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Epidural Review Kate Hagan, M.D. 10/14/2008 Anatomy At each vertebral level, paired spinal nerves exit the central nervous system The 1st cervical vertebra is the atlas The 2nd cervical vertebra is the axis All 12 thoracic vertebrae articulate with their corresponding rib The spinal cord sits in the hollow ring bordered - anteriorly by the vertebral body - laterally by the pedicles and transverse processes - posteriorly by the lamina and transverse processes 3 layers of meninges the pia, arachnoid, and dura CSF is found between the pia and arachnoid membranes Spinal cord goes to L1 in adults and L3 in children At the cervical level nerves arise above their respective vertebrae, but starting at T1 they exit below Subdural space extends to S2 in adults and S3 in children Blood supply to the spinal cord and nerve roots is derived from a single anterior spinal artery and paired posterior spinal arteries Anterior spinal artery is formed from the vertebral artery, supplying the anterior 2/3 of the spinal cored Posterior spinal arteries are derived from the posterior inferior cerebellar arteries and provide for the posterior 1/3 The artery of Adamkiewicz arises from the aorta typically on the left hand side and provides the major blood supply to the anterior, lower 2/3 of the spinal cord Mechanism of Action Principle site of action is the nerve root Smaller myelinated fibers are blocked more easily than larger unmyelinated ones Sympathetic blockade may be 2 segments higher than the sensory block, which is usually 2 segments higher than the motor block Sympathectomy leads to variable decreases in BP, accompanied by a decrease in heart rate and cardiac contractility Vasomotor tone is determined by sympathetic fibers arising T5-T11, when these are blocked vasodilation of vessels occurs in conjunction with blood pooling HR decreases when cardioaccelerator fibers (T1-T4) are blocked Treatment: - volume load with 10-20 cc/kg of IVF in healthy patients prior to placin