高位脊髓损伤患者自主神经过反射的康复护理

高位脊髓损伤患者自主神经过反射的康复护理孙树梅１郑红云１夏艳萍１自主神经过反射（ａｕｔｏｎｏｍｉｃｈｙｐｅｒｅｆｅｌｘｉａ）是交感神经过度活动所引起的综合征。在Ｔ６以上的高位脊髓损伤患者中时有发生，其主要临床表现为血压升高、出汗、头痛及沉重感、面色潮...     

关于脊髓损伤后修复研究的管见

脊髓损伤患者常发生截瘫或四肢瘫，给家庭和社会造成极大负担。患者积极要求治疗，医师也为治疗脊髓损伤，修复损伤的脊髓进行着不懈的努力，并取得很大进展，特别是近年来干细胞和嗅鞘细胞移植，更引起医学界和患者的关注，有人甚至认为脊髓修复的问题将很快得到解决。但医学十分复杂，临床上能否在近期真正解决损伤脊髓的修复问题？根据我们从事脊髓损伤研究二十余年来的观察研究，谈谈自己的观点。一、脑与脊髓损伤的差别脑损伤除在少数情况下(如内囊出血、蝶鞍肿物压迫神经等)损伤传导束外，主要是脑神经细胞的损伤(如脑挫裂伤)。脊髓损…     

脊髓损伤与自主高反射

自主高反射系脊髓损伤患者交感神经系统过度激活乃至失控所引起的一组临床综合征，常见于四肢瘫及高位截瘫(损伤节段位于胸6水平以上)患者。尽管患者脊髓受损，其脊髓反射机制仍存在，可引起高血压、心动过缓、头痛等临床症状。对此综合征的及时有效救治至关重要，否则可能导致死亡等严重并发症。现就自主高反射的病理生理、临床特征、常见原因和治疗策略作一综述。     

外伤性脊髓损伤患者的骨质疏松

为探讨脊髓损伤后骨质疏松的发生规律和特点,对８３名外伤性脊髓损伤患者腰椎及髋部骨折疏松程度放射学观察,并与正常对照者进行比较。结果：脊髓损伤患者的腰椎及髋部骨密度均较正常对照组有明显减少,但完全性瘫痪患者与不完全性瘫痪患者无显著统计学差异,骨密度参数与病程长短亦无显著统计学差异。     

颈椎脊髓损伤患者自主神经性反射异常的临床处理

目的 探讨颈椎脊髓损伤患者自主神经性反射异常（autonomic dysreflexia,AD）的临床诊治措施.方法 2006年9月～2011年9月,共诊治23例颈椎脊髓损伤后发生自主神经性反射异常的患者,主要措施为去除对张力感受器和痛觉感受器的不良刺激.结果 19例患者在去除不良刺激后1-5 min内症状完全缓解,其余4例患者经Ca2＋通道阻滞剂治疗后血压降致正常.结论对于颈椎脊髓损伤的患者,应注意观察并解除可能导致AD发生的因素;一旦诊断为AD,应尽快消除诱因并对症处理,避免出现并发症.     

颈脊髓损伤后自主神经反射不良的诊治体会

自主神经反射不良（AD）或称自主神经反射亢进．是指胸6脊髓或以上平面的脊髓损伤（spinal cord injury,SCI）所引起的以血压阵发性骤然升高为特征的一组临床综合征。本院2006年9月至2009年3月收治的颈脊髓损伤致高位完全截瘫患者中观察到14例自主神经反射不良病例,现将诊治体会报告如下。     

外伤性脊髓损伤患者的骨质疏松

为探讨脊髓损伤后骨质疏松的发生规律和特点,对83名外伤性脊髓损伤患者腰椎及髋部骨质疏松程度作放射学观察,井与正常对照者进行比较。结果:脊髓损伤患者的腰椎及髋部骨密度均较正常对照组有明显减低(P<0.01),但完全性瘫痪患者与不完全性瘫痪患者无显著统计学差异(P>0.05),骨密度参数与病程长短亦无显著统计学差异(P>0.05)。认为:脊髓损伤性骨质疏松与传统意义上的废用性骨质疏松有所不同,其发病机理及影响因素较为复杂,尚有待进一步研究。     

脊髓损伤患者自我间歇导尿的可行性研究

脊髓损伤可致截瘫或四肢瘫及各种并发症 ,其中排尿障碍较为常见 脊髓损伤造成的排尿障 。碍可终身存在 排尿障碍可导致患者泌尿系统感 ,染 结石 肾积水 严重者可造成肾功能不全甚至 、 、 ,死亡 根 据 国 际 临 床 研 究 结 果 间 歇导 尿术 。 ,interm ittent catheterization IC 可明显减少泌尿( , )系统感染的机会[1] 由于患者不能长期住院治疗 。 ,因 此帮 助 患 者 学 习 自 我 间 歇 导 尿 interm ittent (self-catheterization ISC 或家属导尿术 以便他们 …     

步行矫形器在脊髓损伤患者康复中的应用

脊髓损伤所致截瘫是人体最严重的残疾之一。近年来，脊髓损伤的诊断、治疗取得了一定的进展．但完全性脊髓损伤仍难以恢复。随着现代生物力学、生物工程学的发展，使截瘫患者在应用矫形器特别是步行矫形器（walkingorthosis）方面有了明显进步。目前截瘫患者应用的步行矫形器主要有往复式截瘫步行器（reciprocating gait orthosis，RGO）、改进往复式截瘫步行器（advanced reciprocating gait orthosis．ARGO）和新型互动截瘫行走器（Walkabout）。     

Perioperative autonomic hyperreflexia in high spinal cord lesions: a case report

We report the case of a 20-year-old man with serious perioperative attacks of autonomic hyperreflexia starting during urological surgery 14 months after a complete C6-C7 spinal cord injury. The intraoperative attacks were controlled by deepening the level of anaesthesia, while the postoperative attacks were treated with emepronium bromide. A brief discussion of the pathophysiology and treatment is given.     

Exploring detailed characteristics of autonomic dysreflexia

Objectives: Identify clinical and pathophysiologic insights into autonomic dysreflexia (AD) in patients with spinal cord injury (SCI).

Study Design: Analysis of prospectively gathered AD dataset.

Setting: Inpatient Veterans Affairs SCI unit.

Participants: 78 male patients with SCI who experienced AD.

Methods: Statistical methods were utilized to identify the frequency of relative bradycardia vs. tachycardia during AD, the effectiveness of supplemental opioids in managing suspected nociceptive pain mediated AD, the effect of chronicity of SCI on response to pharmacological management of AD, and the response to nitroglycerin ointment in suspected bladder related AD.

Results: 445 episodes of AD were analyzed. The frequency of relative bradycardia and tachycardia with AD were 0.3% and 68.0% respectively. The addition of opioids to an antihypertensive medication protocol did not significantly decrease AD episode duration or magnitude of systolic blood pressure (SBP) change. A strongly matched positive linear correlation was identified between the duration of pharmacologically treated AD episodes and chronicity of SCI (R²=0.83). Bladder related AD episodes treated with nitroglycerin ointment had a faster onset of action (10.8 minutes vs. 15.9 minutes), faster time to reach a safe target blood pressure (16.5 minutes vs 20.9 minutes), and greater decrease in SBP (84.3mmHg vs. 68.6mmHg) than non-bladder related episodes (P=0.19, 0.23, and 0.02 respectively).

Conclusions: AD may commonly occur with relative tachycardia. While further investigation is needed on the effects of chronicity of SCI and pharmacologic management, this study raises multiple directions for future research to understand clinical signs and treatment variables of AD following SCI.     

经尿道膀胱壁A型肉毒毒素注射治疗脊髓损伤患者逼尿肌反射亢进及神经原性尿失禁

目的　评估逼尿肌A型肉毒毒素注射治疗脊髓损伤患者逼尿肌反射亢进和神经原性尿失禁的临床效果。　方法　损伤平面在骶髓以上的完全性脊髓损伤患者 31例 ,男 2 0例、女 11例 ,平均年龄 30岁。均表现为肾积水、输尿管返流及严重尿失禁。将 30 0UA型肉毒毒素溶解于 15ml生理盐水 ,使用膀胱镜注射针分 30个点注射于三角区以外的膀胱壁 ,0 .5ml/点。治疗前后记录排尿日记、行尿动力学检查 ,并观察毒副作用。　结果　治疗后第 3周 ,31例平均尿失禁次数由 14 .2次 /d降至 2 .5次 /d ,平均导尿量由 12 4ml/次增至 4 95ml/次 ,尿动力学结果表明平均最大膀胱测压容积由 133ml增至 4 75ml、平均充盈末逼尿肌压力由 6 2 .7cmH2 O(1cmH2 O =0 .0 98kPa)降至 17.1cmH2 O。起效平均时间为 6 .8d(3～ 14d) ,6 .5 % (2 /31)患者因治疗后症状无改善改用其它方法 ,12 .9% (4 /31)患者因症状再次加重而接受第 2次肉毒素治疗 ,12 .9% (4 /31)患者因症状改善有限而同时服用托特罗定治疗。随访 1～ 15个月 ,平均 8.5个月。随访期未观察到任何毒副作用。　结论　逼尿肌A型肉毒毒素注射是一种治疗脊髓损伤患者逼尿肌反射亢进和神经原性尿失禁的有效、安全、可行、可重复的微创方法。     

The knowledge about autonomic dysreflexia among nursing and physiotherapy students

Context/Objective Autonomic dysreflexia is a clinical syndrome affecting persons with spinal cord lesions. The aim of the study was to detect the level of knowledge among students about autonomic dysreflexia in persons with spinal cord lesions.

Design: Single centre questionnaire study.

Setting: Faculty of Health Studies, Rijeka, Croatia.

Participants Nursing (n?=?43) and physiotherapy (n?=?48) students.

Outcome Measures: AD knowledge test.

Results: More of the half of the students (57%) had contact with persons with spinal cord lesions during work, especially nursing students. The self-estimated knowledge of autonomic dysreflexia was judged as poor or none in 73.6% of students. On the autonomic dysreflexia knowledge test, nursing students collected mean of 5.6 points and physiotherapy students 4.9 points (P?=?0.173). There was no difference in the autonomic dysreflexia test results regardless of work experience or group affiliation.

Conclusion: The level of knowledge about autonomic dysreflexia among students was low. Our results suggest the need for more education of students and health care professionals to apply adequate treatment to persons with episodes of autonomic dysreflexia.     

Intravesical lidocaine decreases autonomic dysreflexia when administered prior to catheter change

Objective: To evaluate the role of intravesical lidocaine in preventing autonomic dysreflexia (AD) during routine catheter changes in individuals with spinal cord injury (SCI) at T6 or above.

Design: Prospective observational cohort study.

Setting: Outpatient urology clinic.

Participants: Fifty consecutive individuals with SCI at or above T6 and a history of AD having a routine indwelling catheter change.

Interventions: A treatment group of individuals received 10?ml of 2% lidocaine administered into the existing catheter 4–6 minutes prior to catheter change. The control group had the same amount of lidocaine administered into the urethra or suprapubic tract after removing the old catheter and immediately prior to inserting the new catheter (due to the delayed onset of action of the anesthetic, this was assumed to have no initial effect). Systolic blood pressures (SBP) were measured immediately after catheter insertion and then every 30–45 seconds for 5 minutes.

Outcome measures: Incidence and magnitude of AD as determined by SBP following catheter change.

Results: The incidence of AD in the lidocaine treatment group was 14.8% vs 47.8% in the control group (P?=?.011). Pretreatment with lidocaine also demonstrated a significantly attenuated rise in SBP immediately after the catheter change (9.5?mmHg vs 26.9?mmHg for post-treatment, P?=?.014) relative to baseline SBP.

Conclusion: In individuals with SCI at risk of AD, pretreatment with intravesical lidocaine prior to catheter change significantly decreased both the incidence and magnitude of AD. This suggests that pretreatment with intravesical lidocaine is helpful in individuals with SCI who are prone to AD.     

Anesthetic management of parturients with pre-existing paraplegia or tetraplegia: a case series

With improvements in management and rehabilitation, more women with spinal cord injury are conceiving children. Physiologic manifestations of spinal cord injury can complicate anesthetic management during labor and delivery. Patients who delivered at Mayo Clinic, Rochester, Minnesota between January 1, 2001 and May 31, 2012 with a history of traumatic spinal cord injury were identified via electronic record search of all parturients. Eight patients undergoing nine deliveries were identified. Six deliveries (67%) among five patients (63%) involved a trial of labor. Among these deliveries, three (50%) occurred vaginally, all with successful epidural analgesia. Trial of labor failed in the remaining three patients, and required cesarean delivery facilitated via epidural (n=1), spinal (n=1) and general anesthesia (n=1). Three patients (33%) underwent scheduled cesarean delivery via epidural (n=1), spinal (n=1), and general anesthesia (n=1). Four patients having five deliveries had a history of autonomic hyperreflexia before pregnancy. One patient had symptoms during pregnancy, two patients had episodes during labor and delivery, and three patients described symptoms in the immediate postpartum period. These symptoms were not reported by any patient without a history of autonomic hyperreflexia. Neuraxial labor analgesia may have a higher failure rate in patients with spinal cord injury, possibly related to the presence of Harrington rods. Postpartum exacerbations of autonomic hyperreflexia are common in patients with a history of the disorder.     

Anxiety masquerading as autonomic dysreflexia

Context: Autonomic dysreflexia (AD) is characterized by a sudden onset of hypertension in those with spinal cord injuries (SCI) at T6 or above. Prompt recognition and treatment of AD is important. Herein are two individuals with SCI and acute hypertension due to anxiety that may easily have been confused for AD.

Findings: Case 1: A 77-year-old male with C4 AIS D SCI and a history of anxiety and AD presented for urodynamics to evaluate the effectiveness of onabotulinumtoxinA injections into his urethral sphincter. After lying down on the urodynamics table, his systolic blood pressure (SBP) was noted to rise, from 138 to 170?mmHg over six minutes without any instrumentation or position change. Upon announcing urodynamics would be postponed and preparing for AD management, his SBP returned to below baseline within two minutes. Case 2: A 57-year-old male with T12 AIS A SCI and a history of anxiety presented for routine urodynamics. His baseline SBP was 140?mmHg. During bladder filling, incidental SBP was elevated to 170?mmHg. Filling was stopped and he was told the study was complete. One minute later, prior to draining his bladder, SBP decreased to 150?mmHg.

Conclusions: An individual's psychological state should be considered in addition to traditional management of AD when an individual with SCI presents with hypertension. Moreover, Case 2 may possibly explain reports of individuals presenting with AD with injuries below T6.     

PRES secondary to autonomic dysreflexia: A case series and review of the literature

Context: Autonomic dysreflexia (AD) is a complex syndrome seen in patients with spinal cord injuries (SCI) and can be life-threatening with a significant negative impact on the health of the individual. Posterior reversible encephalopathy syndrome (PRES) is thought to be caused, in part, by rapid elevations in blood pressure; leading to posterior cerebral circulatory edema. This can result in seizures, blindness and can progress to fatal intracranial hemorrhages.Findings: Here we present two cases of patients with SCI who developed PRES from AD. Each patient was correctly diagnosed, leading to appropriate treatment of the factors leading to their AD and subsequent resolution of their PRES symptoms.Conclusions/Clinical Relevance: In SCI patients who present with new seizures, visual deficits, or other neurologic signs, PRES should be considered as a part of the differential diagnosis as a good outcome relies on rapid recognition and treatment of AD.     

Autonomie Hyperreflexia Associated with Exacerbation of Reflex Sympathetic Dystrophy

ABSTRACT

Autonomic hyperreflexia is a condition of massive paroxysmal reflex sympathetic outflow in response to noxious stimuli occurring below the major splanchnic sympathetic outflow in patients with spinal cord injuries. This heightened sympathetic outflow can result in dramatic sudomotor and vasomotor manifestations. The unique nature of this sympathetic-mediated response following traumatic spinal cord injury provides a model for the study of the autonomic nervous system in normal and pathological conditions. A case of autonomic hyperreflexia exacerbating the pain of reflex sympathetic dystrophy in a patient with tetraplegia illustrates the role of the sympathetic nervous system in the pathophysiology of sympathetic-mediated pain and supports current treatment options for these conditions. (J Spinal Cord Med; 19:255–257)