Autonomic dysreflexia in urological practice: pathophysiology, prevention and treatment considerations.

PURPOSE: Spinal cord injury (SCI) leads to sensorimotor impairments; however, it can also be complicated by significant autonomic dysfunction, including cardiovascular and lower urinary tract (LUT) dysfunctions. Autonomic dysreflexia (AD) is a dangerous cardiovascular complication of SCI often overlooked by healthcare professionals. AD is characterized by a sudden increase in blood pressure (BP) that can result in severe cardiovascular and cerebrovascular complications. In this review, we provide an overview on the clinical manifestations, risk factors, underlying mechanisms, and current approaches in prevention and management of AD. METHODS: After conducting a literature research, we summarized relevant information regarding the clinical and pathophysiological aspects in the context of urological clinical practice CONCLUSIONS: The most common triggers of AD are those arising from LUT, such as bladder distention and urinary tract infections. Furthermore, AD is commonly observed in individuals with SCI during urological procedures, including catheterization, cystoscopy and urodynamics. Although significant progress in the clinical assessment of AD has been made in recent decades, effective approaches for its prevention and treatment are currently lacking.

[Efficacy of fesoterodine for prevention of autonomic dysreflexia in patients with neurogenic dysfunction of the bladder after spinal cord injury].

AIM: to evaluate the effectiveness of fesoterodine for the prevention of autonomic dysreflexia (AD) in patients with neurogenic bladder dysfunction (NBD) after spinal cord injury (SCI). MATERIALS AND METHODS: a total of 53 patients with AD were included in the study. In the main group (n=33) patients received fesoterodine 4 mg per day for 12 weeks as a treatment for neurogenic bladder dysfunction and prevention of AD. In the control group (n=20), patients were monitored for 12 weeks without specific treatment. The assessment was based on the results of ADFSCI and NBSS questionnaires, daily blood pressure monitoring with the completion of a self-observation diary, cystometry with simultaneous monitoring of blood pressure and heart rate. RESULTS: In the main group there was a significant decrease in episodes and severity of AD according to ADFSCI questionnaire and an improvement in the quality of life according to NBSS questionnaire compared to the control group (p<0.001). Also, in the main group, the number of episodes of AD and systolic blood pressure decreased. The maximum bladder capacity and bladder compliance increased (p<0.001), and the maximum detrusor pressure and systolic blood pressure when the cystometric capacity was reached, decreased significantly (p<0.001) in the main group compared in comparison with the control group. CONCLUSION: Fesoterodine at a dosage of 4 mg for 12 weeks reduced the severity of symptoms of AD in patients with SCI and NBD, which was manifested by the stabilization of blood pressure and a decrease in the number of episodes of AD, which significantly improved the quality of life. Also, the drug led to a significant improvement in urodynamic parameters during cystometry, in the form of a decrease in detrusor pressure and an increase in cystometric capacity. We can conclude that fesoterodine is effective in the prevention of AD in patients with NBD after SCI.

Are local analgesics effective in reducing autonomic dysreflexia in individuals with spinal cord injury? A systematic review.

STUDY DESIGN: Systematic review. OBJECTIVES: To systematically review the evidence on the use of local analgesics, specifically lidocaine or bupivacaine, to prevent autonomic dysreflexia (AD) during iatrogenic procedures or bowel and bladder care routines in individuals with spinal cord injury (SCI). METHODS: A keyword search of MEDLINE, CINAHL, CENTRAL, Cochrane Reviews, PsycInfo, Embase, and Web of Science databases identified all English-language studies evaluating the efficacy of local analgesics in reducing AD. Included studies were either randomized controlled trials (RCTs) or quasi-experimental studies. Participants were adults with chronic SCI who received local analgesics prior to AD-triggering procedures or routines. Additionally, studies were required to report blood pressure values as an outcome. The methodology of this review followed the PRISMA checklist and was registered with PROSPERO (CRD42021219506). RESULTS: Four RCTs and two quasi-experimental studies met inclusion criteria. Results were narratively synthesized as meta-analysis was not possible due to heterogeneity across studies included in the review. All six studies administered lidocaine. Lidocaine was found to have a beneficial effect on AD in three studies, no effect in two studies and a detrimental effect in one study. CONCLUSIONS: Presently, RCTs and quasi-experimental studies on the use of lidocaine for reducing AD in individuals with SCI had small sample sizes and opposing findings. There is a strong need for definitive, well-monitored clinical trials with adequate sample sizes. Presently there is not enough compelling evidence to support or refute recommendations for the use of lidocaine from the AD management clinical practice guidelines.

Effects of early exercise training on the severity of autonomic dysreflexia following incomplete spinal cord injury in rodents.

Hemodynamic instability and cardiovascular (CV) dysfunction are hallmarks of patients living with cervical and high thoracic spinal cord injuries (SCI). Individuals experience bouts of autonomic dysreflexia (AD) and persistent hypotension which hamper the activities of daily living. Despite the widespread use of exercise training to improve health and CV function after SCI, little is known about how different training modalities impact hemodynamic stability and severity of AD in a model of incomplete SCI. In this study, we used implantable telemetry devices to assess animals with T2 contusions following 3.5 weeks of exercise training initiated 8 days post-injury: passive hindlimb cycling (T2-CYC, n = 5) or active forelimb swimming (T2-SW, n = 6). Uninjured and non-exercised SCI control groups were also included (CON, n = 6; T2-CON, n = 7; T10-CON, n = 6). Five weeks post-injury, both T2-CON and T2-CYC presented with resting hypotension compared to uninjured CON and T10-CON groups; no differences were noted in resting blood pressure in T2-SW versus CON and T10-CON. Furthermore, pressor responses to colorectal distention (AD) were larger in all T2-injured groups compared to T10-CON, and were not attenuated by either form of exercise training. Interestingly, when T2-injured animals were re-stratified based on terminal BBB scores (regardless of training group), animals with limited hindlimb recovery (T2-LOW, n = 7) had more severe AD responses. Our results suggest that the spontaneous recovery of locomotor and autonomic function after severe but incomplete T2 SCI also influences the severity of AD, and that short periods (3.5 weeks) of passive hindlimb cycling or active forelimb swimming are ineffective in this model.

Pharmacological Inhibition of Soluble Tumor Necrosis Factor-Alpha Two Weeks after High Thoracic Spinal Cord Injury Does Not Affect Sympathetic Hyperreflexia.

After a severe, high-level spinal cord injury (SCI), plasticity to intraspinal circuits below injury results in heightened spinal sympathetic reflex activity and detrimentally impacts peripheral organ systems. Such sympathetic hyperreflexia is immediately apparent as an episode of autonomic dysreflexia (AD), a life-threatening condition characterized by sudden hypertension and reflexive bradycardia following below-level sensory inputs; for example, pressure sores or impacted fecal matter. Over time, plasticity within the spinal sympathetic reflex (SSR) circuit contributes to the progressive intensification of AD events, as the frequency and severity of AD events increase greatly beginning ∼2 weeks post-injury (wpi). The neuroimmune system has been implicated in driving sympathetic hyperreflexia, as inhibition of the cytokine soluble tumor necrosis factor-alpha (sTNFα) using the biological mimetic XPro1595 beginning within days post-SCI has been shown to attenuate the development of AD. Here, we sought to further understand the effective therapeutic time window of XPro1595 to diminish sympathetic hyperreflexia, as indicated by AD. We delayed the commencement of continuous intrathecal administration of XPro1595 until 2 weeks after a complete, thoracic level 3 injury in adult rats. We examined the severity of colorectal distension-induced AD biweekly. We found that initiation of sTNFα inhibition at 2 wpi does not attenuate the severity or intensification of sympathetic hyperreflexia compared with saline-treated controls. Coupled with previous data from our group, these findings suggest that central sTNFα signaling must be targeted prior to 2 weeks post-SCI in order to decrease sympathetic hyperreflexia.

Clinical recommendations for use of lidocaine lubricant during bowel care after spinal cord injury prolong care routines and worsen autonomic dysreflexia: results from a randomised clinical trial.

STUDY DESIGN: Clinical trial. OBJECTIVE: Spinal cord injury (SCI) impacts autonomic function and bowel management. Bowel care is a potential trigger for autonomic dysreflexia (AD; paroxysmal hypertension elicited by sensory stimuli below the level of lesion). AD can be life threatening so strategies to minimise AD are prioritised after SCI. Lidocaine lubricant is recommended during bowel care with the rationale to minimise the sensory stimulus, reducing AD. The objective of this study was to assess whether lidocaine lubricant (Xylocaine 2%) ameliorates AD during at-home bowel care compared with standard lubricant (placebo). SETTING: Community. METHOD: Participants (n = 13; age 44.0 ± 3.3 years) with high-level SCI (C3-T4) performed their normal at-home bowel care on two days, each time using a different lubricant, with continuous non-invasive cardiovascular monitoring. Injury to spinal autonomic (sympathetic) nerves was determined from low-frequency systolic arterial pressure (LF SAP) variability. RESULTS: Participants displayed reduced autonomic function (LF SAP 3.02 ± 0.84 mmHg2), suggesting impaired autonomic control. Bowel care duration was increased with lidocaine (79.1 ± 10.0 min) compared to placebo (57.7 ± 6.3 min; p = 0.018). All participants experienced AD on both days, but maximum SAP was higher with lidocaine (214.3 ± 10.5 mmHg) than placebo (196.7 ± 10.0 mmHg; p = 0.046). Overall, SAP was higher for longer with lidocaine (6.5 × 105 ± 0.9 × 105 mmHg • beat) than placebo (4.4 × 105 ± 0.6 × 105 mmHg • beat; p = 0.018) indicating a higher burden of AD. Heart rate and rhythm disturbances were increased during AD, particularly with lidocaine use. CONCLUSIONS: At-home bowel care was a potent trigger for AD. Our findings contradict recommendations for lidocaine use during bowel care, suggesting that anaesthetic lubricants impair reflex bowel emptying, resulting in longer care routines with an increased burden of AD.

[A rare complication of transrectal electrostimulation for sperm retrieval]. / Das ist doch kein Beinbruch?! Eine seltene Komplikation der transrektalen Elektrostimulation zur Spermagewinnung.

In men who wish to have children after a spinal cord injury, assisted ejaculation is frequently needed for sperm retrieval. Transrectal electrostimulation (TES) is often used for this purpose. Typical side effects of TES are autonomic dysreflexia or pain. In a 33-year old man with complete tetraplegia below C6 since 2004, TES caused massive leg spasticity, leading to transcervical fracture of the femoral neck. This previously unreported complication of TES demonstrates that, in men with long-term chronic tetraplegia, spasticity and osteoporosis, TES in anesthesia should be taken into consideration.

Reconstructive surgery and patients with spinal cord injury: Perioperative considerations for the plastic surgeon.

BACKGROUND: Patients with spinal cord injury (SCI) requiring reconstructive surgery, particularly for pressure ulcers, are ubiquitous in Plastic and Reconstructive Surgery practices. Much of the current literature focuses on operative techniques, antibiotic indications, sitting protocols, and dressing and bedding choices. METHODS: This paper reviews normal neuroanatomy, outlines changes in neurophysiology observed in spinal cord injury, and addresses concepts related to perioperative care that are highly relevant but often under-emphasised. RESULTS: Vascular disturbances such as autonomic dysreflexia and orthostatic hypotension are dangerous phenomena occurring in this patient population that, if not properly recognised and treated, may result in complications such as haematoma, flap loss, inadequate tissue perfusion, and death. The management of spasticity, deep venous thrombosis, and perioperative pain are also relevant and discussed in this paper. CONCLUSION: A basic understanding of these concepts is essential for the Plastic Surgeon involved in the care of patients with SCI and pressure ulcers, particularly before and after debridement or reconstruction.

Prevention of recurrent autonomic dysreflexia: a survey of current practice.

OBJECTIVE: There is a dearth of literature on the treatment of chronic recurrent autonomic dysreflexia (AD), a well-known complication of spinal cord injury that can have life-threatening implications. This study sought to identify clinical practices regarding the treatment of AD, both acute and recurrent, in patients with spinal cord injury (SCI). METHODS: Online survey regarding AD management in SCI composed of 11 questions designed to obtain information on respondent characteristics, AD treatment options, and causes of AD. SETTING: Veterans Administration health care system. PARTICIPANTS: Veterans Health Administration National SCI Staff Physicians were sent an electronic email to participate in the anonymous web-based survey. INTERVENTION: None applicable. RESULTS: The response rate was 52%. The most commonly prescribed medications for minor and severe acute manifestations of AD were nitrates. For recurrent AD, clonidine was the most commonly prescribed medication. INTERPRETATION: Anti-hypertensive medications continue to be the mainstay in the management of both acute and chronic recurrent AD. Current literature is lacking in prospective randomized controlled trials investigating the relative efficacy of AD interventions. Evidence-based practice guidelines are necessary to improve clinical care.

[Subarachnoid hemorrhage due to autonomic dysreflexia: rare consequence of sexual stimulation in a paraplegic]. / Subarachnoidalblutung durch autonome Dysreflexie: Seltene Folge einer sexuellen Stimulation bei Paraplegie.

Nearly all men with spinal cord injury suffer from neurogenic sexual dysfunction which is often treated with phosphodiesterase-5 (PDE5) inhibitors. We describe a case of subarachnoid hemorrhage due to autonomic dysreflexia (AD) caused by sexual stimulation. Nitrates are frequently used for acute treatment of AD; however, the use of these drugs in combination with PDE5 inhibitors is contraindicated. Therefore, meticulous information from patients and relatives on the risk of AD and possible drug interactions is of vital importance.

Testing for boosting at the Paralympic games: policies, results and future directions.

BACKGROUND: 'Boosting' is defined as the intentional induction of autonomic dysreflexia (AD) by athletes with a spinal cord injury (SCI) at or above the level of T6 for the purpose of improving sports performance. Boosting has been shown to confer up to a 9.7% improvement in race time. Additionally, to compete in a hazardous dysreflexic state, whether intentional or unintentional, would present an extreme health risk to the athlete. For these reasons, the International Paralympic Committee strictly bans the practice of boosting, and has developed a protocol to test for its presence. METHODS: Testing was performed at three major international Paralympic events. Education regarding the dangers of AD was provided to athletes and team staff. Testing was conducted on athletes from the relevant sport classes: Athletics (wheelchair racing classes T51/T52/T53) and Handcycling (H1). Key parameters included the athlete's demographics (gender, country of origin), classification and blood pressure measurements. An extremely elevated blood pressure was considered to be a proxy maker for AD, and a systolic blood pressure of ≥180 mm Hg was considered a positive test. RESULTS: A total of 78 tests for the presence of AD were performed during the three games combined. No athlete tested positive. The number of athletes tested, by classification, was: 6 in Athletics T51, 47 in Athletics T52, 9 in Athletics T53 and 16 in Handcycling H1. Of those tested, the average systolic and diastolic blood pressures were 135 mm Hg (range 98-178) and 82 mm Hg (range 44-112), respectively. All athletes were compliant with testing. No athletes were withdrawn from competition due to the presence of AD. DISCUSSION: Testing for the presence of AD in paralympic athletes with SCI prior to competition has been carried out for the first time at three major international paralympic competitions. There have been no positive tests thus far. Knowledge gained during these early testing experiences will be used to guide ongoing refinement of the testing protocol and the development of further educational initiatives.

Autonomic dysreflexia: recognizing a common serious condition in patients with spinal cord injury.

OBJECTIVE: To raise family physicians' awareness of autonomic dysreflexia (AD) in patients with spinal cord injury (SCI) and to provide some suggestions for intervention. SOURCES OF INFORMATION: MEDLINE was searched from 1970 to July 2011 using the terms autonomic dysreflexia and spinal cord injury with family medicine or primary care. Other relevant guidelines and resources were reviewed and used. MAIN MESSAGE: Family physicians often lack confidence in treating patients with SCI, see them as complex and time-consuming, and feel undertrained to meet their needs. Family physicians provide a vital component of the health care of such patients, and understanding of the unique medical conditions related to SCI is important. Autonomic dysreflexia is an important, common, and potentially serious condition with which many family physicians are unfamiliar. This article will review the signs and symptoms of AD and offer some acute management options and preventive strategies for family physicians. CONCLUSION: Family physicians should be aware of which patients with SCI are susceptible to AD and monitor those affected by it. Outlined is an approach to acute management. Family physicians play a pivotal role in prevention of AD through education (of the patient and other health care providers) and incorporation of strategies such as appropriate bladder, bowel, and skin care practices and warnings and management plans in the medical chart.

Autonomic dysreflexia: an important cardiovascular complication in spinal cord injury patients.

Autonomic dysreflexia (AD) is a life-threatening complication of spinal cord injury (SCI) at T6 or above that results in an uncontrolled sympathetic discharge in response to noxious stimuli. It is a symptom complex characterized by a lethal rise in blood pressure with dangerous consequences. Autonomic dysreflexia is often secondary to urological, gastrointestinal, or gynecological problems or manipulations. Early recognition and prompt treatment of AD is vital to prevent complications, including death. Its management starts primarily with its prevention. Easy measures can avoid this high risk event, and physicians should be aware of the simple procedures and the possible treatment cascade that could be undertaken. The purpose of this systematic review is to review the clinical data on the mechanisms and pathophysiology of this condition and the clinical evidence about the various strategies currently used to prevent and manage AD in the SCI population; and to improve awareness of AD among cardiologists, family physicians and medical personnel in the emergency department.

Obstetric management following traumatic tetraplegia: case series and literature review.

OBJECTIVE: Pregnancy in tetraplegia is a rare event, with only sporadic cases reported. This case series describes seven pregnancies in five tetraplegic women, all with spinal cord injuries in the region of C6. DESIGN: Retrospective case series. SETTING: Sydney, Australia. POPULATION: All tetraplegic women presenting to the obstetric service of a university teaching hospital, which also provides a regional spinal injury service, between 1981 and 2006. METHODS: Hospital records of all patients were examined and information extracted regarding demographics, pregnancies and their complications, labour and delivery and neonatal data. MAIN OUTCOME MEASURES: Course, complications, management and outcomes of pregnancy in tetraplegic women. RESULTS: Mean age at the time of injury was 22 years, and, at the time of pregnancy, 33 years. All patients suffered recurrent, and sometimes severe, urinary tract infections and episodes of autonomic dysreflexia during pregnancy. Frequent and sometimes lengthy hospital admissions were required for these and other reasons. Only two pregnancies required caesarean section and all entered labour spontaneously, at a mean of 37.9 weeks of gestation. Episodes of autonomic dysreflexia were aggressively managed using pre-emptive epidural anaesthesia and sublingual nifedipine. All pregnancies resulted in normal, near-term babies with no serious perinatal problems. CONCLUSIONS: Pregnancy and childbirth in tetraplegic women can be undertaken safely, usually with spontaneous onset of labour and vaginal delivery. However, hospitalisation for intercurrent problems is common. Management requires a multidisciplinary approach and is best undertaken in major centres with both obstetric and spinal cord injuries medical expertise.