This document discusses the anatomy relevant to central neuraxial blockade. It describes the structure of the vertebral column, spinal cord, meninges, epidural space, and related landmarks. Key points include the levels the spinal cord ends in infants versus adults, differences in pediatric anatomy and physiology that impact central blockade, and how surface landmarks can help identify vertebral levels for safe epidural injection.
The transversus abdominis plane, more commonly referred to as the TAP block,
Places local anesthetic in the lateral abdominal wall in a plane between the internal oblique and the transversus abdominis muscles.
Here, the local anesthetic block can block many of the abdominal nerves as they pass to the abdominal structures.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
This presentation was delivered during a webinar held by the association of anaesthetists in association with RA-UK entitled "New Blocks - Friend or Foe?".
This took place on 19th October 2021.
In this short presentation - Dr Pawa covers: a brief overview of the history of Paravertebral blocks; how he got introduced to them; some updates on our understanding on the anatomy; and whether they still have a role in modern anaesthetic practice.
THIS IS A CASE REPORT WHERE SCIATIC BLOCK WAS GIVEN FOR A CARDIAC PATIENT REQURING TIBIA SURGERY.
TITLE OF FIRST SLIDE IS GIVEN BY MISTAKE AS LAPAROSCOPIC SURGERY,ACTUALLY IT IS LOWER LIMB SURGERY.
The transversus abdominis plane, more commonly referred to as the TAP block,
Places local anesthetic in the lateral abdominal wall in a plane between the internal oblique and the transversus abdominis muscles.
Here, the local anesthetic block can block many of the abdominal nerves as they pass to the abdominal structures.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
This presentation was delivered during a webinar held by the association of anaesthetists in association with RA-UK entitled "New Blocks - Friend or Foe?".
This took place on 19th October 2021.
In this short presentation - Dr Pawa covers: a brief overview of the history of Paravertebral blocks; how he got introduced to them; some updates on our understanding on the anatomy; and whether they still have a role in modern anaesthetic practice.
THIS IS A CASE REPORT WHERE SCIATIC BLOCK WAS GIVEN FOR A CARDIAC PATIENT REQURING TIBIA SURGERY.
TITLE OF FIRST SLIDE IS GIVEN BY MISTAKE AS LAPAROSCOPIC SURGERY,ACTUALLY IT IS LOWER LIMB SURGERY.
A primer on lower extremity regional anesthesia, including instructions for sciatic, parasacral, lumbar plexus, femoral, saphenous, popliteal, lateral femoral cutaneous, obturator, and ankle blocks
Spinal cord lecture containing notes on spinal cord composition, different nuclei, ascending and descending tracts ,functions of different tracts, first order, 2nd order and 3rd order neurons, reflex arc and common pathologies
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
2. Anatomy
• The key to safe and effective administration of an CNB blockade begins with a
thorough understanding of the anatomy of the vertebral column, ligaments, and
blood supply, the epidural space, spinal canal, and associated structure.
Vertebral Column-The vertebral column consists of 7 cervical, 12 thoracic, and 5
lumbar vertebrae. At the caudal end, the 5 sacral vertebrae are fused to form the
sacrum, and the 4 coccygeal vertebrae are fused to form the coccyx . The primary
functions of the vertebral column are to maintain erect posture, to encase and
protect the spinal cord, and to provide attachment sites for the muscles
responsible for movements of the head and trunk. The normal spinal column is
straight when viewed dorsally or ventrally.When viewed from the side, there are
two ventrally convex curvatures in the cervical and lumbar regions, giving the spinal
column the appearance of a double C.
Structure of Vertebrae-Each vertebra is composed of a vertebral body and a bony
arch. The arch consists of two anterior pedicles and two posterior laminae. The
transverse processes are located at the junction of the pedicles and lamina, and the
spinous process is located at the junction of the laminae. The spinous processes
vary in their angulation in the cervical, thoracic, and lumbar regions. The spinous
processes are almost horizontal in the cervical, lower thoracic, and lumbar regions,
but become significantly more sharply angled in the midthoracic region. The
greatest degree of angulation is found between the T3 and T7 vertebrae, making
insertion of an epidural needle in the midline more difficult.
7. Joints of the Vertebral Column
• vertebrae articulate at the intervertebral and facet joints.
• intervertebral joints are located between adjacent vertebral bodies. They
maintain the strength of attachment between vertebrae.
• facet joints form between articular processes. The facet joints are heavily
innervated by the medial branch of the dorsal ramus of the spinal nerves.
This innervation serves to direct contraction of muscle that moves the
vertebral column
8. Ligaments
• Vertebrae are joined together by a series of ligaments and disks. vertebral
bodies are separated by the intervertebral disks. The ligament connecting them
runs from the base of the skull to the sacrum and is called the anterior
longitudinal ligament.
• posterior surface of the vertebral bodies is connected by the posterior
longitudinal ligament, which also forms the anterior wall of the vertebral canal.
The other ligaments of importance :
• Intertransverse ligaments: connects transverse processes
• Supraspinous ligaments: attaches to the apices of the spinous processes,
extends from sacrum to skull where it becomes the ligamentum nuchae
• Interspinous ligaments: connects spinous processes
• Ligamentum flavum: thick, elastic ligament, connects the laminae, composed
of a right and left ligament that joins in the middle forming an acute angle;
narrows toward the articular processes
11. Spinal Cord
• Runs through the vertebral canal
• Extends from foramen magnum to second
lumbar vertebra or lower end of 1st vertebrae
• Regions
– Cervical
– Thoracic
– Lumbar
– Sacral
– Coccygeal
• Gives rise to 31 pairs of spinal nerves
– All are mixed nerves
• Not uniform in diameter
– Cervical enlargement: supplies upper limbs
– Lumbar enlargement: supplies lower limbs
• Conus medullaris- tapered inferior end
– Ends between L1 and L2
• Cauda equina - origin of spinal nerves
extending inferiorly from conus medullaris.
13. spinal cord, which is continuous cephalad with the brainstem through the foramen
magnum and terminates distally in the conus medullaris. This distal
termination, because of differential growth rates between the bony vertebral canal
and the central nervous system (CNS), varies from L3 in infants to the lower border of
L1 in adults.
• Most of us develop the impression that the spinal nerve roots are uniform in size and
structure, but that there is large interindividual variability in nerve root size. These
differences may help explain the interpatient differences in neuraxial block quality
when equivalent techniques are used on seemingly similar patients.
• Another anatomic relationship may affect neuraxial blocks; although the dorsal
(sensory) roots are generally larger than the anterior (motor) roots, the dorsal roots
are often blocked more easily.
• This seeming paradox is explained by organization of the dorsal roots into component
bundles, which creates a much larger surface area on which the local anesthetics
act, thus explaining why larger sensory nerves are blocked more easily than smaller
motor nerves.
14. Meninges
• Connective tissue membranes
– Dura mater: outermost layer; continuous with
epineurium of the spinal nerves
– Arachnoid mater: thin and wispy
– Pia mater: bound tightly to surface
• Forms the filum terminale
– anchors spinal cord to coccyx
• Forms the denticulate ligaments that attach the
spinal cord to the dura
• Spaces
– Epidural: external to the dura
• Anesthestics injected here
• Fat-fill
– Subdural space: serous fluid
– Subarachnoid: between pia and arachnoid
• Filled with CSF
15. Spinal Cord and its membrane
.
• From the spinal cord extends a series of dorsal and ventral roots that converge to
form mixed spinal nerves. The mixed nerves contains motor, sensory, and in many
cases, autonomic fibers.
• There are eight cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal pairs of
spinal nerves.
• The roots inferior to the conus medullaris become the cauda equina before exiting
through the lumbar and sacral foramina. After the spinal nerves leave the spinal
canal through the intervertebral foramina, they divide into the anterior and
posterior primary rami.
• The posterior primary rami innervate the skin and muscles of the back. The
anterior rami supply the rest of the trunk and the limbs. Each spinal nerve supplies
a specific region of skin referred to as a dermatome .
• There is overlap between adjacent segmental nerves. Loss of a single spinal nerve
will produce an area of altered sensation, but won’t result in total sensory loss. For
instance, destruction of at least three consecutive spinal nerves is required to
produce a total sensory loss of the dermatome supplied by the middle nerve of the
three.
16.
17. Spinal Cord and its membrane
• pia mater is a highly vascular membrane that closely invests the spinal cord .
• arachnoid mater is a delicate, nonvascular membrane closely attached to the
outermost layer, the dura.
• Of these two membranes, it is thought that the arachnoid functions as the principal
barrier to drugs crossing in and out of the CSF and is estimated to account for 90%
of the resistance to drug migration.
• In the subarachnoid space -- CSF, spinal nerves, a trabecular network between the
two membranes, and blood vessels that supply the spinal cord and lateral
extensions of the pia mater and dentate ligaments, which provide lateral support
from the spinal cord to the dura mater .
• Although the spinal cord ends at the lower border of L1 in adults, the
subarachnoid space continues to S2.
18. Membrane......
• Third and outermost membrane in the spinal canal is a randomly organized
fibroelastic membrane, the dura mater (or theca).
• This layer is a direct extension of the cranial dura mater and extends as the
spinal dura mater from the foramen magnum to S2, where the filum terminale
(an extension of the pia mater beginning at the conus medullaris) blends with
the periosteum on the coccyx .
• There is a potential space between the dura mater and the arachnoid, the
subdural space, that contains only small amounts of serous fluid and thus
allows the dura and arachnoid to move over each other.
• This space is not intentionally used by anesthesiologists, although injection into
it during spinal anesthesia may explain the occasional failed spinal anesthetic
and the rare “total spinal” after epidural anesthesia when there is no indication
of errant injection of local anesthetic into CSF.
19. •Surrounding the dura mater is another space that is often used by anesthesiologists,
the epidural space. The spinal epidural space extends from the foramen magnum
to the sacral hiatus and surrounds the dura mater anteriorly, laterally, and more
usefully, posteriorly.
•The epidural space is bounded anteriorly by the posterior longitudinal ligaments,
laterally by the pedicles and intervertebral foramina, and posteriorly by the
ligamentum flavum.
•Contents of the epidural space include the nerve roots that traverse it from foramina
to peripheral locations, as well as fat, areolar tissue, lymphatics, and blood vessels,
including the well-organized Batson venous plexus.
•
•This lack of epidural space uniformity also extends to age-related differences. There is
evidence that adipose tissue in the epidural space diminishes with age.
• Another anatomic change in epidural space anatomy that has long been promoted is
that the intervertebral foramina decrease in size with increasing age.
•This decrease has been linked conceptually to higher block levels for similar epidural
doses of local anesthetic. considered together, it may be that the decrease in epidural
space adipose tissue with age may dominate the age-related changes in epidural dose
reqirement
21. conti.......
• Posterior to the epidural space is the ligamentum flavum (the so-called yellow
ligament), which also extends from the foramen magnum to the sacral hiatus.
Although classically portrayed as a single ligament, it is really composed of two
ligamenta flava, the right and the left, which join in the middle and form an
acute angle with a ventral opening .
• The ligamentum flavum is not uniform from skull to sacrum, nor even within
an intervertebral space. Ligament thickness, distance to the dura, and skin-to-
dura distance vary with the area of the vertebral canal . The two ligamenta
flava are variably joined (fused) in the midline, and this fusion or lack of fusion
of the ligamenta flava even occurs at different vertebral levels in individual
patients.
• Immediately posterior to the ligamentum flavum are the lamina and spinous
processes of vertebral bodies or the interspinous ligaments. Extending from
the external occipital protuberance to the coccyx posterior to these structures
is the supraspinous ligament, which joins the vertebral spines .
22. Surface Anatomy
• Surface structures assist in determining the level of entry into the epidural and
subarch space. The spinous processes help define the location of the midline as
they are usually midline structures. The cervical and lumbar spinous processes are
horizontally directed whereas the T4 through T9 thoracic spinous processes have a
sharp caudal angulation .
• Needle entry into the cervical and lumbar regions should be directed horizontally
with a slight upward angulation, whereas in the upper thoracic region, a midline
approach to the epidural space is more difficult because of the angulation of the
spinous processes. A paramedian approach is usually more successful
• safest point of entry into the epidural space is below the level of the spinal cord. In
adults, this corresponds to the lower border of the L1 vertebrae, and in children, at
the lower border of the L3 vertebrae. Epidural insertion in adults is commonly
introduced at either the L3-4 interspinous space or one higher, L2-3. A line drawn
between the superior aspect of the iliac crests crosses either the spinous process of
L4 or the L4-5 interspace.
• The interspinous space above this point (L3-4 interspinous space) or one higher
(L2-3) can safely be chosen for needle entry into the epidural space of adults. Some
research has challenged the accuracy of the iliac crest in assessing the level, but
this is still a generally accepted surface landmark. By approximately the age of 8
years, the same interspaces can be chosen for children; however, under the age of
7, to avoid accidental cord injury the caudal approach to the epidural space is safer.
23. Anatomic Landmarks to Identify Vertebral Levels Before Epidural
Injection
Anatomic Landmark Features
C7
Vertebral prominence, the most prominent
process in the neck
T3 Root of the spine of the scapula
T7 Inferior angle of the scapula
L4 Line connecting iliac crests
S2
Line connecting the posterior inferior iliac
spines
Sacral hiatus
Groove or depression just above or between
the gluteal clefts above the coccyx
24. Dermatomal Levels of Spinal Anesthesia for Common
Surgical Procedures
Procedure Dermatomal Level
Upper abdominal surgery T4
Intestinal, gynecologic, and urologic surgery T6
Transurethral resection of the prostate T8
Vaginal delivery of a fetus, and hip surgery T10
Thigh surgery and lower leg amputations L1
Foot and ankle surgery L2
Perineal and anal surgery S2 to S5 (saddle block)
25. Anatomical and physiological differences in children
•
There are certain features of paediatric anatomy and physiology which are different
from the adult and thus make the central neuraxial blockade a good alter-native
anaesthetic technique.
• spinal cord ends at L3 level at birth and reaches L-1 by 6-12 months.
• The dural sac is at the S4 level at birth and reaches S2 by the end of the first year.
The line joining the two supe-rior iliac crests (inter-cristal line) crosses at L5-S1
in-terspace at birth, L5 vertebra in young children and L3/4 interspace in adults.
• It is for this reason that the lumbar puncture be done at a level below which the
cord ends, safest being at or below the inter cristal line.
• bones of the sacrum are not fused posteriorly in children enabling an access to the
subarachnoid space even at this level.
• Another feature which is unique in infants is that there is only one anterior concave
curvature of the vertebral column at birth. The cervical lordosis begins in the first 3
months of life with the child's ability to hold the head upright. The lumbar lordosis
starts as the child begins to walk at the age of 6-9 months. Therefore, the spread of
isobaric local anaesthetic is different in infants particularly as compared to adults.
26. conti.....
• The subarachnoid space is incompletely divided by the denticulate ligament
laterally, and the subarachnoid septum medially.
• The volume of cerebrospinal fluid CSF is 4 ml.kg -1 which is double the adult
volume. Moreover, in infants half of this volume is in the spinal space whereas
adults have only one-fourth. This significantly affects the pharmocokinetics of
intrathecal drugs.
• The spinal fluid hydrostatic pressure of 30-40mm H 2 O in horizontal position is also
much less than that in adults.
• The neck can be in extension for lateral positioning while performing a lumbar
puncture as cervical flexion is of no benefit in children and in fact, may obstruct the
airway during the procedure. It can also be performed in sitting position with the
head extended.
• The physiological impact of sympathectomy is minimal or none in smaller age
groups.
• fall in blood pressure and a drop in the heart rate are practically not seen in
children less than five years. Therefore there is no role of preloading with fluids
before a subarachnoid block.
27. conti.....
• This may be due to the immature sympathetic nervous system in children younger
than five-eight years or a result of the relatively small intravascular volume in the
lower extremities and splanchnic system limiting venous pooling and relatively
vasodilated peripheral blood vessels.
• Infants respond to high thoracic spinal anaesthesia by reflex withdrawal of vagal
parasympathetic tone to the heart. It is one of the reasons why spinal anaesthesia
has been the technique of choice in critically ill and moribund neonates who
present for surgery in grave haemodynamic instability.
• most important concern with the use of intrathecal local anaesthetics in infants
and young children is the risk of toxicity. This age group is particularly prone to
direct toxicity to the spinal cord when administered in large doses.
• Neonates with immature hepatic metabolism and decreased plasma proteins like
albumin and alpha 1 acid glycoprotein have higher serum levels of unbound amide
local anaesthetics, which are normally highly protein bound (90%).
• A relatively higher cardiac output and regional blood flow in infants also increases
the drug uptake from neuraxial spaces and can predispose them to local
anaesthetic toxicity besides decreasing the duration of action. Infants may have
decreased levels of plasma pseudocholinesterase which may augment local
anaesthetic toxicity especially with the ester group.
29. Somatic Blockade
• Neuraxial anesthesia effectively stops the transmission of painful sensation and
abolishes the tone of skeletal muscle, enhancing operating conditions for the
surgeon.
• Sensory blockade involves somatic and visceral painful stimulation.
• Motor blockade involves skeletal muscles. Neuraxial anesthesia results in a
phenomenon known as differential blockade.
• This effect is due to the activity of local anesthetics and anatomical factors. Local
anesthetic factors include the concentration and duration of contact with the spinal
nerve root.
• As the local anesthetic spreads out from the site of injection the concentration
becomes less, which may in turn effect which nerve fibers are susceptible to
blockade. Anatomical factors are related to various fiber types found within each
nerve root.
• Small myelinated fibers are easier to block than large unmyelinated fibers. In
general, the differential blockade found after neuraxial blockade is as follows:
sympathetic blockade is 2-6 dermatome segments higher than sensory and sensory
blockade is generally 2 dermatome levels higher than motor.
30. Autonomic Blockade
• Neuraxial blockade effectively blocks efferent autonomic transmission of the spinal
nerve roots, producing a sympathetic block and a partial parasympathetic block.
• Sympathetic fibers are small, myelinated, and easily blocked. During neuraxial
blockade, sympathetic block occour prior to sensory, followed by motor.
• sympathetic nervous system (SNS) is described as thoracolumbar since
sympathetic fibers exit the spinal cord from T1 to L2.
• The parasympathetic nervous system (PNS) has been described as craniosacral
since parasympathetic fibers exit in the cranial and sacral regions of the CNS. It
should be noted that neuraxial blockade does not affect the vagus nerve (10th
cranial nerve).
• End result of neuraxial blockade is a decreased sympathetic tone with an
unopposed parasympathetic tone. This imbalance will result in many of the
expected alterations of normal homeostasis noted with the administration of
epidural and spinal anesthesia.
31. Cardiovascular Effects
• Neuraxial blockade can impact the cardiovascular system by causing the
following changes:
1. Decrease in blood pressure (33% incidence of hypotension in non-obstetric
populations)
2. Decrease in heart rate (13% incidence of bradycardia in non-obstetric
populations)
3. Decrease in cardiac contractility
• Sympathectomy is the term used to describe blockade of sympathetic outflow.
Nerve fibers that affect vasomotor tone of the arterial and venous vessels arise
from provider wants to block with neuraxial blockade.
• The sympathetic dermatome ranges from 2-6 levels higher than the sensory
dermatome level. Sympathectomy is directly related to the height of the block
and results in venous and arterial vasodilatation.
• The venous system contains about 75% of the total blood volume while the
arterial system contains about 25%. Dilation of the venous system is
predominantly responsible for decreases in blood pressure since the arterial
system is able to maintain much of its vascular tone. T5-L1, which is generally
within the area that the anesthesia
32. •Total peripheral vascular resistance in the normal patient (normal cardiac output and
normovolemic) will decrease 15-18%.
•In the elderly the systemic vascular resistance may decrease as much as 25% with a
10% decrease in cardiac output.
•Heart rate may decrease during a high block due to blockade of the
cardioaccelerator fibers (T1-T4). Heart rate may also decline as a result of a decrease
in SVR, decreased right atrial filling, and decreases in the intrinsic chronotropic stretch
receptor response.
• that epidural and spinal anesthesia differ in their effect on arterial blood pressure? A
common concept is that the decrease in arterial blood pressure is more gradual and of
less magnitude with epidural than with spinal anesthesia of comparable levels. During
the T10 block, there was no significant change in organ blood flow; during the T1
block, with a 22% decrease in mean arterial pressure, cerebral and myocardial blood
flow was insignificantly altered
33. Respiratory Effects
• Neuraxial blockade plays a very minor role in altering pulmonary function. Even
with high thoracic levels of blockade, tidal volume is unchanged. There is a slight
decrease in vital capacity.
• This is the result of relaxation of the abdominal muscles during exhalation.
• phrenic nerve is innervated by C3-C5 and is responsible for the diaphragm.
phrenic nerve is extremely hard to block, even with a high spinal.
• In fact, apnea associated with a high spinal is thought to be related to brainstem
hypoperfusion and not blockade of the phrenic nerve. This is based on the fact
that spontaneous respiration resumes after hemodynamic resuscitation has
occurre.
• risk and benefits of neuraxial anesthesia should be carefully weighed for the
patient with severe lung disease.
• Patients with chronic lung disease depend on intercostal and abdominal muscles
to aid their inspiration and exhalation.
• Neuraxial blockade may reduce the function of these muscles, having a
detrimental impact on the patient’s ability to breathe, as well as affect the ability to
clear secretions and cough.
• For procedures above the umbilicus, a pure regional anesthetic may not be
beneficial for the patient with chronic lung disease.
• However, postoperative analgesia with thoracic epidurals has been found to be
helpful to the patient with severe lung disease undergoing a thoracic or abdominal
procedure.
• .
34. • Thoracic and abdominal surgical procedures are associated with decreased phrenic
nerve activity resulting in decreased diaphragmatic function and FRC (functional
reserve capacity). This can lead to atelectasis and hypoxia due to
ventilation/perfusion mismatching.
• Thoracic epidural analgesia has been found to decrease the incidence of
pneumonia, respiratory failure, improve oxygenation, and decrease the amount of
time that the patient may require for postoperative ventilation
•
35. Gastrointestinal Effects
•Another organ system affected during neuraxial blockade is the gastrointestinal tract.
•Nausea and vomiting may be associated with neuraxial block in up to 20% of patients
and are primarily related to gastrointestinal hyperperistalsis caused by unopposed
parasympathetic (vagal) activity.
•Atropine is effective in treating nausea associated with high (T5) subarachnoid
anesthesia.
• This gastrointestinal hyperperistalsis has the advantage of providing excellent surgical
conditions because of a contracted gut.
• An often-cited advantage of regional anesthesia in patients with compromised
gastrointestinal function (e.g., hepatic dysfunction) is that less physiologic impairment
is possible than with general anesthesia.
• decrease in hepatic blood flow during spinal anesthesia parallels the decrease in
mean arterial blood pressure.When epidural analgesia is continued into the
postoperative period, there may be a protective effect on the gastric mucosa because
intramucosal pH is higher during postoperative epidural analgesia than during systemic
analgesia.
36. Renal Effects
• Neuraxial blockade has little effect on the blood flow to the renal system.
• Autoregulation maintains adequate blood flow to the kidneys as long as perfusion
pressure is maintained.
• Neuraxial blockade effectively blocks sympathetic and parasympathetic control of
the bladder at the lumbar and sacral levels.
• Urinary retention can occur due to the loss of autonomic bladder control.
Detrusor function of the bladder is blocked by local anesthetics. Normal function
does not return until sensory function returns to S3.
• Risk factors for prolonged blockade of the detrusor muscle include the use of long
acting local anesthetics, age > 50 years, volume of fluids administered, and surgical
procedure. Prolonged blockade of the detrusor muscle may lead to bladder over
distention and urinary retention. This should be taken into consideration if no
urinary catheter will be placed. If possible, short acting medications should be
used.
• It should be monitor the amount of intravenous fluids administered to prevent over
distention of the bladder.
• patient with a history of an enlarged prostrate is at risk for urinary retention.
Patients should be monitored for urinary retention.
37. Metabolic and Endocrine Effects
• Surgery produces a host of neuroendocrine responses related to inflammatory
response and activation of somatic and visceral afferent nerve fibers.
• This response results in the release of adrenocorticotropic hormone, cortisol,
epinephrine, norepinephrine, vasopressin, and activation of the renin-
angiotension-aldosterone system.
• release of these substances has the following clinical manifestations: hypertension,
tachycardia, hyperglycemia, protein catabolism, depressed immune response, and
alteration in renal function. As noted earlier, neuraxial blockade can effectively
block this response.
• In intra-abdominal surgery, it may only partially suppress its effects. For lower
extremity surgery, it can totally suppress these effects. The effect of neuraxial
blockade is beneficial by reducing catecholamine release, decreasing stress related
arrhythmias, and decreasing the incidence of ischemia.
38. caudal Anatomy
• The sacrum results from fusion of the five sacral vertebrae.
• The sacral hiatus, which is failure of the laminae of S5 and usually part of S4 to fuse
in the midline, is the detail of interest.
• It results in a variably shaped and sized inverted V–shaped bony defect covered by
the posterior sacrococcygeal ligament, a functional counterpart to the ligamenta
flava.
• The sacral hiatus is identified by locating the sacral cornua, remnants of the S5
articular processes . This bony defect allows access to the sacral canal, although
needle insertion through this defect may be difficult because of the frequency of
anatomic variation.
• The sacral canal contains the terminal portion of the dural sac, which typically ends
cephalad to a line joining the posterior superior iliac spines, or S2.
39. caudal Anatomy
• Variation is found in this feature as well, with the termination of the dural
sac being lower in children, ease of palpating the sacral hiatus in children
may make the pediatric caudal technique easier overall.
• In addition to the dural sac, the sacral canal contains a venous plexus,
which is part of the valveless internal vertebral venous plexus.
• It is estimated from magnetic resonance imaging (MRI) studies that the
volume of the caudal canal in adults, excluding the foramina and dural sac,
is about 10 to 27 mL. Perhaps this wide variability in volume accounts for
some of the variation in block height with caudal anesthesia