Autonomic hyperreflexia with spinal cord injury

Anaesthetic management of tetraplegic pregnant patients during child delivery: A systematic review

BACKGROUND

Pregnancy in spinal cord injured patients has specific issues that must be carefully addressed. However, guidelines for their management are scarce.

METHODS

A systematic review of the literature regarding the anaesthetic management during delivery of pregnant patients with cervical spinal cord injury was performed on the electronic databases of PubMed (Medline) and Cochrane.

RESULTS

Twenty-two papers were included. A higher incidence of preterm birth and caesarean delivery were seen. Anaesthetic management was diverse, although most pregnant patients received epidural analgesia. Autonomic dysreflexia symptoms were present in 51% of pregnancies.

CONCLUSION

Timely management of these patients could possibly reduce caesarean and preterm delivery rates, avoid or minimize common complications, as well as reduce costs. An early reference to anaesthesiology consultation and a multidisciplinary approach is recommended.

Unravelling innervation of pancreatic islets

The central and peripheral nervous systems play critical roles in regulating pancreatic islet function and glucose metabolism. Over the last century, in vitro and in vivo studies along with examination of human pancreas samples have revealed the structure of islet innervation, investigated the contribution of sympathetic, parasympathetic and sensory neural pathways to glucose control, and begun to determine how the structure and function of pancreatic nerves are disrupted in metabolic disease. Now, state-of-the art techniques such as 3D imaging of pancreatic innervation and targeted in vivo neuromodulation provide further insights into the anatomy and physiological roles of islet innervation. Here, we provide a summary of the published work on the anatomy of pancreatic islet innervation, its roles, and evidence for disordered islet innervation in metabolic disease. Finally, we discuss the possibilities offered by new technologies to increase our knowledge of islet innervation and its contributions to metabolic regulation.

Autonomic Dysreflexia After Hip Fractures Managed by Regional Anesthesia: A Case Report

Autonomic dysreflexia occurs after a spinal cord injury usually at the level of T6 or above, and its hallmark feature is exaggerated autonomic response to noxious stimuli resulting in uncontrolled hypertensive episodes with reflexive bradycardia that can be fatal if not controlled. We present a case highlighting regional anesthetic techniques, including peripheral nerve blocks, to ameliorate the symptoms of autonomic dysreflexia triggered by hip fractures in a 57-year-old woman with an old C5-C6 spinal cord injury before definitive hip surgery. The regional techniques described provide anesthesiologists with a simple strategy to potentially mitigate a life-threatening situation.

Treatment Plan and Challenges in Full-Mouth Rehabilitation of a Quadriplegic Patient: A Clinical Report

Spinal cord injuries lead to physical limitations, and the resulting levels of dependency and emotional distress have devastating consequences on individuals' oral health. A 46-year-old patient with incomplete quadriplegia due to a complicated medical history presented for prosthetic rehabilitation. The patient's ability and tolerance to be treated in the dental chair was assessed. Prosthetic treatment options were discussed considering his dependency on alternating caregivers. The final treatment plan involved restorative treatment, implant-supported crowns, an implant-supported fixed dental prosthesis and, in the upper jaw, an implant-supported overdenture to allow proper oral hygiene. The dental treatment sessions were performed with frequent interruptions in the dental chair, whereas the implants were placed under general anesthesia in the maxillo-facial surgery department. The final treatment plan resulted in a compromise between the prosthetic recommendation and the patient's wish. The decisive factor for choosing an implant-supported overdenture rather than an implant-supported fixed dental prosthesis in the upper jaw was the inability of the patient to maintain adequate hygiene measures by himself and his dependence on the caregivers. This clinical report demonstrates how special care dentistry can improve quality of life, even in people with severe physical and/or mental impairments. We would like to encourage dental professionals to provide high-quality care for patients with disabilities in particular, and this practice is in line with the requirements of the UN convention on the rights of persons with disabilities.

Headache Attributed to Autonomic Dysreflexia: Clinical Presentation, Pathophysiology, and Treatment

A patient presenting with marked elevation in blood pressure and concurrent headache often presents a diagnostic challenge for even the most seasoned clinician. When marked hypertension and headache occur in a patient with a history of upper spinal cord injury, the patient should be presumed to have autonomic dysreflexia until proven otherwise. Autonomic dysreflexia can at times trigger headaches, hypertension, and variations in pulse, as well other autonomic signs and symptoms. Autonomic dysreflexia is a medical emergency for which appropriate treatment may be life-saving. In this review, we address the historical origins, risk factors, pathophysiology, diagnostic criteria, clinical presentation, differential diagnosis, and treatment of headache attributed to autonomic dysreflexia. Included are two case presentations from the authors' clinic, which illustrate the diagnosis and treatment of headache attributed to autonomic dysreflexia.

Angiotensin II system in the nucleus tractus solitarii contributes to autonomic dysreflexia in rats with spinal cord injury

Background

Autonomic dysreflexia (AD) is a potentially life-threating complication after spinal cord injury (SCI), characterized by episodic hypertension induced by colon or bladder distension. The objective of this study was to determine the role of impaired baroreflex regulation by the nucleus tractus solitarii(NTS) in the occurrence of AD in a rat model.

Methods

T4 spinal cord transection animal model was used in this study, which included 40 Male rats Colorectal distension (CD) was performed to assess AD and compare the changes of BP, HR, and BRS, six weeks after operation. After that, SCI rats with successfully induced AD were selected. Losartan was microinjected into NTS in SCI rats, then 10, 30, 60 minutes later, CD was performed to calculate the changes of BP, HR, and BRS in order to explicit whether Ang II system was involved in the AD occurrence. Ang II was then Intra-cerebroventricular infused in sham operation rats with CD to mimic the activation of Ang II system in AD. Finally, the level of Ang II in NTS and colocalization of AT1R and NMDA receptor within the NTS neurons were also detected in SCI rats.

Results

Compared with sham operation, SCI significantly aggravated the elevation of blood pressure (BP) and impaired baroreflex sensitivity (BRS) induced by colorectal distension; both of which were significantly improved by microinjection of the angiotensin receptor type I (AT₁R) antagonist losartan into the NTS. Level of angiotensin II (Ang II) in the NTS was significantly increased in the SCI rats than sham. Intracerebroventricular infusion of Ang II also mimicked changes in BP and BRS induced by colorectal distension. Blockade of baroreflex by sinoaortic denervation prevented beneficial effect of losartan on AD.

Conclusion

We concluded that the activation of Ang II system in NTS may impair blood pressure baroreflex, and contribute to AD after SCI.

Advanced Hip Osteoarthritis Causing Autonomic Dysreflexia and Severe Spasticity in a Patient With Spinal Cord Injury: A Case Report

The life expectancy of persons with spinal cord injury (SCI) is increasing due to advances in medicine and technology. As a result, there is a higher incidence of age-associated illnesses in this population. Degenerative joint disease is a common age-associated illness that causes pain and thus, in persons with SCI above the T6 level, can serve as a noxious stimulus to trigger autonomic dysreflexia (AD). This is a case report of severe bilateral hip osteoarthritis (OA) causing unyielding AD in a person with tetraplegia leading to bilateral girdle stone surgeries. Hip OA as an etiology for AD has not previously been reported and is important to recognize as this population continues to age and to develop age-associated diseases.

LEVEL OF EVIDENCE

V.

Monitoring development of autonomic dysreflexia during urodynamic investigation in patients with spinal cord injury

OBJECTIVES

We aimed to investigate whether autonomic dysreflexia (AD) develops during urodynamic investigation in patients with spinal cord injury (SCI) with neurological level below thoracic (T) 6 together with the frequency and related factors for AD development.

STUDY DESIGN

Prospective study.

METHODS

The systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) of 51 SCI patients with a neurological level below T6 were measured and recorded at the beginning and every two minutes during the filling phase of the urodynamic study. The changes between the SBP, DBP and HR values at the beginning and end of the filling phase were analyzed.

RESULTS

Autonomic dysreflexia developed only in one of the 51 patients included into the study. The BP of this patient increased from 105/76 mmHg to 145/102 mmHg and the HR dropped from 88 beats/minute (bpm) to 69 bpm together with development of the AD symptoms. The patient was a 47-year-old male with a neurological level at T8. A significant difference was found between the mean SBP and the mean DBP values at the beginning and end of the filling phase.

CONCLUSIONS

Although rare, AD can be seen during urodynamic investigation in patients with a neurological level below T6, especially when close to the T6 level. Therefore, we suggest that the patients with a neurological level below T6 and especially closer to T6 level should be followed-up in terms of development of AD. The clinicians should take into account the HR values in addition to the the SBP and DBP values at follow-ups.

Effects of liposome-based local suppression of nerve growth factor in the bladder on autonomic dysreflexia during urinary bladder distention in rats with spinal cord injury

PURPOSE

To examine (1) whether spinal cord injury (SCI) time-dependently increases the severity of autonomic dysreflexia (AD) and expression levels of bladder nerve growth factor (NGF) protein, and (2) whether local suppression of NGF in the bladder improves SCI-induced AD in rats.

MATERIALS AND METHODS

SCI was produced by the transection of the T2/3 spinal cord in female Sprague-Dawley rats. At 4 or 8weeks after SCI, differences in the mean arterial blood pressure (ΔMAP) and heart rate (ΔMHR) during graded increases in intravesical pressure to 20, 40 and 60cm H₂O from those before bladder distention and NGF protein levels in the bladder wall were evaluated in spinal intact and SCI rats under urethane anesthesia. Seven weeks after SCI liposome-NGF antisense conjugates were administered intravesically to the animals. At 1week after intravesical treatment (8weeks after SCI), ΔMAP and ΔMHR during bladder distention and bladder NGF protein expression were evaluated.

RESULTS

The ΔMAP and ΔMHR were increased in a graded manner in response to bladder distention at intravesical pressures of 20, 40 and 60cm H₂O in SCI rats. These AD-like cardiovascular responses and NGF protein expression in the bladder mucosal and muscle layers were increased after SCI in a time-dependent manner. The liposome-NGF antisense treatment significantly reduced the NGF protein overexpression in the mucosal layer of SCI rat bladder and reduced ΔMAP and ΔMHR elicited by bladder distention.

CONCLUSIONS

These results indicate that the duration of the post-SCI recovery period affects the severity of AD induced by bladder distention as well as the level of bladder NGF protein, and that local suppression of NGF expression in the bladder reduces SCI-induced AD. Thus, Intravesical application of liposome-NGF antisense conjugates can be a new effective therapy for bladder distention-induced AD after SCI.

Patients with neuromuscular disorder

This article describes the preoperative preparation of patients with neuromuscular disorders. These entities are a relatively rare and diverse group of diseases that can affect various organ systems in addition to the central nervous system. The anesthetic implications for the various comorbidities are varied and can be profound. These patients should be optimized before surgery, with the involvement of a multidisciplinary team of specialists.

Disordered cardiovascular control after spinal cord injury

Damage to the spinal cord disrupts autonomic pathways, perturbing cardiovascular homeostasis. Cardiovascular dysfunction increases with higher levels of injury and greater severity. Disordered blood pressure control after spinal cord injury (SCI) has significant ramifications as cord-injured people have an increased risk of developing heart disease and stroke; cardiovascular dysfunction is currently a leading cause of death among those with SCI. Despite the clinical significance of abnormal cardiovascular control following SCI, this problem has been generally neglected by both the clinical and research community. Both autonomic dysreflexia and orthostatic hypotension are known to prevent and delay rehabilitation, and significantly impair the overall quality of life after SCI. Starting with neurogenic shock immediately after a higher SCI, ensuing cardiovascular dysfunctions include orthostatic hypotension, autonomic dysreflexia and cardiac arrhythmias. Disordered temperature regulation accompanies these autonomic dysfunctions. This chapter reviews the human and animal studies that have furthered our understanding of the pathophysiology and mechanisms of orthostatic hypotension, autonomic dysreflexia and cardiac arrhythmias. The cardiovascular dysfunction that occurs during sexual function and exercise is elaborated. New awareness of cardiovascular dysfunction after SCI has led to progress toward inclusion of this important autonomic problem in the overall assessment of the neurological condition of cord-injured people.

Transanal irrigation for disordered defecation: a systematic review

Transanal irrigation for treatment of disordered defecation has been widely used among caregivers. Unique in its simplicity, reversible and minimally invasive, transanal irrigation has begun to find its place in the treatment hierarchy. Scheduled transanal irrigation aims to ensure emptying of the left colon and rectum. This prevents faecal leakage between washouts, providing a state of pseudocontinence, and re-establishes control over the time and place of defecation. Furthermore, regular evacuation of the rectosigmoid prevents constipation. The studies presented in this review represent the continuum of increasing evidence and knowledge of transanal irrigation for disordered defecation: from proof in principle through better knowledge of the physiology, towards establishing the indications and ensuring the safety of the treatment. Evidence of the superiority of transanal irrigation in spinal cord injury patients with neurogenic bowel dysfunction is provided, also from a health-economic perspective. Finally, a proposal is presented for an algorithm for the introduction of transanal irrigation for disordered defecation before irreversible surgery is considered.

Progressive protocol in the bowel management of spinal cord injuries

Research into bowel management in spinal cord injury is sparse. Specifically, the use of laxatives in this group, while widespread, is not supported by research evidence. A prospective study in which baseline and intervention data were collected from each subject was undertaken with 17 individuals. The baseline was the routine method of bowel management in the study unit. The intervention was the use of a progressive protocol which allowed the use of physical interventions and rectal stimulants prior to the use of laxative therapy if required. Though the response of individuals varied, the number of successful bowel management episodes employing laxatives was significantly less in the intervention phase, the proportion of glycerine suppository uses which were successful was significantly greater, the use of manual evacuation was significantly reduced and the duration of bowel management episodes was significantly less. These findings suggest that use of laxatives in bowel management is not essential for all newly spinal cord injured individuals, while the use of physical interventions in this population may be beneficial. The variable response of individuals to the progressive protocol highlights the need for individual assessment in the area of bowel. The findings of this small study must be validated by a larger study.

Operant conditioning of H-reflex can correct a locomotor abnormality after spinal cord injury in rats

This study asked whether operant conditioning of the H-reflex can modify locomotion in spinal cord-injured rats. Midthoracic transection of the right lateral column of the spinal cord produced a persistent asymmetry in the muscle activity underlying treadmill locomotion. The rats were then either exposed or not exposed to an H-reflex up-conditioning protocol that greatly increased right soleus motoneuron response to primary afferent input, and locomotion was reevaluated. H-reflex up-conditioning increased the right soleus burst and corrected the locomotor asymmetry. In contrast, the locomotor asymmetry persisted in the control rats. These results suggest that appropriately selected reflex conditioning protocols might improve function in people with partial spinal cord injuries. Such protocols might be especially useful when significant regeneration becomes possible and precise methods for reeducating the regenerated spinal cord neurons and synapses are needed for restoring effective function.

The flushing patient: Differential diagnosis, workup, and treatment

Cutaneous flushing-a common presenting complaint to dermatologists, allergists, internists, and family practitioners-results from changes in cutaneous blood flow triggered by multiple conditions. Most cases are caused by very common, benign diseases, such as rosacea or climacterum, that are readily apparent after a thorough taking of history and physical examination. However, in some cases, accurate diagnosis requires further laboratory, radiologic, or histopathologic studies to differentiate several important clinicopathologic entities. In particular, the serious diagnoses of carcinoid syndrome, pheochromocytoma, mastocytosis, and anaphylaxis need to be excluded by laboratory studies. If this work-up is unrevealing, rare causes, such as medullary carcinoma of the thyroid, pancreatic cell tumor, renal carcinoma, and others, should be considered.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with the mechanisms of flushing, its clinical differential diagnosis, the approach to establish a definitive diagnosis, and management of various conditions that produce flushing.

Anesthetic Requirements and Stress Hormone Responses in Spinal Cord-Injured Patients Undergoing Surgery Below the Level of Injury

Neuraxial anesthesia decreases the minimum alveolar concentration. We determined the effects of spinal cord injury (SCI) on sevoflurane requirements and stress hormone response. Twenty-two chronic SCI patients undergoing surgery below the level of the injury were enrolled in the study, and 15 patients without cord injury served as control patients. Bispectral index score was maintained at 40-50. Measurements included end-tidal sevoflurane concentrations, systolic arterial blood pressure, heart rate, and plasma catecholamine and cortisol concentrations. During surgery, systolic arterial blood pressure, heart rate, and Bispectral index were comparable between SCI and control groups. However, end-tidal sevoflurane concentration was significantly smaller in the SCI (0.81%-1.06%) versus control (1.28%-1.31%) patients. In the control group, plasma norepinephrine and cortisol concentrations were significantly increased during and 1 h after surgery compared with awake baseline values. In the SCI group, the sympathoadrenal and cortisol responses were virtually abolished. We conclude that SCI reduces the anesthetic requirement by 20%-39% during surgery below the level of injury, in association with blunted sympathoadrenal and cortisol responses.

Animal models in urological disease and sexual dysfunction

There are several conditions associated with dysfunction of the lower urinary tract or which result in a reduction in the ability to engage in satisfactory sexual function and result in significant bother to sufferers, partners and/or carers. This review describes some of the animal models that may be used to discover safe and effective medicines with which to treat them. While alpha adrenoceptor antagonists and 5-alpha-reductase inhibitors deliver improvement in symptom relief in benign prostatic hyperplasia sufferers, the availability of efficacious and well-tolerated medicines to treat incontinence is less well served. Stress urinary incontinence (SUI) has no approved medical therapy in the United States and overactive bladder (OAB) therapy is limited to treatment with muscarinic antagonists (anti-muscarinics). SUI and OAB are characterised by high prevalence, a growing ageing population and a strong desire from sufferers and physicians for more effective treatment options. High patient numbers with low presentation rates characterizes sexual dysfunction in men and women. The introduction of Viagra in 1998 for treating male erectile dysfunction and the success of the phosphodiesterase type 5 inhibitor class (PDE5 inhibitor) have indicated the willingness of sufferers to seek treatment when an effective alternative to injections and devices is available. The main value of preclinical models in discovering new medicines is to predict clinical outcomes. This translation can be established relatively easily in areas of medicine where there are a large number of drugs with different underlying pharmacological mechanisms in clinical usage. However, apart from, for example, the use of PDE5 inhibitors to treat male erectile dysfunction and the use of anti-muscarinics to treat OAB, this clinical information is limited. Therefore, current confidence in existing preclinical models is based on our understanding of the biochemical, physiological, pathophysiological and psychological mechanisms underlying the conditions in humans and how they are reflected in preclinical models. Confidence in both the models used and the pharmacological data generated is reinforced if different models of related aspects of the same disorder generate confirmatory data. However, these models will only be fully validated in retrospect once the pharmacological agents they have helped identify are tested in humans.

Prevalence and etiology of autonomic dysreflexia in children with spinal cord injuries

OBJECTIVE

To delineate the prevalence, etiologies, clinical manifestations, complications, and management of autonomic dysreflexia in individuals who sustained spinal cord injury (SCI) as children.

METHOD

Retrospective chart review.

PARTICIPANTS

All individuals with > or = T6 SCI who were injured at 13 years of age or younger and who were cared for at one pediatric SCI program.

OUTCOME MEASURES

Outcome measures included prevalence, etiologic factors, and symptoms of autonomic dysreflexia as documented in both inpatient and outpatient records. Blood pressure and heart rate for observed episodes of autonomic dysreflexia also were recorded.

RESULTS

Of 121 participants who met the study criteria, 62 (51%) had experienced autonomic dysreflexia. The most common causes of dysreflexia were urologic (75%) and bowel impaction (18%), and the distribution of causative factors were similar in the 3 age ranges (0-5 years, 6-13 years, and 14-21 years). For all age groups, the most common symptoms were facial flushing (43%), headaches (24%), sweating (15%), and piloerection (14%). However, headaches (5%) and piloerection (0%), were uncommonly seen in children 5 years of age and younger. For observed episodes of autonomic dysreflexia, the majority (93%) demonstrated blood pressure elevations consistent with published guidelines, 50% experienced tachycardia, and 12.5% experienced bradycardia. Autonomic dysreflexia was significantly more common in individuals with complete lesions and in those who were injured between 6 and 13 years old compared with those injured at a younger age. Individuals with cervical injuries were not at significantly higher risk of dysreflexia than were those with upper thoracic level injuries. However, among individuals with complete lesions, autonomic dysreflexia was significantly more common in those with tetraplegia.

CONCLUSION

Autonomic dysreflexia has a similar prevalence in pediatric-onset SCI compared with the adult SCI population. Dysreflexia is diagnosed less commonly in infants and preschool-aged children, and these 2 populations may present with more subtle signs and symptoms.

Unique issues in pediatric spinal cord injury

Spinal cord injuries are devastating events, and they are particularly tragic when they affect children or adolescents who have barely had an opportunity to experience life. Of the approximately 10,000 individuals who sustain spinal cord injury each year in the United States, 3% to 5% occur in individuals younger than 15 years of age and approximately 20% occur in those younger than 20 years of age (Nobunaga, Go, & Karunas, 1999). Because of the growth and development inherent in children and adolescents and the unique manifestations and complications associated with spinal cord injuries, management must be developmentally based and directed to the individual's special needs (Vogel, 1997). The many unique facets of pediatric spinal cord injuries are addressed in this article. They clearly delineate the need for care that is responsive to the dynamic changes that occur with growth and development. The multidisciplinary team, combined with a focus on family-centered care, is essential in pediatric spinal cord injuries.

[Paraplegia and pregnancy: anaesthesic management]

Pregnancy is a rare occurrence in patient suffering from spinal cord lesion. The authors report the case of labour and delivery in a paraplegic patient who was suffering from lesion located T6 level. In early labour epidural analgesia was maintained and the vaginal delivery was successful without associated fluctuation of blood pressure or other signs of autonomic hyperreflexia. The epidural catheter was maintained for 48 h post-partum. The main risks and anaesthesic management of pregnancy in paraplegic patients are discussed.

Evaluation of captopril for the management of hypertension in autonomic dysreflexia: a pilot study

OBJECTIVE

To evaluate the efficacy of captopril for management of hypertensive urgencies in autonomic dysreflexia.

DESIGN

A 1-year, prospective, open-label pilot study.

SETTING

Rehabilitation hospital.

PATIENTS

Twenty-six consecutive patients older than 15 years with spinal cord injury above T6.

INTERVENTIONS

During an autonomic dysreflexia episode, captopril 25mg was administered sublingually if systolic blood pressure (SBP) was at or above 150mmHg despite the use of nondrug measures. If SBP remained elevated 30 minutes after captopril administration, 1 dose of immediate-release nifedipine 5mg was given as rescue by the bite and swallow method and repeated, if necessary, in 15 minutes.

MAIN OUTCOME MEASURE

SBP 30 minutes after captopril administration at initial autonomic dysreflexia episode.

RESULTS

A total of 33 autonomic dysreflexia episodes were documented, of which 18 episodes in 5 patients were treated with drug therapy. Captopril alone was effective in 4 of 5 initial episodes (80%). Mean SBPs at baseline and 30 minutes after captopril were 178+/-18mmHg and 133+/-28mmHg, respectively. There were no cases of reactive hypotension. The addition of nifedipine successfully reduced SBP in the remaining patient. Of the combined 18 initial and repeat autonomic dysreflexia episodes, 94% were successfully treated with our protocol.

CONCLUSION

Captopril appears to be safe and effective for autonomic dysreflexia management.

Hypothermia associated with autonomic dysreflexia after traumatic spinal cord injury

Individuals with traumatic upper thoracic and cervical spinal cord injuries are at increased risk for the development of both thermoregulatory dysfunction and autonomic dysreflexia. It is unclear, however, what effect reflex autonomic sympathetic outflow has on thermoregulatory dysfunction during episodes of autonomic dysreflexia. The following case of an individual with C5 tetraplegia and both thermoregulatory dysfunction and autonomic dysreflexia illustrates the profound effects that the autonomic nervous system may have on body temperature in individuals at risk for this complication.

Management of life-threatening autonomic hyper-reflexia using magnesium sulphate in a patient with a high spinal cord injury in the intensive care unit

We report the successful use of i.v. magnesium sulphate to control life-threatening autonomic hyper-reflexia associated with chronic spinal cord injury in the intensive care environment. A 37-yr-old, male was admitted to the intensive care unit with a diagnosis of septic shock and acute renal failure secondary to pyelonephritis. He had been found unresponsive at home following a 2-day history of pyrexia and purulent discharge from his suprapubic catheter. He had sustained a T5 spinal cord transection 20 yr previously. Initial management included assisted ventilation, fluid resuscitation, vasopressor support, and continuous veno-venous haemofiltration. The sepsis was treated with antibiotic therapy and percutaneous nephrostomy drainage of the pyonephrosis. On the fifth day, the patient developed profuse diarrhoea. This was associated with paroxysms of systemic hypertension and diaphoresis, his arterial pressure rising on occasion to 240/140 mm Hg. A diagnosis of autonomic hyper-reflexia was made and a bolus dose of magnesium sulphate 5 g was administered over 15 min followed by an infusion of 1-2 g h(-1). There was an almost immediate decrease in the severity and frequency of the hypertensive episodes. There were no adverse cardiac effects associated with the administration of magnesium, only a slight decrease in minute ventilation as the plasma level approached the upper end of the therapeutic range (2-4 mmol litre(-1)). In view of the beneficial effects observed in this case we advocate further research into the use of magnesium sulphate in the treatment or prevention of autonomic hyper-reflexia secondary to chronic spinal cord injury in the intensive care unit.

Sexually transmitted infections in women with disabilities: diagnosis, treatment, and prevention: a review

BACKGROUND AND OBJECTIVES

Women with disabilities can and do contract sexually transmitted diseases (STDs). However, because of access barriers, attitudinal misconceptions, and lack of awareness of their risk status, these infections may go under or undiagnosed.

GOAL

To address issues regarding the treatment of women with disabilities and to suggest ways in which the patient and the provider can work together for a positive outcome.

STUDY DESIGN

A literature review was performed using recent textbooks, publications, and medical journals to collect information regarding the health behaviors of women with disabilities and sexually transmitted disease symptom manifestations, which may differ in this population. The Physicians Desk Reference was consulted to assemble information on medical selection.

RESULTS

The treatment of STDs in women with disabling conditions presents diagnostic and therapeutic challenges to clinicians, because symptoms may be confusing and may mimic manifestations of underlying disorders. Women with spinal cord injury may be at risk for the development of autonomic activation as a sign of STDs.

CONCLUSION

To enhance compliance with medication regiments, the limitations of the patient should be considered. Furthermore, women with disabilities are at high risk for sexual abuse; therefore, the presence of an STD may be of special concern. Developing good communication with the patient will enable the clinician to work with her to sort out symptoms, design therapeutic regiments, and to help protect her from abuse.

Cardiovascular consequences of loss of supraspinal control of the sympathetic nervous system after spinal cord injury

Spinal cord injury (SCI) with resultant quadriplegia or high paraplegia is associated with significant dysfunction of the sympathetic nervous system. This alteration of sympathetic nervous system activity occurs as a consequence of loss of supraspinal control of the sympathetic nervous system and is further complicated by at least three subsequent phenomena that occur below the level of SCI: reduced overall sympathetic activity, morphologic changes in sympathetic preganglionic neurons, and peripheral alpha-adrenoceptor hyperresponsiveness. Reduced sympathetic activity below the level of SCI appears to result in orthostatic hypotension, low resting blood pressure, loss of diurnal fluctuation of blood pressure, reflex bradycardia, and, rarely, cardiac arrest. Peripheral alpha-adrenoceptor hyperresponsiveness likely accounts for some, if not the majority, of the excessive pressor response in autonomic dysreflexia and may also contribute to decreased blood flow in the peripheral microcirculation, potentially increasing susceptibility to pressure sores. What has yet to be established is whether this alpha-adrenoceptor hyperresponsiveness is a consequence of receptor hypersensitivity or a failure of presynaptic reuptake of noradrenaline at the receptor level. Better understanding of the pathophysiology of sympathetic nervous system dysfunction after high-level SCI should allow development of more effective measures to manage clinical complications.

Practical considerations in the performance of physical examinations on women with disabilities

There are over 28 million women with disabilities in the United States (1). This includes women with mobility and self-care limitations of varying degrees. Many of these women have difficulty obtaining comprehensive, accessible, and dignified physical examinations. Additionally, patients and clinicians are often misinformed about issues pertaining to healthcare needs of women with disabilities (2). This article outlines strategies to overcome physical barriers and gaps in knowledge, and proposes creative solutions for common problems encountered during the performance of the basic physical examination of a woman who has disabilities. It discusses the reality of sexually transmitted disease, promotes awareness of abuse in the population of women with disabilities, and offers guidelines physicians can follow in assisting their patients in resolving this abuse.

Anaesthesia for chronic spinal cord lesions

Increasing numbers of patients with spinal cord injury present for surgery or obstetric care. Spinal cord injury causes unique pathophysiological changes. The most important peri-operative dangers are autonomic dysreflexia, bradycardia, hypotension, respiratory inadequacy and muscle spasms. Autonomic dysreflexia is suggested by headache, sweating, bradycardia and severe hypertension and may be precipitated by surgery, especially bladder distension. Patients with low, complete lesions, undergoing surgery below the level of injury, may safely do so without anaesthesia provided there is no history of autonomic dysreflexia or troublesome spasms. An anaesthetist should be present to monitor the patient in this situation. General anaesthesia of sufficient depth is effective at controlling spasms and autonomic dysreflexia but hypotension and respiratory dysfunction are risks. There is a growing consensus that spinal anaesthesia is safe, effective and technically simple to perform in this group of patients. We present a survey of 515 consecutive anaesthetics in cord-injured patients and a review of the current literature on anaesthesia for patients with chronic spinal cord lesions.

Spinal cord injury rehabilitation. 2. Medical complications

This self-directed learning module highlights new advances in understanding medical complications of spinal cord injury through the lifespan. It is part of the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article covers reasons for transferring patients to specialized spinal cord injury centers once they have been stabilized, and the management of common medical problems, including fever, autonomic dysreflexia, urinary tract infection, acute and chronic abdominal complications, deep vein thrombosis, pulmonary complications, and heterotopic ossification. Formulation of an educational program for prevention of late complications is also discussed, including late renal complications, syringomyelia, myelomalacia, burns, pathologic fractures, pressure ulcers, and cardiovascular disease. New advances covered in this section include new information on old problems, and a discussion of exercise tolerance in persons with tetraplegia, the pathophysiology of late neurologic deterioration after spinal cord injury, and a view of the care of these patients across the lifespan.

Immune system-neuroendocrine dysregulation in spinal cord injury

Multiple communicative pathways among the nervous, endocrine and immune systems facilitate physiological immunoregulation. Spinal cord injury (SCI) patients have decreased natural (NK cell) and adaptive (T cell) immune function and reduced blood levels of cellular adhesion molecules (CAMs) that participate in immune function and wound healing. We found decreased LFA-1 and VLA-4 on peripheral blood leukocytes in SCI patients and lower levels of CAMs in SCI patients with pressure ulcers than in those without them. SCI might affect immune cells and immune responsiveness by: (1) disrupting the outflow of signals from the sympathetic nervous system to lymphoid tissues and their blood vessels as well as the returning afferent signals from these tissues to the brain; (2) immunosuppression caused by the stressors affecting SCI patients; (3) interrupting returning signals to the CNS from the periphery thereby reducing facilitation of immunoregulatory CNS neurons and decreasing their activity; or a combination of all three. SCI patients may develop dysregulation of the sympathetic nervous system that is intimately involved in immune function. Chronic stress mediates immunosuppression by corticosteroids, catecholamines, endorphins and met-enkephalin. The hypothalamus coordinates the response to stress through the release of soluble products from the sympathetic nervous system and hypothalamic-pituitary-adrenal axis. Whereas the nervous and endocrine systems are not concerned with immunological specificity, they do influence the intensity, kinetics and localization of immune responses. Products of an activated immune system may generate feedback circuits capable of inhibiting, enhancing or regulating neuronal input. Immune system cells can produce neurologically active peptides including ACTH, CRF, growth hormone, thyrotropin, prolactin, human chorionic gonadotropin, endorphin, enkephalins, substance P, somatostatin and VIP. Cytokines are likely important mediators of the HPA response to immune stimuli.

Sacral insufficiency stress fracture as etiology of positional autonomic dysreflexia: case report

The medical literature is replete with case reports of the syndrome known as autonomic dysreflexia. Although the majority of cases are known to be induced by either bladder or bowel distention. there does exist a small number of cases in which the inciting stimulus is more obscure. In such cases, a comprehensive medical evaluation is necessary to ensure proper identification of the source of irritation and the appropriate medical management of the patient. We present a patient with a heretofore unreported suspected etiology of autonomic dysreflexia, axial loading of a sacral stress fracture.

Chronic spinal cord injury

Spinal cord injuries predispose patients to numerous complications. The care of such patients requires attention to multiple bodily systems, sensitivity to the effects of interventions on function and lifestyle, and a special vigilance because of the tendency of spinal cord injuries to mask problems. Improved clinical care, however, has increased the life expectancy of people with spinal cord injuries and therefore the prevalence of such injuries. The Americans with Disabilities Act should make people with spinal injuries more visible, as they participate in and contribute to society in greater numbers. Maintenance of health brings greater opportunities for self-care and mobility through rehabilitation and may allow people with spinal cord injuries to take advantage of future opportunities for neurologic improvement or cure.