Treatment of autonomic hyperreflexia in a quadriplegic patient by epidural anesthesia in the postoperative period

Perioperative Complications and Anesthesia Practices in Managing Patients With Quadriplegia Undergoing Surgery: A Systematic Review

Quadriplegia is associated with a multitude of health complications affecting numerous organ systems. Complications during the perioperative periods are not uncommon in this patient population due to abnormal responses to surgical stressors. Such complications include autonomic dysreflexia, cardiac ischemia, and respiratory compromise. Currently, there is no clear consensus on the ideal technique for perioperative anesthesia management in this population. In addition, the relationship between the perioperative complications and anesthesia practices have not been explored in-depth. Therefore, we aimed to investigate perioperative complications in the context of anesthesia that are associated with patients with quadriplegia undergoing various surgical procedures. Our PRISMA compliant systematic review included 12 articles covering the literature from inception to January 12, 2021. The review showed complications being pulmonary, cerebral, but most importantly and commonly cardiac in nature, with many patients suffering hypertension, and many others hypotension. In addition, our review showed that autonomic dysreflexia is common and in majority of patients, it was managed successfully with good recovery. Based on our findings, the use of anesthesia, either general or spinal, can be considered. Future studies are needed to elucidate the exact mechanisms involved in perioperative complications and anesthetic management that are associated with patients with quadriplegia. This review will aid in developing general recommendations based on the information available in the literature to guide perioperative management of this vulnerable patient population.

Autonomic hyperreflexia after spinal cord injury managed successfully with intravenous lidocaine: a case report

Background

Some paraplegic patients may wish undergo some surgical procedures, like urological procedures, without anesthesia. However, these patients can develop autonomic hyperreflexia if cystoscopy is performed without anesthesia.

Case presentation

We present a case of severe autonomic hyperreflexia in a 44-year-old male with spinal cord injury at the level of T4 during urologic procedure under sedation and analgesia successfully treated with intravenous lidocaine.

Conclusions

This case illustrates that patients with spinal cord injuries are likely to develop autonomic hyperreflexia during urological procedures performed without anesthesia. Health professionals should educate spinal cord injury patients regarding risks of this serious condition and be aware to prevent and manage autonomic hyperreflexia. In an acute episode, nifedipine, nitrates and captopril are the most commonly used and recommended agents. To our knowledge, this is the first case report of severe autonomic hyperreflexia treated successfully with intravenous lidocaine.

Spinal cord injury: present and future therapeutic devices and prostheses

A range of passive and active devices are under development or are already in clinical use to partially restore function after spinal cord injury (SCI). Prosthetic devices to promote host tissue regeneration and plasticity and reconnection are under development, comprising bioengineered bridging materials free of cells. Alternatively, artificial electrical stimulation and robotic bridges may be used, which is our focus here. A range of neuroprostheses interfacing either with CNS or peripheral nervous system both above and below the lesion are under investigation and are at different stages of development or translation to the clinic. In addition, there are orthotic and robotic devices which are being developed and tested in the laboratory and clinic that can provide mechanical assistance, training or substitution after SCI. The range of different approaches used draw on many different aspects of our current but limited understanding of neural regeneration and plasticity, and spinal cord function and interactions with the cortex. The best therapeutic practice will ultimately likely depend on combinations of these approaches and technologies and on balancing the combined effects of these on the biological mechanisms and their interactions after injury. An increased understanding of plasticity of brain and spinal cord, and of the behavior of innate modular mechanisms in intact and injured systems, will likely assist in future developments. We review the range of device designs under development and in use, the basic understanding of spinal cord organization and plasticity, the problems and design issues in device interactions with the nervous system, and the possible benefits of active motor devices.

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.