Cardiovascular aspects of autonomic dysreflexia since Guttmann and Whitteridge (1947)

Abstract

word: Dysreflexia.'AUTONOMIC DYSREFLEXIA ' in patients with high spinal cord lesions has been used in reference to the changes induced by a variety of stimuli which occur in target organs supplied by the sympathetic and parasympathetic nervous systems. The earliest description of the symptoms of autonomic dysreflexia which we have been able to find is by Hilton (1860) who described a 21-year-old man with a tetraplegia complete below C5 segment whose 'bowels (did) not open without medicine (senna). On some days he has peculiar sensations of chilliness, becoming pale, then feels hot and flushed both at defaecation and micturition. The more constipated the bowel, the more these peculiar sensations are experienced.' Hilton described these phenomena but drew no conclusion.It was during World War I that Head and Riddoch made detailed observations of autonomic dysreflexia in patients with spinal cord injuries. They accurately described the responses of sweat glands, genitalia, urinary bladder and rectum which were evoked by cutaneous stimulation below the level of the lesion and by injection of fluid into the bladder and the bowel (Head & Riddoch, 1917;Riddoch, 1917). Riddoch (1917) also described the initial stage of spinal shock during which tendon reflexes could not be elicited and retention of urine and faeces occurred. This stage was followed by the second stage of reflex activity when stimulation of the skin produced sweating around and above the segmental level of the lesion, evacuation of the bladder and rectum and erection of the penis and seminal emission important components of the 'mass reflex'.In recently injured patients with high spinal cord injuries who are in spinal shock there is minimal cardiovascular reflex activity presumably because both the parasympathetic and sympathetic pathways in the isolated spinal cord are depressed (Mathias et al., , 1979a. Pronounced cardiovascular changes, however, occur when spinal cord reflex activity returns. These were classically described by Guttmann and Whitteridge (1947) in patients with lesions at or above the level of T 5 during distension of the urinary bladder. They reported marked hypertension, a decrease in pulse rate, change of rhythm on the electrocardiograph (in particular extrasystoles), vasodilatation of the face, neck and nasal mucosa and vasoconstric tion of fingers and toes. The patients complained of flushing and sweating of the face and neck, blockage of nasal air passages and headache. The authors thought these were important alarm symptoms of visceral activity in parts of the paralysed body. Since then there have been numerous reports which have confirmed Gutt mann and Whitteridge's pioneering observations on the cardiovascular changes occurring during autonomic dysreflexia in patients with high thoracic and cervical spinal cord lesions. Similar changes also occur during cutaneous stimulation 46

Leg sympathetic response to noxious skin stimuli is similar in high and low level human spinal cord injury

“…Our results support Frankel's concept of AD being a "sympathetic storm" (Frankel and Mathias, 1979) that targets lower extremity and splanchnic vascular beds as well as the heart, depending on the degree of lost descending control corresponding to the location of the injury. Although a lack of inhibition from higher centers is prerequisite to the development of AD (Curt et al, 1996), a time dependent reorganization of the neural circuitry and changes in peripheral receptor sensitivity contribute to this pathologic reflex (Krassioukov et al, 2002;Weaver et al, 2002).…”

“…The injury-level dependent nature of AD is clear with occurrences reported almost exclusively in individuals with injuries at level T5 and above (Guttmann and Whitteridge, 1947;Frankel and Mathias, 1979;Mathias and Frankel, 1986;Somers, 2001) with one exception reported in an individual with a T10 injury (Gimovsky et al, 1985). Although individuals with injuries from T6-L2 rarely demonstrate a systemic pressor response to noxious stimuli, they typically have intact sympathetic reflexes as indicated by lower extremity cutaneous and muscular vasoconstriction (Cunningham et al, 1953;Wurster and Randall, 1975).…”

Management of the Pregnant Woman With Spinal Cord Injuries

“…1980;Mathias & Frankel, 1988). Lower limb splanchnic vaso-constriction associated with the lack of baro-receptor compensation is also strongly implicated in the sustained hypertensive response (Wallin 1988 Dramatic changes in blood pressure can occur within seconds of the stimulus accompanied by tachycardia andlor bradycardia (Guttmann & Frankel, 1965;Frankel & Mathias, 1979). These commonly include a severe pounding headache, sweating, blotching of the skin and pilo-erection above the level of the lesion.…”

Blood distribution adaptations in paraplegics during posture changes: peripheral and central reflex responses

“…Spinal sympathetic re¯exes may contribute to the recovery from hypotension (Skagen et al 1982;Krebs et al 1983). The most spectacular observation of this kind of re¯ex is the so-called autonomic dysre¯exia (Frankel and Mathias 1979;Lee et al 1995), which can not be considered of functional value in the homeostatic regulation of blood pressure. Long-term hormonal adjustments have also been considered as possible contributing factors to a more appropriate blood redistribution.…”