APP I Exam 2

Accumulation of cerebral spinal fluid within the ventricles of the brain

Ventriculomegaly

Accumulation of CSF and increased ICP is called

Hydrocephalus

Congenital form of this disease is mostly due to impaired circulation or flow obstruction from structural abnormalities; stenosis of aqueduct of Sylvius, tumors, malformations, and trauma-related effects.

Hydrocephalus

Most common congential genetic cause in hydrocephalus is X-linked and due to what structural issue

Aquaductal stenosis

Toxoplasmosis, Rubella, Cytomegalovirus infection, herpes simplex, and symphillis are examples of intrauterine __________ infections.

TORCHES

Alterations to production and reabsorption of CSF result in what type of hydrocephalus?

Communicating Hydrocephalus

Obstruction in the CSF pathway results in what type of hydrocephalus

Non-communicating Hydrocephalus

Hydrocephalus is ______________.

a) subacute

b) chronic

c) acute

d) all of the above

D

Due to compression of the midbrain an infant with hydrocephalus (increased ICP) may display ___________, which is an impaired ability to gaze upward.

Sunsetting eyes

With increased ICP, infants progress from initial ________ progressing to ________.

Irritability then progressive to lethargy

Surgical interventions for hydrocephalus include?

VP shunt or

Parenchymal (brain tissue) compression from hydrocephalus exhibit what signs and symptoms?

1) CN III & VI palsy

2) Papilledema

3) Bradycardia (compression of medullary centers)

4) HTN

5) Disturbances in respiratory pattern

6) Endocrine abnormalities

7) Impaired fluid and electrolyte balance

8) Headache, nausea, vomiting (irritation of meninges and intracranial vessels)

Term that describes a group of non-progressive disorders characterized by kinetic and postural abnormalities. Demonstrating motor dysfunction due to abnormalities that occurred during brain development

Cerebral Palsy

Static encephalopathy is synonomous with what condition

Cerebral Palsy

Additional disturbances commonly present with cerebral palsy include:

1) Sensation

2) Perception

3) Cognition

4) Behavior

5) Electrical Activity (Seizures)

Cerebral palsy can be categorized based on resting tone, extremities involved, and presence of kinetic abnormalities. What are they?

1) Spastic monoplegia

2) Spastic diplegia

3) Spastic triplegia

4) Spastic quadriplegia

5) Spastic hemiplegia

6) Dyskinesia

Seen in cerebral palsy, demonstrates baseline spasticity with impaired motor function of all four extremities?

Spastic quadriplegia

Spastic resting tone with motor dysfunction of either upper or lower extremities.

Spastic diplegia

Cerebral palsy associated with abnormal movements. These movements may be athetoid, choreatheoid, or dystonic.

dyskinesia

Slow, writhing movements are known as _____________.

athetoid

Jerky, rhythmic movements alternating with athetosis is coined as ____________.

Choreoathetoid

_____________ Cerebral palsy is the most common type. Initially manifested by hypotonia (6 months - 1 year) and later changes into this type.

Spastic

Common problems associated with cerebral palsy include:

1) Gross motor delays

2) Intelligence impairment

3) Recurrent aspiration pneumonia (GERD) (RT poor pharyngeal muscle tone)

4) Spasticity

5) Seizure Disorder

6) Scoliosis d/t poor truncal tone

Loss of sensations d/t Rhizotomy include:

1) pain

2) temperature

3) crude touch

4) tickle

5) itch

Posterior left-sided Rhizotomy would result in loss of sensations carried in the _____________ system on the ____________ side.

anterolateral; contralateral

What sensations would be lost after a rhizotomy by the dorsal lemniscal system (dorsal root) on the ipsilateral side.

1) fine touch

2) pressure

3) proprioception

Sensations after a rhizotomy would be lost ___________ the level of the rhizotomy.

at and below

Anterior rhizotomies, severing of anterior or motor spinal nerve roots, are performed to relieve what?

spastic disorders

A 2 year-old with cerebral palsy is scheduled to undergo general anesthesia for iliopsoas release. Which of the following would be the most appropriate technique for inducing general anesthesia in this patient?

Prolonged emergence from general anesthesia and neuromuscular blockade drugs are common.

Caution with NMB- children with CP have low pharyngeal tone and high incidence of GERD decreasing threshold to protect against aspiration during ETT placement—NMB may further decrease threshold not to mention delay emergence later.

Lower MAC concentrations should be administered to increase emergence.

Why is it difficult to position a cerebral palsy patient and what is a major consideration

1) Contractures limit joint mobility

2) Be mindful of pressure points

Which anesthetic agents must be used with caution for they may lower the seizure threshold? Possible drug-drug interactions can occur if what type of drug is used?

Etomidate and Ketamine; cytochrome P-450 (barbiturate)

Approximately 70% of adults experience this condition and is the most common cause of back pain.

intervertebral disk disease

If nucleus pulposus protrudes through annulus fibrosis this can lead to nerve root and spinal cord ______________.

compression

Compression of a single nerve root in the intervertebral disk, patients may experience

Single dermatomal distribution

or

localized muscle weakness.

What can lead to complex sensory, motor, and autonomic symptoms at and below the level of insult

Cord compression

In this type of intervertebral disk disease lateral protrusion can be secondary to trauma or can occur spontaneously. Symptoms are aggrevated by coughing. May be due to osteophytes that compress nerve roots in the intervertebral formina.

Cervical disk disease

In cervical disk disease lateral protrussion usually occurs at what level?

C5-C6

or

C6-C7

Initial treatment of cervical disk protrussion usually is conservative and includes rest, pain control, and possible epidural steroid injections. If symptoms persist or significant motor involvement is present then what might be necessary?

surgical decompression

Primary concern in perioperative care of patients with cervical spine disease is?

Airway management

Surgical anterior approach in cervical spine procedures retract the airway structures to attain access to the cervical spine this may result in injury to what nerve. Injury may be from direct compression or traction.

Ipsilateral recurrent laryngeal nerve

If the ipsilateral recurrent laryngeal nerve injury occurs what are some possible problems that might manifest?

hoarseness, stridor, or frank airway compromise (post-op)

Compression of laryngeal nerve fibers may be caused by what?

1) ETT (rigidly held in place by cuff and taped at mouth)

2) Directly from inflated cuff

What is common practice to prevent compression from ETT cuff following airway retraction during surgery?

Let air out of cuff and then reinflate to point at which no air leak is noted.

This type of intervertebral disk disease produces low back pain and radiates down the posterior and lateral thighs and calves (sciatica). Trauma commonly associated w/ sudden onset. Aggravated by coughing or stretching of sciatic nerve.

Lumbar disk disease

If neurological symptoms persist despite conservative treatments of bed rest, analgesics, and centrally acting "muscle relaxants" what procedures may be considered to decompress the affected nerve roots?

laminectomy or microdiskectomy

Alternatives to surgical interventions in patients with lumbar disk disease include ___________. These decrease inflammation and edema around nerve roots and may provide temporary relief of signs and symptoms however provide no significant functional benefit and does not decrease need for surgery.

Epidural steroids

Supression of hypothalamic-pituitary adrenal axis is possible for patients treated with oral steroids for what condition.

lumbar disk disease

Congential anomalies and degenerative diseases of the vertebral column include:

1) Spina bifida

2) Spondylosis

3) Spondylolisthesis

Incomplete formation of a single lamina in lumbosacral spine with or without other abnoramilies. Present in 20% of individuals. Usually no symptoms present and discovery often incidential.

Spinal bifida occulta

Spinal anesthesia increases risk of spinal cord injury in patients with spinal bifida occulta? True/False

False

(No associated abnormailies)

Characterized by bony defect involving more than one lamina. Many associated with tethered spinal cord and may cause progressive neurological symptoms. Up to 50% with tethered cord have cutaneous manifestations over anomaly like tufts of hair, hyperpigemented areas, cutaneous lipomas, and skin dimples.

Occult spinal dysraphism

Spinal anesthesia does not increase the risk of cord injury in patients with occult spinal dysraphism? True or False

False

(Associated abnormalities present)

Acquired disorder leading to osteophyte formation and degenerative disk disease. Used synonymously with spinal stenosis. The spinal canal narrows and compresses spinal cord by transverse osteophaytes or nerve root by bony spurs in intervertebral foramina. Cord dysfuction may reflect ischemia caused by bony compression of spinal arteries.

Spondylosis

Neck and radicular pain in arms and shoulders with sensory loss and skeletal muscle wasting are present with this disorder. Signs may appear in legs later producing unsteady gait.

Cervical spondylosis

This condition leads to radicular pain and muscle wasting in the lower extremities.

Lumbar spondylosis

Anterior subluxation of one vertebral body on another. Radicular signs and symptoms involve nerve root inferior to pedicle of anteriorly subluxed vertebra. Surgery is performed only if myelopathy, radiculopathy, or neurogenic claudication are present.

Spondylolisthesis

Two types of spinal cord tumors

1) Intramedullary

2) Extramedullary

Spinal cord tumor located within the spinal cord. Account for approximately 10% of tumors affecting spinal column. Vast majority are gliomas and ependymomas.

Intramedullary tumor

Spinal cord tumor located either intradural or extradural.

Extramedullary tumor

Intradural extramedullary spinal cord tumors are typicallly what type?

neurofibromas or meningiomas

Extradural extramedullary metastatic lesions usually originate from?

lung, breast, prostate cancer, or myeloma

Reflex response appearing following spinal shock and in association with return of spinal cord reflexes. Condition can be life-threatening.

Autonomic hyperreflexia

What can trigger the initiation of autonomic hyperreflexia?

Cutaneous or visceral stimulation below the level of injury due to loss of supraspinal inhibitory influence or noxious stimuli. Dermatomes below injury are not inhibited by feedback from higher center.

Reflex response seen in autonomic hyperreflexia results from stimulation of what?

Sympathetic preganglionic neurons arising in anterolateral column of spinal cord below the level of injury.

In autonomic hyperreflexia, cord lesion outflow is isolated from inhibitory impulses from above so generalized ______________ occurs below injury level.

vasoconstriction

Hallmark signs of autonomic hyperreflexia include?

Hypertension

and

bradycardia (carotid sinus baroreceptor stimulation from HTN)

Hypertension in autonomic hyperreflexia can cause what symptoms to occur?

1) Headache

2) Blurred vision

3) Possible cerebral, retinal, or subarachnoid hemorrhage

4) LOC

5) Seizures

6) Cardiac dysrhythmias

7) Pulmonary edema (r/t acute LV failure d/t increased afterload)

Approximately 85% occurrence of autonomic hyperreflexia with spinal cord lesions above?

T5 and T6

What is the most important goal in the autonomic hyperreflexia?

Prevention

What type of anesthesia is preferred in patients with autonomic hyperreflexia?

Spinal anesthesia

What is a possible treatment when autonomic hyperreflexia is encountered?

1)Remove the caustic stimuli

2) Deepening anesthesia and administration of direct acting vasodilator

Greater, lesser, and least splanchnic nerves receive innervation from T5 -T9, T10 & T11, and T12. Loss of input from higher centers to these nerves and to sympathetic chain will place larger regions of the body at risk of what?

Exaggerated autonomic reflexes

Lumbar lesions will leave the SNS intact? True or False

True

Lesions above T5 and T6 will completely isolate the ___________ nerves from higher centers of control.

splanchnic

In this condition, vasoconstriction below the injury and vasodilation above the injury occurs due to massive sympathetic discharge and causes intense vasoconstriction below the level of cord damage. Blood pressure increases and the baroreceptor reflex is activated, which leads to reflex vasodilation above the level of damage (bradycardia is reflexly mediated).

Autonomic hyperreflexia

Sequale of chronic spinal cord injury includes:

1) Impaired alveolar ventilation

2) Cardiovascular instability manifested as autonomic hyperreflexia

3) Chronic pulmonary and urinary tract infections

4) Anemia

5) Altered thermoregulation

Spinal cord injuries that occur more _________ tend to have more significant systemic effects.

a) caudal

b) distal

c) lateral

d) rostral

d

Prolonged immobility in chronic spinal cord injury leads to:

osteoporosis, skeleteal muscle atrophy, and decubitus ulcer formation. Also predisposed to DVT

Pain in individuals with chronic spinal cord injury include:

Nerve root pain (at or near level of injury); visceral pain (bladder or bowel distention); phantom body pain in areas of complete sensory loss

This drug increases the inhibitory effects of y-aminobutyric acid (GABA) is useful in spinal cord injuries to treat overactivity of SNS and involuntary skeletal muscle spasms.

Baclofen

If baclofen is abruptly withdrawn what undesired reaction can occur?

Seizures

What other medications can be given to facilitate the inhibitory effects of y-aminobutyric acid?

Benzodiazapines

If spasticity is refractory to medications in chronic spinal cord injury what surgical procedures may be indicated? Prior to surgical intervention what other methods may be attempted?

Rhizotomy or myelotomy; spinal cord stimulator or subarachnoid baclofen pump

Injury above the 5th cervical vertebra may result in what?

denervation of diaphragm, apnea

In spinal cord injury, coughing and clearing secretions are often impaired due to decreased expiratory reserve volumes related to denervation of what muscles?

Intercostal and abdominal muscles

What happens to vital capacity in individuals with an acute spinal cord injury?

Decreased

In anesthesia management of a patient with a chronic spinal cord injury what NDMR should be avoided? Why?

Succinylcholine; it is likely to increase K+ especially in the first 6 months following injury. Should be avoided if injury is > 24hrs.

What are some potential risks of anesthesia in patients with chronic spinal cord injury?

Altered hemodynamics (esp. with high cervical and thoracic lesions; increased risk of pulmonary embolism d/t immobility; autonomic hyperreflexia

Post-operative monitoring of patients with spinal cord injuries should be aimed at?

Airway management. Hypoventilation and impaired cough with secretion accumulation may occur.

Should you discontinue baclofen and benzodiazepines preoperatively in patients with chronic spinal cord injuries?

No, may potentiate withdrawal (seizures)

This type of injury acutely produces flaccid paralysis with loss of sensation below the level of injury. Classified by motor and sensory impairments.

Acute spinal cord injury

What part of the spinal cord produces the most severe derangements when injured?

Cervical spinal cord

The more _________ the spinal cord injury the less severe physiologic derangements occur.

a) rostral

b) superior

c) caudal

d) anterior

C

Hypotension and bradycardia is common in cervical spinal cord injuries and are influenced by losses in what?

- SNS activity and decreased SVR

- Bradycardia d/t loss of T1-T4 sympathetic innervation to heart

Cervical and upper thoracic injuries are major causes of morbidity and mortality due to?

1) Alveolar hypoventilation

2) Inability to clear bronchial secretions

In what level of spinal cord injury are respiratory muscles affected?

Lumbar and low thoracic injuries

During spinal shock what are constant threats?

1) Aspiration

2) Pneumonia

3) Pulmonary embolism

Tx acute cervical spine injury should include immediate immobilization of the neck to limit?

Neck flexion and extension

With direct laryngoscopy c-spine movement is likely in the _______________ area and increases risk of spinal cord injury even with in-line stablization. Greatest risk is encountered with neck motion that elongates cord. Fiberoptic laryngoscopy alternative.

Occipito-atlanto-axial area

Occurs when the spinal cord is suddenly transected. All functions below the transection, including cord reflexes, are depressed to point of stupor.

Spinal shock