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PR Anestesi – 2 Raswinarsih Indah B.


1. Difference between Conus Medullaris Syndrome and Cauda Equina

Conus Medullaris
Cauda Equina Syndrome
Presentation Sudden and bilateral Gradual and unilateral
Reflexes Knee jerks (++) Knee and ankle jerks (-)
Ankle jerks (-)
Radicular Pain Less severe More severe
Low Back Pain More severe Less severe
Sensory signs and Numbness: perianal area; Numbness: saddle area;
symptoms symmetrical and asymmetrical, no sensory
bilateral; sensory dissociation
dissociation occurs
Motor strength Symmetric, hyperreflexic Asymmetric areflexic
distal paresis of lower paraplegia that is more
limbs that is less marked; marked; fasciculations rare;
fasciculations may be atrophy more common
Impotence Frequent Less frequent
Sphincter dysfunction Urinary retention  Urinary retention; tends to
overflow urinary present late
incontinence and fecal
incontinence; present

2. Bromage score

3. Transient Neurological Symptoms

 A painful condition of the buttocks and thighs with possible
radiation to the lower extermities.
 Pain can be mild to severe.
 No bowel or bladder dysfunction, neurologic, MRI, and
electrophysiologic examinations are normal.
 Cause: Subarachnoid block with Lidocaine/Mepivacaine

 Timing: Few hours to ~ 1 day, lasting up to 10 days

 Symptoms usually self-limited

4. Antidote of Marcaine toxicity

Lipid Emulsion Therapy
IV infusion of a 20% lipid emulsion (eg, Intralipid 20%)

5. Sequence of blockage of nerve fibers

The ability of a given local anesthetic to block a nerve is related to the
length of the nerve exposed, the diameter of the nerve, the presence of
myelination, and the anesthetic used. Small or myelinated nerves are
more easily blocked than large or unmyelinated nerves. Myelinated nerves
need to be blocked only at nodes of Ranvier for successful prevention of
further nerve depolarization, requiring a significantly smaller portion of
these nerves to be exposed to the anesthetic. Differential blockade to
achieve pain and temperature block (A-δ, C fibers) while minimizing
motor block (A-α fibers) can be achieved by using certain local anesthetics
and delivering specific concentrations to the nerve.

The large nerve fibers recover quicker than smaller ones, thus motor
function returns before other functions followed by light tough and
pressure, temperature, and pain. Motor function and sensation generally
return from the hip to feet, with higher dermatome levels recovering first.

6. Post spinal anesthesia and vomiting

 Chemoreceptor trigger zone (CRTZ): at the caudal end of the fourth
ventricle in the area postrema.
 Nucleus tractus solitarius (NTS): in the area postrema and lower
CRTZ lacks of the blood–brain barrier, receives input from vagal afferents
in the gastrointestinal tract, triggered by several perioperative stimuli,
including opioids, volatile anaesthetics, anxiety, adverse drug reactions,
and motion.

Projects to the NTS

Triggers vomiting by stimulating the rostral nucleus, the nucleus

ambiguous, the ventral respiratory group, and the dorsal motor nucleus of
the vagus.

7. PDPH and needle size

The pathogenesis of PDPH remains unclear but is thought to be caused by
CSF leakage into the epidural space via a tear in the dura. CSF loss leads to
a reduction in intracranial pressure and downward traction on pain-
sensitive intracranial structures, including veins, meninges and cranial
nerves, resulting in a headache that is classically worse in the upright
position. The fall in intracranial pressure may also cause compensatory
cerebro-vascular venodilation and this may contribute to the development
of the headache.
This can be prevented by using the right needle for the procedure.
Presumably, larger needles leave larger holes in the dura mater, which
close with more difficulty, and allow for more cerebrospinal fluid (CSF)
loss. Hence why it is safer to use more refined and thinner needles to
reduce CSF leakage.