Autonomic Dysreflexia in a Man With Multiple Sclerosis

Background/Objective:

To report manifestation of autonomic dysreflexia (AD) in a man with multiple sclerosis (MS).

Design:

Case report.

Findings:

A young man presented with a history of several admissions to the emergency department with complaints of hypertensive attacks, palpitations, difficulty in breathing, headaches, and flushing. The attacks were attributed to a previously diagnosed anxiety disorder. Onset of numbness of the left leg numbness prompted a more thorough study, which showed evidence of MS. AD was suspected as the cause of his recurrent attacks of hypertension. Bladder distension was identified as the cause of AD, and his hypertensive attacks were controlled by management of neurogenic bladder.

Conclusions:

This report emphasizes that AD can occur in MS. Somatic symptoms warrant thorough investigation before attributing them to psychosomatic causes.     

Autonomic Dysreflexia: Incidence In Persons With Neurologically Complete And Incomplete Tetraplegia

Abstract

Background: Autonomic dysreflexia (AD) is a common problem in patients with spinal cord injury (SCI) above the T6 neurologic level and may cause serious medical complications if untreated. Previous studies have focused on patients with complete SCI.

Design: Prospective analysis of a historic cohort. A retrospective review of a subset of the cohort also was performed.

Objectives: To examine the percentage of persons with complete and incomplete tetraplegia who developed AD and determine whether patients with incomplete injuries were at risk for developing AD; and to study the onset of AD and determine the time period that patients are at risk for developing AD.

Methods: Data were collected prospectively on 332 patients with tetraplegia to determine American Spinal Injury Association (ASIA) impairment score, neurologic level, presence of AD, and length of hospital stay. The charts of 3 4 patients who developed AD were then reviewed retrospectively for further data such as onset and contributing factors of AD. Also obtained were data from the National SCI Statistical Center database for comparison of percentage of patients with complete and incomplete injuries who developed AD.

Results: Patients with motor-complete SCI (ASIA A or ASIA B) had a higher percentage of AD (P = 0.001) during their initial hospitalization than did patients with motor-incomplete SCI. However, patients with motor-incomplete injuries also were at risk for developing AD. The onset of AD occurred between 1 and 6 months after injury.

Conclusion: Patients with incomplete tetraplegia are at risk for developing AD. As hospital lengths of stay decrease, patients may be discharged before onset of symptoms. Patient and family education about AD is, therefore, increasingly important for all patients with tetraplegia.     

Autonomic Dysreflexia as a Complication of a Fecal Management System in a Man With Tetraplegia

Background/Objective:

To present a case of autonomic dysreflexia caused by the use of a fecal management system in a patient with tetraplegia.

Design:

Case report.

Setting:

Military rehabilitation center.

Results:

A man with tetraplegia had a fecal management system inserted to divert stool away from his sacral pressure ulcer to reduce contamination and infection risk. Two days later, he developed severe autonomic dysreflexia that improved after removal of the system.

Conclusions:

Autonomic dysreflexia, a life-threatening complication, has not been reported before as a side effect of a fecal management system. These systems should be used with caution in patients with high-level spinal cord injury.     

Evaluating Knowledge of Autonomic Dysreflexia Among Individuals With Spinal Cord Injury and Their Families

Background/Objective:     

Effect of intravesical botulinum toxin injection on symptoms of autonomic dysreflexia in a patient with chronic spinal cord injury: a case report

Context: There are few treatment options for managing autonomic dysreflexia in patients with chronic spinal cord injury (SCI). According to some studies, intravesical botulinum toxin for SCI patients with autonomic dysreflexia has a preventive effect on symptoms of autonomic dysreflexia. However, the usefulness of an intravesical botulinum toxin injection has never been reported for autonomic dysreflexia in an adult patient with chronic cervical SCI, although there has been for one pediatric patient.

Findings: A 62-year-old man with chronic cervical SCI had neurogenic bladder due to C6-7 SCI since sustaining a fall in 1980. He presented with an intermittent headache and severe hypertension because of persistent autonomic dysreflexia. His symptoms did not improve with conservative management, and he could not undergo an operation to resect the lung cancer because of his uncontrolled blood pressure. To control his fluctuating blood pressure, he was taken to an operating room to receive an intravesical botulinum toxin injection for refractory bladder spasms. Subsequently, his blood pressure was controlled, and then the lung mass could be surgically removed. His improved condition lasted for more than 6 months.

Conclusion: This case suggests that botulinum toxin is a logical treatment option for autonomic dysreflexia as well as neurogenic detrusor overactivity in patients with chronic SCI. Dedicated research is warranted to assess the efficacy of an intravesical botulinum toxin injection, as it was used successfully to stop the symptoms of autonomic dysreflexia in our patient.     

A safe and effective multi–day colonoscopy bowel preparation for individuals with spinal cord injuries

Context/Objective: Colonoscopy with polypectomy is associated with a reduced risk of colorectal cancer (CRC), but poor bowel cleansing limits the diagnostic yield of the procedure. Patients with spinal cord injury (SCI) frequently have suboptimal bowel cleansing with standard pre-colonoscopy bowel preparation regimens. We aimed to assess the safety, tolerability, and efficacy of a multi–day inpatient bowel preparation regimen in a population of patients with SCI.

Design: Retrospective case series.

Setting: VA Puget Sound SCI Center.

Participants: All patients with SCI (n?=?53) who underwent inpatient colonoscopy at the VA Puget Sound from July 12, 2013 to February 12, 2015.

Outcome Measures: Patient characteristics, tolerance of full bowel preparation, pre- and post-bowel preparation electrolyte values, adverse events, and adequacy of bowel cleansing were abstracted.

Results: Sixty-eight percent of patients had a cervical level of injury and the majority were either American Spinal Injury Association Impairment Scale A (41%) or D (43%). The full bowel preparation was tolerated by 91% of inpatients. In those with pre- and post-bowel preparation laboratory testing, there were small, but statistically significant decreases in serum calcium and phosphate. No patient had symptoms associated with electrolyte abnormalities or required treatment. Five out of 53 inpatients experienced autonomic dysreflexia (AD) during bowel preparation. Eighty-nine percent of patients had adequate bowel cleansing at colonoscopy.

Conclusions: We demonstrate a safe and effective inpatient bowel preparation regimen in a SCI population. The regimen was associated with mild, asymptomatic hypophosphatemia and hypocalcemia. AD was an uncommon event, predominantly occurring in patients who experienced frequent AD episodes at baseline.     

A retrospective review of safety using a nursing driven protocol for autonomic dysreflexia in patients with spinal cord injuries

Objective/Background: Autonomic dysreflexia is a potentially life-threatening condition which afflicts a significant proportion of individuals with spinal cord injuries (SCI). To date, the safety and efficacy of several commonly used interventions for this condition have not been studied.

Design: A retrospective chart review of the safety of a previously implemented nursing driven inpatient autonomic dysreflexia protocol.

Methods: Seventy-eight male patients with SCI who experienced autonomic dysreflexia while inpatient at our Veterans Affairs SCI unit over a 3–1/2-year period were included. The safety of a nursing driven protocol utilizing conservative measures, nitroglycerin paste, and oral hydralazine was evaluated.

Outcome Measures: Occurrence of adverse events and relative hypotensive events during all episodes treated with the protocol, and efficacy of attaining target blood pressure for all episodes with protocol adherence and for initial episode experienced by each patient.

Results: Four hundred forty-five episodes of autonomic dysreflexia were recorded in the study period, with 92% adherence to the protocol. When the protocol was followed, target blood pressure was achieved for 97.6% of all episodes. Twenty-three total adverse events occurred (5.2% of all episodes). All adverse events were due to hypotension and only 0.9% required interventions beyond clinical monitoring. Of each patient's initial autonomic dysreflexia episode, 97.3% resolved using the protocol without need for further escalation of care.

Conclusion: This inpatient nursing driven-protocol for treating autonomic dysreflexia utilizing conservative measures, nitroglycerin paste and oral hydralazine achieved target blood pressure with a high success rate and a low incidence of adverse events.     

Safety and preliminary efficacy of functional electrical stimulation cycling in an individual with cervical cord injury,autonomic dysreflexia,and a pacemaker: Case report

Context: Functional electric stimulation (FES) cycling is a commonly used therapeutic exercise modality after spinal cord injury (SCI); however, additional precautions must be taken in certain situations. The purpose of this study was to develop and apply a safety monitoring protocol for autonomic dysreflexia (AD) during FES cycling and to determine if an interval-FES cycling program can be safe and beneficial to an individual with cervical SCI, a history of AD, and a non-dependent cardiac pacemaker.The participant was a 36-year-old male with C6 AIS-C SCI sustained 9 years earlier, intermittent AD, and implanted cardiac pacemaker. Ten sessions of interval-FES cycling were performed twice weekly for 5 weeks. Rating of perceived exertion (RPE), blood pressure (BP), oxygen saturation (O2sat), and heart rate (HR) were monitored before, after, and every 5 min during cycling. ECG and cardiac pacemaker were evaluated by a cardiologist after ending the program.Findings: The participant reported self-limited chills 27 times over 10 sessions (19 “light”, 3 “moderate”, 5 “sharp”). Chills coincided with BP increases 59% of the time and their magnitudes moderately correlated (r = 0.32). The ECG was determined to be normal and the pacemaker fully functional at the end of the study, while blood glucose decreased (111–105 mg/dl), HbA1c levels increased (5.5–5.9%), and resting BP decreased (118/84–108/66 mmHg).Conclusion/Clinical Relevance: A person with cervical SCI, symptomatic AD, and a non-dependent pacemaker can safely participate and benefit from the interval-FES cycling program provided adequate monitoring of symptoms and vital signs.     

Cortical blindness associated with autonomic dysreflexia in a man with tetraplegia: a rare but serious complication

CONTEXT: To describe a case of a 44-year-old man with complete C4 tetraplegia who developed transient cortical blindness in the subacute setting following episodes of autonomic dysreflexia. FINDINGS: Transient cortical blindness the day after surgery for appendicitis that had resulted in severe autonomic dysreflexia (AD) requiring aggressive blood pressure management. Imaging showed no evidence of acute stroke, but did show vasospasm in the occipital lobes. Vision improved over the next couple of months. Conclusion/clinical relevance: This case illustrates a possible profound vasomotor phenomenon (cortical blindness) associated with AD and its symptomatic treatment. Early recognition of AD and treatment of its underlying cause cannot be overemphasized.     

Cortical blindness associated with autonomic dysreflexia in a man with tetraplegia: A rare but serious complication

Abstract

Context

To describe a case of a 44-year-old man with complete C4 tetraplegia who developed transient cortical blindness in the subacute setting following episodes of autonomic dysreflexia.

Findings

Transient cortical blindness the day after surgery for appendicitis that had resulted in severe autonomic dysreflexia (AD) requiring aggressive blood pressure management. Imaging showed no evidence of acute stroke, but did show vasospasm in the occipital lobes. Vision improved over the next couple of months.

Conclusion/clinical relevance

This case illustrates a possible profound vasomotor phenomenon (cortical blindness) associated with AD and its symptomatic treatment. Early recognition of AD and treatment of its underlying cause cannot be overemphasized.     

Life-threatening outcomes associated with autonomic dysreflexia: A clinical review

Context

Autonomic dysreflexia (AD) is a life-threatening complication of chronic traumatic spinal cord injury (SCI).

Objective

To document and provide insight into the life-threatening sequelae associated with AD.

Methods

A review was conducted to identify literature which documented cases of AD associated with life-threatening outcomes (and death). The search strategy comprised of a keyword search on the PubMed database as well as manual searches of retrieved articles. Outcomes were categorized into three main classes: central nervous system (CNS), cardiovascular (CV), and pulmonary.

Results

Thirty-two cases of death or life-threatening complications of AD were found. Twenty-three (72%) cases were CNS-related, seven (22%) cases were CV-related, and two (6%) cases were pulmonary-related. In total, seven (22%) deaths were noted as a direct result of complications following an AD attack.

Conclusion

AD is a well-known consequence of SCI among individuals with high thoracic and cervical injuries. Many of these individuals experience this condition on a daily basis. Medical personnel, care givers, and individuals with SCI should be aware of the importance of timely diagnosis and management of this life-threatening condition, which can result in a variety of significant complications including stroke, seizures, myocardial ischemia, and death.     

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.     

“The ABCs of AD”: A prospective evaluation of the efficacy of an educational intervention to increase knowledge of autonomic dysreflexia management among emergency health care professionals

Context/Objective: Despite the availability of consensus-based resources, first responders and emergency room (ER) health care professionals (HCPs) have limited knowledge regarding autonomic dysreflexia (AD) recognition and treatment. The purpose of this study was to assess the efficacy of “The ABCs of AD” educational seminar for improving HCPs’ short- and long-term knowledge of AD recognition, diagnosis, and management.

Design: Multi-center prospective pre, post, and follow-up questionnaire study.

Setting: Level I trauma centers with emergency departments in British Columbia, Manitoba, and Ontario.

Methods: ER professionals completed measures immediately before and after (n?=?108), as well as 3-months following (n?=?23), attendance at “The ABCs of AD” seminar.

Outcome Measures: AD knowledge test; seminar feedback.

Results: Following the seminar, participants had higher ratings of their AD knowledge and had significantly higher AD knowledge test scores (M?±?SD pre?=?11.85?±?3.88, M?±?SD post?=?18.95?±?2.39, out of 22; P?<?0.001, d?=?2.21). Most participants believed the seminar changed their AD knowledge, and rated the seminar information as having the potential to influence and change their practice. AD knowledge test scores significantly decreased between post-seminar and 3-month follow-up (M?±?SD 3mo?=?17.04?±?3.28; P?=?0.004, d?=?–0.70); however, 3-month scores remained significantly higher than baseline.

Conclusion: “The ABCs of AD” seminar improves HCPs’ perceived and actual AD knowledge in the short-term. To enhance knowledge retention in both the short- and long-term, the inclusion of additional active learning strategies and follow-up activities are recommended. The seminar is being translated into an online training module to enhance the dissemination of the AD clinical practice guidelines among first responders, ER staff, and SCI practitioners.     

Accuracy Of Individuals With Spinal Cord Injury At Predicting Urinary Tract Infections Based On Their Symptoms

Abstract

Objective: To determine whether individuals with spinal cord injuries (SCis) who complain of symptoms of a urinary tract infection (UTI) actually have a UTI.

Design: A 9-month prospective case review.

Participants: One hundred and forty-seven persons with SCI who presented to an outpatient urology clinic with symptoms they attributed to a UTI.

Main Outcome Measures: Presence or absence of a UTI as determined by signs and symptoms of a UTI and a microscopic urine analysis (UA) for white blood cell (WBC) and bacterial colony counts.

Methods: A UTI was defined as new onset of clinical signs and symptoms, significant bacterial colony counts in the urine, and evidence of tissue invasion with elevated WBC count 2:10/ high power field in the urine. Evaluation of each individual included history, physical examination, and UA with a culture and sensitivity. Evaluation for other medical problems was undertaken if history, physical examination, and laboratory results were not consistent with a UTI.

Results: Sixty-one percent (90/147) of SCI persons we re accurate in predicting the presence of a UTI based on their symptoms; 39% (57 /147) were not accurate. In the group of 57 pe rsons who were not accurate in predicting whether they had a UTI, 12 persons had other medical problems including fecal impaction, bowel obstruction, dehydration, heat intolerance, glucosuria, other infectious processes, respiratory problems, and neurologic problems. The remaining 45 had bacteriuria with no pyuria. The type of bladder management did not have an impact on the accuracy of predicting the presence or absence of a UTI (P = 0 .03).     

Reliability Of Cystometrically Obtained Intravesical Pressures In Patients With Neurogenic Bladders

Abstract

Background and Purpose: Urodynamic studies in patients with neurogenic bladder detect and categorize neurourodynamic states, identify the risk for urologic sequelae, and determine the necessity for interventions. Because urodynamic studies serves as a prognostic indicator and guides patient management, pressure measurements during the study must accurately represent bladder function under physiologic conditions. Because nonphysiologic bladder filling used during conventional urodynamic studies may alter the bladder s accommodative properties, we studied how closely the intravesical pressures obtained before filling cystometry resembled those obtained during the filling phase of the cystometrogram.

Methods: Twenty-two patients (21 men, 1 woman) with neurogenic bladders underwent standard urodynamic studies. A 16F triple-lumen catheter was inserted into the bladder, and the intravesical pressures were recorded (physiologic volume-specific pressures, PVSP). After emptying the bladder, an equal volume of normal saline solution was reinfused, and the pressures were recorded again (cystometric volume-specific pressure, CVSP). All patients underwent routine fluoroscopically assisted urodynamic testing. The PVSP and the CVSP were compared using the Wilcoxon signed ranks test. P value of .05 was significant.

Results: The mean PVSP was 14.5 cmH₂O (range, 4-42 cmH₂O) and mean CVSP was 20.6 cmH₂O (range, 6-70 cmH₂O). The CVSP was significantly higher than the PVSP (P = .01).

Conclusion: Filling pressures during cystometry (CVSP) were significantly higher than the pressures measured at rest (PVSP). This study also suggests a strong correlation between PVSP and CVSP.     

Inflammatory Sacroiliitis in a Man With Spinal Cord Injury

Abstract

Background: Inflammatory sacroiliitis associated with spinal cord injury (SCI) as an unusual cause of elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level has not been reported previously to our knowledge.

Objective: To represent a case of SCI associated with bilateral sacroiliitis causing ESR and CRP level elevation.

Methods: Case report of a man with T9 paraplegia.

Findings: ESR and CRP levels were high. Pelvic radiography was nearly normal, except for mildly blurred sacroiliac joints with normal margins. A 3-phase bone scan revealed bilateral sacroiliitis and heterotopic ossification at medial side of the left knee. Past history was significant for a recent urinary tract infection. Indomethacin and etidronate were prescribed. Significant decreases in ESR and CRP level were seen 1 month later.

Conclusions: Sacroiliitis might be an unusual cause of elevated ESR and CRP levels in patients with SCI. Sensory and motor deficits may obscure the typical clinical presentation; therefore, imaging studies are essential for the diagnosis.     

Muscle invasive bladder cancer presenting as recurrent autonomic dysreflexia – a wolf in wolf’s clothing

Context: Autonomic dysreflexia is a potentially lethal condition experienced by spinal cord injury (SCI) patients. It has a wide range of causes, most of which are genitourinary in nature. However, there has been no documented case of primary bladder cancer as a trigger for recurrent autonomic dysreflexia.

Findings: We present a case of a 51-year-old spinal cord injury patient with multiple presentations of autonomic dysreflexia. Work up revealed locally invasive bladder cancer, and following definitive surgery, his symptoms were alleviated.

Conclusions: In SCI patients with recurrent AD, comprehensive work up with involvement of a specialized Urologist is required as AD may be the only presenting symptom of a serious underlying medical condition.     

Vertebral insufficiency fractures as a cause of autonomic dysreflexia in a patient with chronic tetraplegia: A case report

Context: Osteoporosis is a known complication in spinal cord injury patients and can result in an increased risk of fractures and associated morbidity. Bone demineralization is most common in long bones below the level of injury. The pathogenesis is complex and not fully understood.Findings: We present the case of a 65-year-old male with chronic spinal cord injury who was found to have multiple vertebral compression fractures causing autonomic dysreflexia and new onset spasticity.Conclusion/Clinical Relevance: This case illustrates the need for improved awareness, diagnosis, and prevention for this disease process.