D. Continue with daily stool softener
30. You are consulted by an emergency room (ER) physician to evaluate a patient
experiencing a severe and bilateral retro-orbital headache, described as constant,
along with diplopia. The ER physician also indicated that the patient presented to the
ER 2 days prior with fever, chills, and photophobia when a diagnostic lumbar
puncture was performed with a 20G needle. The CSF study proved negative for
meningitis, but now the patient has returned to the ER with complaints of a severe
A. Repeat the CSF study as one set of negative results is not definitive
B. Recommend opioids for treatment of the headache
C. Recommend performing an epidural blood patch
D. Continue with conservative therapy as it will eventually prevail
31. Incorrect statement regarding neuraxial blockade is
A. Dermatome level of anesthesia achieved with a spinal anesthetic is often more
predictable than following an epidural blockade
B. Spinal anesthesia can more rapidly and consistently produce denser motor
blockade than epidural anesthesia
C. Local anesthetics administered during epidural anesthesia are typically more
volume-dependent, and during spinal anesthesia are more concentrationdependent
D. Thoracic epidural anesthesia has an increased risk of urinary retention
compared to lumbar epidural anesthesia when the same volume of local
32. Following performance of spinal anesthesia at the L4–L5 level with 3 mL of 5%
lidocaine, you suspect a potential injury to the conus medullaris. Which of the
following symptoms is least likely to be associated with cauda equina syndrome?
33. You are called to see a 76-year-old female who had a L3–L4 lumbar epidural placed
3 days prior for postoperative analgesia for a colectomy. The epidural placement
was traumatic on the first attempt (at L4–L5 level) with evidence of positive blood
aspiration. The patient is now complaining of new onset back pain with radiation to
the right lower extremity and right knee weakness that was confirmed by physical
exam. The most likely diagnosis and optimal management is
A. Breakthrough pain in a patient who is confused, treat with additional pain
B. Stat MRI of the back to rule out neuraxial hematoma
C. Surgical complication, consult orthopedics
D. Symptomatic spinal stenosis, consult neurology for suggestions
1. C. In spinal and epidural anesthesia, differential blockade is frequently reported to
observe the “two segments rule,” namely, sympathetic block is two segments higher
than sensory block, and sensory block is two segments higher than motor block. In
this spinal block, alcohol swab tested the level of sensory/sympathetic blockade.
2. C. A large local anesthetic bolus to a parturient with an anticipated epidural space
reduced in size secondary to engorged epidural veins and enlarged uterus can cause a
higher level of epidural blockade than anticipated. If the block level reaches higher
than T4 and influences T1–T4 (cardiac accelerator fibers), patients may have
bradycardia, hypotension, anxiety on physical exam and report symptoms such as
nausea, vomiting, and headache, and even paresthesia in the upper extremities.
3. D. Neuraxial block is a great alternative to general anesthesia for many surgical
procedures below the diaphragm and an excellent choice for postoperative pain
control. However, there are conditions where neuraxial block needs to be used with
caution. Neuraxial blocks are associated with a sympathectomy and can therefore
worsen existing hypotension and hypovolemia. Hypotension in combination with
aortic and/or mitral valve stenosis may not be very well tolerated. Although
spinal/epidural hematoma is rare yet possible, the risk of bleeding is significantly
higher in patients with a known coagulopathy.
4. B. To perform an epidural block, the needle passes through several layers,
including skin, subcutaneous tissue, supraspinous ligament, intraspinous ligament,
and ligament flavum. To perform a spinal anesthesia, the needle goes deeper to
penetrate the dura and frequently the subarachnoid membrane.
5. C. Neuraxial blocks in upper abdominal and thoracic procedures offer advantages
of decreased pulmonary and cardiac complications in high-risk patient populations,
promote peristalsis, and reduce conditions for a hypercoagulation state
perioperatively. However, urinary retention is one of the potential major side effects
associated with neuraxial blockade.
6. B. The spinal cord typically ends around L1 in adults, and around L3 in children.
This is the reason why neuraxial blocks are performed below these levels and carry a
lower risk of direct spinal cord injury. The dural sac and subarachnoid spaces end at
S2 in adults and S3 in children.
7. D. Blood supply to the spinal cord is by one anterior spinal artery and two
posterior spinal arteries. The anterior spinal artery supplies the anterior two-thirds of
the spinal cord, and the posterior spinal arteries supply the posterior one-third. The
anterior spinal artery is branched from the vertebral artery, and the posterior spinal
artery arises from the posterior inferior cerebellar artery.
8. B. Major site of action of neuraxial blockade takes place on the nerve roots. Local
anesthetics act on nerve roots in the subarachnoid space in the case of a spinal
blockade and on the nerve roots in the epidural space in the case of epidural
9. C. A total of 3 mL of 1.5% lidocaine with 1:200,000 epinephrine is commonly
used when testing for epidural anesthesia to rule out intrathecal (lidocaine can result
in spinal blockade) and/or intravascular injection. Intravascular injection of
epinephrine (15 μg) can result in a transient increase in heart rate of 20% or higher,
within 30 seconds of injection and without evidence of a BP change.
10. D. During epidural anesthesia, epinephrine in the dose of 5 μg/mL will improve the
quality of an epidural anesthetic. Additionally, epinephrine can also prolong
blockade duration, delays local anesthetic intravascular absorption, and decreases
peak plasma local anesthetic concentration(s).
11. D. It is currently believed that body weight alone does not influence the level of an
epidural block (although extreme obesity may). Patient height (vertebral levels
covered decrease with height) and age (vertebral levels covered increase with age)
along with local anesthetic volume (about 1 to 2 mL local anesthetic medication per
segment) and patient position (theory of gravity) can play significant roles.
12. D. Addition of a base with acidic local anesthetic medications will increase the
amount of uncharged local anesthetic molecules injected and can therefore increase
diffusion of local anesthetic molecules through the lipid layer of the cell membrane.
However, sodium bicarbonate is not used with bupivacaine as it can precipitate in
13. D. Major factors influencing the level of spinal anesthesia includes baricity of local
anesthetic solution, patient position immediately following spinal block placement,
drug dose used, site of injection, patient age and spine anatomy, pH of the CSF, drug
volume used, needle orifice direction, patient height, and patients being pregnant.
14. D. Major factors influencing the level of spinal anesthesia includes baricity of local
anesthetic solution, patient position immediately following spinal block placement,
drug dose used, site of injection, patient age and spine anatomy, pH of the CSF, drug
volume used, needle orifice direction, patient height, and patients being pregnant.
15. D. Complications from neuraxial blockade can be diverse and range from death,
cardiac arrest, seizures, paraplegia, radiculopathy, anterior spinal artery syndrome,
high/total spinal anesthesia, arachnoiditis, post–dural puncture headache, back pain,
epidural hematoma, epidural abscess, and urinary retention. However, the
complication rates are typically low and may even improve bowel function and
16. C. Potential complications of neuraxial blockade can be diverse and range from
death, cardiac arrest, seizures, paraplegia, radiculopathy, anterior spinal artery
syndrome, high/total spinal anesthesia, arachnoiditis, post–dural puncture headache,
back pain, epidural hematoma, and epidural abscess. However, complication rates
are low and patients do not typically experience delirium unless systemic opioid
17. C. Although transient neurological symptoms are usually self-limiting, it can be
bothersome to patients. The etiology is mostly likely due to the high concentration of
lidocaine; therefore, 5% lidocaine is now avoided in spinal anesthesia when possible.
18. D. According to the ASRA guidelines, waiting period for the commonly used
antiplatelet agents are as follows: ticlopidine (Ticlid) 14 days, clopidogrel (Plavix) 7
days, abciximab (ReoPro) 48 hours, and eptifibatide (Integrilin) 8 hours.
19. B. Subcutaneous heparin prophylaxis at once or twice daily is not a
contraindication to neuraxial anesthesia placement or prior to epidural catheter
removal. Systemic heparin administration can be considered safe if given 1 hour or
longer following neuraxial blockade according to the ASRA guidelines.
20. D. Factors associated with a decreased CSF volume include pregnancy, large
abdominal tumor, ascites, and the elderly, and can be associated with an exaggerated
spread of neuraxial local anesthetic (volume and amount of local anesthetic injected
21. D. Adjuvants added to neuraxial local anesthetics may improve quality and/or
prolong the duration of spinal anesthesia. Some commonly used agents include the
following: opioids such as morphine and fentanyl, α1 agonist such as epinephrine and
α2 agonists such as clonidine/dexmedetomidine. Indirect-acting vasopressors added
to local anesthetic mixtures have not been shown to be effective.
22. A. According to ASA closed-claims database, LAST is more common than what is
being formally reported. Performing a test dose with epinephrine and aspiration is not
always 100% effective. Small and incremental dosing of epidural medications should
always be considered as another safety measure to decrease the risk.
23. C. In LAST management, steps taken toward advanced life support still need to be
followed despite evidence that intralipid administration is the definitive treatment.
Administration of epinephrine as well vasopressin in the treatment of LAST should
be avoided as it has not been shown to be associated with improved patient
24. B. Initial vertebral level achieved with epidural anesthesia can be variable and is
not as predictable as spinal anesthesia. The generally accepted rule is that 1 to 2 mL
of an appropriately selected local anesthetic should be administered for each
vertebral level of anesthesia desired in adults.
25. A. Caudal anesthesia is a type of epidural anesthesia performed in the sacral region
just as lumbar epidural anesthesia is performed in the lumbar region. Caudal
anesthesia can also be used in adults, but may be more difficult to perform due to
calcification of the sacrococcygeal ligament. Caudal anesthesia needle/catheter
placement must penetrate the sacrococcygeal ligament in order to enter the caudal
space. Within the sacral canal, the dural sac stops at the first sacral vertebra in adults
and approximately around the third sacral vertebra in infants; therefore, the risk of
spinal anesthesia is higher in younger children.
26. C. Rapid injection of large volumes of local anesthetics either epidurally or
accelerator fibers were affected, and therefore, the patient experienced bradycardia
27. C. Although phrenic nerve palsy may contribute to patient’s experiences of
shortness of breath and apnea, the most likely reason for dyspnea following a high
neuraxial blockade is persistent hypotension-induced brain-stem hypoperfusion.
Therefore, airway support is needed and aggressive control of hypotension is
important in the management of high neuraxial blockade effects.
28. C. Hypotension associated with a high spinal may be worsened as a result of
effects on the cardiac accelerator fibers at the T1–T4 levels. Therefore, a
vasopressor that can simultaneously increase both HR and BP would be the most
ideal medication to administer. All of the above drugs, except phenylephrine, can be
used to treat severe bradycardia in the management of a high neuraxial block
associated with a decreasing heart rate.
29. B. In patients who may experience a “wet tap” during placement of an epidural,
conservative therapy should include bed rest and plenty of fluid intake, including
caffeine; food diet low in fiber and stool softeners are encouraged to prevent
30. C. Initially, a post–dural puncture headache is typically treated conservatively. If
there is insufficient or no evidence of symptomatic improvement after 24 to 48 hours,
most clinicians may choose to perform an epidural blood patch (if no
contraindications) with 15 to 20 mL of autologous blood.
31. D. During neuraxial blockade, urinary retention is most often due to the local
anesthetic effects on the S2–S4 nerve roots. Opioids can also adversely affect
bladder function. Therefore, a lumbar epidural anesthetic has a higher risk of bladder
reflex inhibition and urinary retention than a thoracic epidural.
32. C. Cauda equina syndrome is usually secondary to neurotoxic effects from local
anesthetics on the sacral nerve roots. All of above symptoms, with the exception of
the quadriceps muscles, could be explained by the cauda equina syndrome
(innervated by the sacral plexus). Quadriceps muscles are innervated by lumbar
plexus and lumbar nerve roots and are rarely involved in the cauda equine syndrome.
33. B. Epidural hematoma may present with back pain, focal neurological deficits, and
bowel and bladder dysfunction. If a neuraxial hematoma is suspected, emergent
intervention needs to be taken to confirm diagnosis and then to perform an emergency
decompression as soon as possible to avoid permanent spinal cord/nerve roots
1. An 85-year-old male is scheduled for a right distal radius and ulnar open reduction
interior fixation at the wrist. Medical history is significant for chronic obstructive
pulmonary disease dependent on 2 L of oxygen, hypertension, diabetes mellitus, and
coronary artery disease with a stent inserted one year ago. Given that the surgeon
plans to use a forearm tourniquet, the regional anesthesia technique that would be
most appropriate for this patient is
A. An interscalene brachial plexus block plus an intercostal brachial nerve block
B. A supraclavicular approach to the brachial plexus plus an intercostal brachial
C. An infraclavicular block of the brachial plexus at the cords plus an intercostal
D. Superficial cervical plexus blockade plus an intercostal brachial nerve block
2. While performing an axillary brachial plexus block, all of the following nerves are
C. Lateral brachial cutaneous nerve
D. Medial brachial cutaneous nerve
3. Contraindications to safely perform peripheral regional anesthesia include all of the
A. Patients who may not provide absolute cooperation during nerve block
placement (mental retardation) without administration of sedation
C. Severe coagulopathy while anticipating a deep nerve plexus blockade
D. Evidence of infection at injection site
4. While performing a peripheral nerve block in an awake patient, access and/or use of
all of the following should be considered mandatory, except
A. Administer supplemental oxygen
B. Apply standard ASA monitors
C. Access to resuscitation medications and equipment
D. Immediate access to a mechanical ventilator
5. The most correct statement regarding the appropriate use of ultrasound equipment
during performance of regional anesthesia is
A. Higher frequency ultrasound probes are used for deeper penetration
B. High-frequency ultrasound probes provide for higher image resolution
C. Liner array probes are typically used for imaging deeper anatomical structures
D. The curvilinear probe is designed to best image superficial structures
6. Which of the following nerves is typically spared during performance of an
interscalene brachial plexus block?
7. Following successful performance of a right interscalene block for surgical rotator
cuff repair in a 27-year-old patient with no other medical issues, you are called to
the recovery room (post–anesthesia care unit) 3 hours later to evaluate the patient.
The patient’s symptoms include drooping of the right eyelid, redness of the
conjunctiva, and pupillary constriction. The most likely diagnosis is
B. Subdural injection of local anesthetic
D. Cerebrovascular accident (CVA)
8. A supraclavicular block of the brachial plexus does not provide consistent surgical
anesthesia for shoulder surgery secondary to potential sparing of which of the
following nerve branches of the brachial plexus?
A. Musculocutaneous and axillary nerve branches
B. Axillary and suprascapular nerve branches
C. Ulnar and axillary nerve branches
D. Suprascapular and supraclavicular nerve branches
9. Performing an infraclavicular approach for brachial plexus blockade would deposit
local anesthetics at which of the following anatomical levels of the plexus?
10. A supraclavicular approach for brachial plexus blockade would deposit local
anesthetics at which of the following anatomical levels of the plexus?
11. When performing an axillary block of the brachial plexus for distal upper extremity
surgery, which of the following nerves most often needs to be targeted separately?
12. Anatomical location of the musculocutaneous nerve in the upper forearm is most
frequently found within which of the following muscles?
13. While performing an ultrasound-guided axillary nerve block along with a nerve
stimulator, your needle tip is imaged inferior to the pulsating axillary artery, and you
see evidence of flexion of fourth and fifth digits. The stimulating needle tip is in
closest proximity to which of the following peripheral nerve branches of the brachial
14. During placement of an ultrasound-guided and nerve stimulator–assisted axillary
nerve block, your needle tip is imaged superiorly to the axillary artery. You also see
pronation of the patient’s forearm. The needle tip is in closest proximity to which of
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