Clinical Procedures

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A. Lumbar puncture (Figure 2-4) can be performed to withdraw cerebrospinal fluid or to inject an anesthetic (e.g., spinal anesthesia).

1. A needle is inserted above or below the spinous process of vertebra L4 (i.e., L3—4 or L4—5 interspace, respectively)

2. The needle passes through the following structures: skin superficial fascia supraspinous ligament interspinous ligament ligamentum flavum ~~► epidural space containing the internal vertebral venous plexus ~~► dura mater —► arachnoid subarachnoid space containing cerebrospinal fluid.

3. The needle stops before it pierces the pia mater.

B. Spinal anesthesia (spinal block, or saddle block)

1. Spinal anesthesia is produced by injecting anesthetic into the subarachnoid space; it may be used during childbirth.

2. Sensory nerve fibers for pain from the uterus travel with the pelvic splanchnic nerves (parasympathetic) to spinal levels S2—4 from the cervix, and may be responsible for referred pain to the gluteal region and legs. Sensory nerve fibers for pain also travel with the hypogastric plexus and lumbar splanchnic nerves (sympathetic) to spinal levels LI-3 from the fundus and body of the uterus and oviducts, and may be responsible for referred pain to the back.

3. Spinal anesthesia up to spinal nerve T10 is necessary to block pain from vaginal childbirth. Anesthesia must reach spinal nerve T4 for cesarean delivery, which is accomplished by increasing the amount of anesthetic injected.

4. Pregnant women require less anesthetic than nonpregnant patients because the subarachnoid space is compressed by the internal vertebral venous plexus, which is engorged with blood because the pregnant uterus compresses the inferior vena cava.

5. Complications may include: hypotension as a result of sympathetic blockade and vasodilation; respiratory paralysis involving the phrenic nerve as a result of high spinal blockade and spinal headache as a result of leakage of cerebrospinal fluid.

C. Lumbar epidural anesthesia

1. Lumbar epidural anesthesia is produced by injecting anesthetic into the epidural space, most commonly at the L2—3 or L3—4 interspace; it may be used during childbirth.

Arachnoid Dura Skin

Superficial fascia Supraspinous ligament

Spinal Anaesthetic Subarachnoid Space

Figure 2-4. Lumbar vertebral column and spinal cord. A needle is shown inserted into the subarachnoid space above the spinous process of L4 (L3—4 interspace) to withdraw cerebrospinal fluid or administer spinal anesthesia. A second needle is shown inserted into the epidural space to administer lumbar epidural anesthesia. Note the sequence of layers (superficial to deep) that the needle must penetrate. (Inset reprinted with permission from Scott DB: Techniques of Regional Anaesthesia, East Norwalk, CT, Appleton & Lange, 1989, p 169.)

Figure 2-4. Lumbar vertebral column and spinal cord. A needle is shown inserted into the subarachnoid space above the spinous process of L4 (L3—4 interspace) to withdraw cerebrospinal fluid or administer spinal anesthesia. A second needle is shown inserted into the epidural space to administer lumbar epidural anesthesia. Note the sequence of layers (superficial to deep) that the needle must penetrate. (Inset reprinted with permission from Scott DB: Techniques of Regional Anaesthesia, East Norwalk, CT, Appleton & Lange, 1989, p 169.)

Figure 2-5. (A) MRI scan of an astrocytoma. An astrocytoma is an intramedullary (within the ^ spinal cord) tumor. Note the astrocytoma (arrows) within the substance of the spinal cord; it has a cystic appearance. (B) MRI scan of a meningioma. A meningioma is an intradural (within the meninges) tumor. Note the meningioma (arrow) outside the spinal cord, causing some compression of the spinal cord. (C, D) MRI scan of a schwannoma. A schwannoma is another type of intradural (within the meninges) tumor. (C) Note the schwannoma (arrow) within the dural sac, at approximately vertebral level L3, involving the cauda equina. The key to interpreting this image is to remember that in adults, the spinal cord ends at vertebral level L1 .Therefore, the spinal cord is not present at L3, so this tumor cannot be intramedullary. (D) MRI scan of the intervertebral foramen showing the schwannoma protruding through the intervertebral foramen (arrow), a clear characteristic of a schwannoma (or neurofibroma). (A reprinted with permission from Reimer P, Parizel PM, Stichnoth F-A: Clinical MR Imaging: A Practical Approach. Berlin, Springer-Verlag, 1999, p 147; B—D adapted with permission from Runge VM: Contrast Media in Magnetic Resonance Imaging: A Clinical Approach. Philadelphia, JB Lippincott, 1992, pp 97-99.)

Venous Plexus Mri
Figure 2-5.

2. The needle passes through the following structures: skin superficial fascia supraspinous ligament interspinous ligament ligamentum flavum.

3. Complications include: respiratory paralysis as a result of high spinal blockage if the dura and arachnoid are punctured and anesthetic is mistakenly injected into the subarachnoid space, and central nervous system toxicity (e.g., slurred speech, tinnitus, convulsions, cardiac arrest) if the anesthetic is injected into the internal vertebral venous plexus (intravenous injection versus epidural application).

VIII. RADIOLOGY. Magnetic resonance imaging (MRI) scans of an astrocytoma, a meningioma, and a schwannoma (Figure 2-5)

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Pregnancy And Childbirth

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Responses

  • kelvin
    Where at are your back is an epidural given on what L3?
    7 years ago
  • Ines
    How many lumbar interspace?
    6 years ago

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