 to 72 hours after dural puncture. Patients usually complain of frontal and occipital pain that
is made worse by standing and relieved by lying flat. Severe PDPH can also cause neck, shoulder, or back pain, which may
not be relieved by lying down. Visual disturbances, vertigo, and cranial nerve palsies can occur. Rarely, cortical vein
thrombosis or subdural hematoma occur. Most PDPHs resolve within 5 to 7 days or after therapeutic epidural blood
patch. However, two recent case series report that, compared to matched controls, parturients who suffered an
accidental dural puncture had an increased incidence of chronic headache at 6 weeks (35% vs. 2%) and 24 months (28%
vs. 5%). The exact mechanism of PDPH is unknown. Loss of CSF through the iatrogenic dural tear seems to be the inciting
factor. When the patient is upright, intracerebral CSF volume decreases. This change may cause the brain to sag toward
the foramen magnum, stretching the pain-sensitive meningeal vascular covering. Alternatively, the diminished CSF
volume may incite a compensatory increase in cerebral blood volume and produce a vascular headache.