Autonomic dysreflexia associated with transient aphasia

STUDY DESIGN: Case report of autonomic dysreflexia presenting with transient aphasia in a subject with C4 tetraplegia. OBJECTIVES: To report a rare case of autonomic dysreflexia. SETTING: Rehabilitation Service, The Ohio State University, USA. CASE REPORT: A 21-year-old man with a C4 spinal cord injury (ASIA B) developed aphasia associated with autonomic dysreflexia. He was treated with an adrenergic blocking agent. CONCLUSION: Autonomic dysreflexia manifested by a transient aphasia and seizures is uncommon.     

Autonomic dysreflexia in multiple sclerosis

BACKGROUND: Although autonomic dysreflexia (AD) is well documented in the spinal cord injury (SCI) population, its occurrence in persons with multiple sclerosis (MS) is not. A dense multiple sclerotic lesion in the spinal cord at or above the sixth thoracic level can cause interruption of descending inhibitory impulses and thus result in AD. A patient with MS presented to our facility with classic signs and symptoms of AD. We believe that lack of knowledge about the risks for this condition in MS led to a delay in diagnosis. METHODS: Case report illustrates AD in a person with MS. A convenience survey was conducted among clinicians who provide care to people with MS. The survey looked at both awareness of, and experience with, AD in MS. RESULTS: Forty-five percent of the respondents indicated they were not aware of the potential risk for AD among MS patients. Only 10% indicated they were aware of MS patients in their practice who had experienced AD. CONCLUSION: Although AD is probably less common in MS than in SCI, this case does not appear to be unique. Knowledge of this potential life-threatening complication of MS seems to be limited.     

Autonomic dysreflexia: a plastic surgery primer

Plastic surgeons are integral to the management team for patients with spinal cord injuries, with responsibilities including pressure sore management and upper extremity reconstruction. Injury to the spinal cord profoundly disrupts the body's ability to maintain homeostasis. In particular, the autonomic system can become unregulated, resulting in a massive sympathetic discharge called autonomic dysreflexia. Autonomic dysreflexia occurs in the majority of patients with injuries above the sixth thoracic vertebra and causes sudden, severe hypertension. If left untreated, autonomic dysreflexia can result in stroke or death. Because this syndrome causes morbidity and mortality, it is crucial for plastic surgeons to be able to recognize and treat autonomic dysreflexia. This article reviews the etiology, symptoms, and treatment of this syndrome.     

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。     

An unusual cause of autonomic dysreflexia: pheochromocytoma in an individual with tetraplegia

BACKGROUND: Autonomic dysreflexia (AD) is a frequent, serious acute syndrome that occurs in patients with spinal cord lesions at level T6 and above. The syndrome is caused by massive sympathetic discharge that is triggered by a noxious stimulus below the level of the spinal cord lesion. Pheochromocytomas are rare tumors that present with symptoms similar to AD. METHODS: Case Report. FINDINGS: A 50-year-old man with C7 American Spinal Injury Association scale A tetraplegia presented with episodes of severe headaches and paroxysmal hypertension. He was diagnosed with AD. Despite resolving bladder and bowel problems, he continued to have hypertensive episodes. A CT scan of the abdomen revealed a heterogeneous left adrenal mass. Further workup revealed significantly elevated serum and 24-hour urinary catecholamines. Clonidine failed to fully suppress the markedly elevated concentrations of serum catecholamines. These biochemical findings were consistent with the diagnosis of pheochromocytoma. Prior to surgery, the patient was treated with alpha-receptor blockers and volume expansion with intravenous fluids. A left adrenalectomy was performed. The surgical specimen revealed that the adrenal gland was expanded by a spherical mass. The pathologic report was benign pheochromocytoma of the left adrenal gland. CONCLUSION: Clinical symptoms and hypertensive episodes resolved following adrenalectomy. To our knowledge, this is the first reported case of a pheochromocytoma in an individual with spinal cord injury.     

Autonomic dysreflexia in a parturient with spinal cord injury

Autonomic dysreflexia (ADR) is a syndrome of imbalanced reflex sympathetic discharge occurring in patients with spinal cord injury (SCI) at or above the level of splanchnic sympathetic outflow (T6). We present the case of a 29 year-old, gravida 3, para 1 Caucasian female at 28 weeks gestation, with a history of T3 SCI secondary to a gunshot wound 9 years prior, who developed ADR during preterm labor and received epidural anesthesia during 6 days of labor followed by spinal anesthesia for cesarean section. Spinal anesthesia may be superior to epidural anesthesia for providing hemodynamic protection against ADR during cesarean section.     

Dysphagia in individuals with tetraplegia: incidence and risk factors

Background/objective

Dysphagia following cervical spinal cord injury (SCI) can increase risk for pulmonary complications that may delay the rehabilitative process. The objective of this study was to identify risk factors for dysphagia after cervical SCI.

Design

Prospective cohort study.

Methods

Individuals with cervical SCI within 31 days of injury underwent a bedside swallow evaluation (BSE) followed by a videofluoroscopy swallow study (VFSS) within 72 hours of the BSE. Subjects were diagnosed as having dysphagia if they had positive findings in either BSE or VFSS.

Results

Twenty-nine patients (7 female and 22 male) were enrolled. Of these, 21 (72%) had high cervical tetraplegia (C4 or higher) and 8 (38%) had lower cervical tetraplegia. A tracheostomy was present in 18 (62%) patients; 15 (52%) subjects were on ventilators. Dysphagia was diagnosed in 12 (41%) subjects. Dysphagia was noted in 62% of the subjects with tracheostomy and 53% of the subjects on the ventilator, but only tracheostomy resulted in a statistically significant association with dysphagia (P = 0.047). All three subjects who had nasogastric tubes were diagnosed with dysphagia (P = 0.029). The relationships between dysphagia and gender, high versus low tetraplegia, presence of halo or collar, head injury, and ventilator use were not statistically significant, but age was a significant risk factor (P = 0.028).

Conclusions

Dysphagia is present in about 41% of individuals with acute tetraplegia. Only age, tracheostomy, and nasogastric tubes were identified as significant risk factors for dysphagia for individuals with tetraplegia. No relationship between dysphagia and level of SCI, spine surgery, collar, and ventilator use was found to exist.     

Autonomic dysreflexia and foot and ankle surgery.

Autonomic dysreflexia is a syndrome of massive imbalance of reflex sympathetic discharge occurring in patients with spinal cord injury with a lesion above the splanchnic outflow (Thoracic 6). Autonomic dysreflexia is characterized by a sudden and severe rise in blood pressure and is potentially life threatening. Because the onset of this entity is rapid and the potential morbidity is severe, it is important for those caring for spinal cord injury patients to be aware of this syndrome. The paper presents a review of the literature, and familiarizes one with the diagnosis, pathophysiology, and treatment. Two illustrative case reports are also presented.     

Autonomic dysreflexia in response to pudendal nerve stimulation

STUDY DESIGN: Pudendal nerve stimulation in complete spinal cord injury (SCI). OBJECTIVE: To evaluate the influence of pudendal nerve stimulation on the cardiovascular system in SCI patients in order to assess the underlying neuronal mechanism and the potential risk during stimulation. SETTING: Swiss Paraplegic Center, and University Hospital, Zurich. METHODS: A total of 22 male patients with a complete SCI were divided into two groups according to the level of lesion: group A (C6-T6, n=15) and group B (T7-L2, n=7). A total of 66 stimulations using biphasic rectangular impulses (0.2 ms, 10 Hz) with intensities up to 100 mA were applied to the dorsal penile nerve. Of these, 15 stimulations in five patients were repeated after intravenous application of 7 mg of phentolamine. Heart rate (HR) and blood pressure (BP) were recorded by a Finapres cuff applied to the right index finger. RESULTS: Significant increased diastolic and systolic BP accompanied by significant decreased HR suggested the occurrence of autonomic dysreflexia (AD) during pudendal nerve stimulation. These cardiovascular changes corresponded with the subjective sensation of AD symptoms in patients of group A. Intravenous phentolamine lowered the resting BP and prevented severe hypertension during stimulation. Patients in group B presented with mild HR and BP changes in response to pudendal nerve stimulation and reported no AD symptoms. CONCLUSION: Our results show a considerable effect of electrical pudendal nerve stimulation on HR and BP in patients with high SCI. This may indicate that sacral somatic afferent fibers of the pudendal nerve are involved in the neuronal mechanism of AD in SCI patients with high neurological level. Intravenous phentolamine enables pudendal nerve stimulation without the risk of severe hypertension.     

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.     

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.     

Lipid profiles of persons with paraplegia and tetraplegia: sex differences

BACKGROUND/OBJECTIVE: To examine the lipoprotein profiles of men and women with paraplegia and tetraplegia. Impairment of the sympathetic nervous system (dependent on the level of injury) and the extent of physical capacity and activity were correlated with the lipid profile in men with spinal cord injury (SCI). Sex-related differences of the lipoprotein profiles could be found in nondisabled and premenopausal women with SCI mainly because of the different effects of sexual hormones. METHODS: Lipoprotein profiles of 112 participants with SCI (32 premenopausal women, 80 men) were analyzed and correlated to sex, lesion level, and physical performance capacity. RESULTS: Women with tetraplegia or paraplegia showed significantly higher levels of high-density lipoprotein and lower ratios of total cholesterol to high-density lipoprotein-cholesterol compared with men with corresponding lesion levels, without a difference in peak oxygen consumption. Concentrations of very-low-density lipoproteins were lower in women with paraplegia than in men with paraplegia; no differences were found in total cholesterol, low-density lipoprotein-cholesterol, and triglycerides. Sex-independent elevations in total cholesterol and low-density lipoprotein-cholesterol were associated with paraplegia, and sex-independent elevations in triglyceride levels were associated with tetraplegia. CONCLUSIONS: Persons with SCI showed sex-related differences in their lipoprotein profiles. Independent of physical fitness, the lipoprotein profile of premenopausal women with SCI did not exhibit the adverse lipoprotein characteristics observed in men with SCI, probably because of the influence of sexual hormones independent of lesion level.     

Breathing patterns during breathing exercises in persons with tetraplegia

STUDY DESIGN: Cross-sectional, observational, controlled study. OBJECTIVES: To survey breathing patterns during breathing at rest, ordinary deep breathing (DB), positive expiratory pressure (PEP) and inspiratory resistance-positive expiratory pressure (IR-PEP) among individuals with a cervical spinal cord lesion (SCL) compared with able-bodied controls. SETTING: Sahlgrenska University Hospital, G?teborg, Sweden. METHOD: Participants consisted of 20 persons with a complete SCL at the C5-C8 level (at least 1 year postinjury) and 20 matched, able-bodied controls. Breathing patterns and static lung volumes were measured using a body plethysmograph. RESULTS: Compared to the controls, breathing patterns at rest among the people with tetraplegia were characterised by a decreased tidal volume, stable respiratory rate and total cycle duration resulting in decreased mean inspiratory and expiratory flow, and alveolar ventilation. All volume and flow parameters increased except respiratory rate, which decreased during DB and PEP. During IR-PEP, tidal volume increased less compared to PEP, and combined with a decreased respiratory rate the alveolar ventilation was lower than during breathing at rest. The functional residual capacity increased during PEP and IR-PEP in people with tetraplegia. CONCLUSION: DB exercises with or without resistance during expiration or the whole breathing cycle affect the breathing pattern in persons with tetraplegia. DB was superior in increasing volumes and flow. PEP and IR-PEP increased FRC but IR-PEP decreased volumes and flows. However, large interindividual differences in the SCL group indicate the need for caution in generalising the results. SPONSORSHIP: This work was supported in part by grants from the Memorial Foundation of the Swedish Association of registered Physiotherapists and the Association of Cancer and Road Accident Victims.     

Autonomic dysreflexia in acute spinal cord injury: an under-recognized clinical entity

While autonomic dysreflexia (AD) is well recognized in the chronic stage of spinal cord injury (SCI) this potentially life-threatening complication has been only rarely documented in the acute phase (1 month) after SCI. Based on our clinical experience we hypothesized that AD is under-recognized in the acute phase of SCI. This study was undertaken to determine the incidence and clinical associations of early AD in our center. We reviewed the charts of patients with acute traumatic SCI admitted to the Toronto Western Hospital Spinal Program between 1998 and 2000. Among 58 patients with acute traumatic SCI (15F, 43M; ages 17-89 years, mean of 55.4), all three individuals who developed evidence of early AD had complete cervical tetraplegia (1F, 2M; ages 31-42 years, mean of 38.3). The incidence of early AD was 5.2% (3 of 58), whereas the adjusted incidence for the population at risk (SCI at T6 or above) was 5.7% (3 of 53). A significant number of patients in this series (87.9%, or 51 of 58) had a cervical SCI. While the mean resting systolic arterial blood pressure among these three individuals was 105.7+/-3 mm Hg, the mean systolic blood pressure at the time of early AD was 173.3+/-14.8 mm Hg (increase in systolic blood pressure over baseline ranged from 35.5% to 95%). The earliest episode of AD occurred on the 4(th) post-injury day. The trigger mechanisms for AD were somatic pain, fecal impaction, and abdominal distention. Although numerous reports emphasize AD as a potential complication of chronic SCI, our study demonstrates that AD occurs in 5.7% of patients with acute SCI above T6. Patients with severe cervical SCI are particularly susceptible to the early onset of AD. Clinicians need to be aware and highly vigilant of the potential development of AD in the acute phase of SCI.     

Hemodialysis-associated amyloidosis with cervical spinal cord compression and incomplete tetraplegia: a case report

STUDY DESIGN: Case report. OBJECTIVES: To report a rare case of hemodialysis-associated amyloidosis of cervical spinal canal with incomplete tetraplegia in long-term hemodialysis patient. SETTINGS: Traumatology Clinic, Zagreb; Spinal Unit, Varazdinske Toplice, Croatia. METHODS: Forty-seven-year-old male patient at long-term hemodialysis treatment developed progressive limbs weakness, graded as C4 ASIA C. Cervical computed tomography myelography showed extreme narrowing of the spinal canal. Decompressive laminectomy with bilateral foraminotomies was performed and histological examination revealed amyloidal deposition. RESULTS: Rehabilitation program started immediately after surgery with physical and occupational therapy, along with psychological support aiming at restoring full activities of daily living. Three months after surgery, the patient returned to his community, neurologically improved to ASIA E. Hemodialysis program was regularly maintained perioperatively and during the rehabilitation. CONCLUSION: Vertebral involvement with neurological deterioration in hemodialysis-associated amyloidosis patients prompts for early diagnosis, surgical and rehabilitation management, in this instance with good outcome.Spinal     

Self-reported effects of cold temperature exposure in persons with tetraplegia

Objective: Cervical spinal cord injury (tetraplegia) is known to interrupt sympathetic vasculature control, thereby preventing shunting of blood from the periphery to central organs when exposed to cold temperatures. As a result, persons with tetraplegia are at risk to develop hypothermia. However, information regarding the discomfort experienced during the cooler months (late fall, winter, early spring) is overwhelmingly anecdotal. It is not known, with any certainty, how those with tetraplegia perceive cold and if discomfort in colder environments restricts them from performing activities that they routinely would perform.

Design: Prospective, two-group, self-report surveys.

Setting: VA Medical Center and Kessler Institute for Rehabilitation.

Participants: Forty-four subjects with tetraplegia; 41 matched non-SCI controls.

Outcome Measures: Tetraplegic and control groups responded “yes” or “no” when asked whether cold seasonal temperatures allowed comfort or negatively affected participation in routine activities.

Results: Percentage of responses of tetraplegia compared to controls was different as to whether they felt cold when others in the same room were comfortable (82 vs. 24%; χ²?=?28.2, P?2?=?6.8, P?=?0.009), or whether cold negatively affected bathing routines (55 vs. 15%; χ²?=?14.8, P?=?0.0001), keeping physician appointments (46 vs. 12%; χ²?=?11.3, P?=?0.0008), thinking clearly (41 vs. 7%; χ²?=?12.9, P?=?0.0003), and completing usual work duties (46 vs. 10%; χ²?=?13.3, P?=?0.0003).

Conclusion: Cold seasonal temperatures have a reported greater negative impact on personal comfort and ability to perform vital activities in persons with tetraplegia than that of non-SCI controls. These findings highlight the need to address thermoregulatory impairment in persons with tetraplegia.