Prediction of autonomic dysreflexia during urodynamics: a prospective cohort study

Abstract

BackgroundAutonomic dysreflexia is a severe and potentially life-threatening condition in patients with spinal cord injury, as it can lead to myocardial ischemia, brain hemorrhage, or even death. Urodynamic investigation is the gold standard to assess neurogenic lower urinary tract dysfunction due to spinal cord injury and reveal crucial pathological findings, such as neurogenic detrusor overactivity. However, neurogenic detrusor overactivity and urodynamic investigation are known to be leading triggers of autonomic dysreflexia. Therefore, we aimed to determine predictors of autonomic dysreflexia in individuals with spinal cord injury during urodynamic investigation.MethodsThis prospective cohort study included 300 patients with spinal cord injuries and complete datasets of continuous non-invasive cardiovascular monitoring, recorded during same session repeat urodynamic investigation. We used logistic regression to reveal predictors of autonomic dysreflexia during urodynamic investigation.ResultsWe found that level of injury and presence of neurogenic detrusor overactivity were the only two independent significant predictors for autonomic dysreflexia during urodynamic investigation. A lesion at spinal segment T6 or above (odds ratio (OR) 5.5, 95% CI 3.2–9.4) compared to one at T7 or below, and presence of neurogenic detrusor overactivity (OR 2.7, 95% confidence interval (CI) 1.4–4.9) were associated with a significant increased odds of autonomic dysreflexia during urodynamic investigation. Both odds persisted after adjustment for age, sex, and completeness and stage of injury (adjusted OR (AOR) 6.6, 95% CI 3.8–11.7, and AOR 2.2, 95% CI 1.1–4.5, respectively). Further stratification by lesion level showed level-dependent significantly increased adjusted odds of autonomic dysreflexia, i.e., from C1–C4 (AOR 16.2, 95% CI 5.9–57.9) to T4–T6 (AOR 2.6, 95% CI 1.3–5.2), compared to lesions at T7 or below.ConclusionsIn patients with neurogenic lower urinary tract dysfunction due to spinal cord injury, autonomic dysreflexia is independently predicted by lesion level and presence of neurogenic detrusor overactivity. Considering the health risks associated with autonomic dysreflexia, such as seizures, stroke, retinal bleeding, or even death, we recommend both continuous cardiovascular monitoring during urodynamic investigation in all spinal cord-injured patients with emphasis on those with cervical lesions, and appropriate neurogenic detrusor overactivity treatment to reduce the probability of potentially life-threatening complications.Trial registrationClinicalTrials.gov, NCT01293110.Electronic supplementary materialThe online version of this article (10.1186/s12916-018-1040-8) contains supplementary material, which is available to authorized users.

A study of prostate volumes in patients with spinal cord injury

“…Uncontrolled hyperactivity of these elements is the source of life threatening autonomic dysreflexia, typically manifested by patients with SCI injuries above T6. The higher the injury the greater the segment of intact intermediolateral nuclei and the higher the risk of autonomic dysreflexia . In the proposed model, patients with cervical or high thoracic spinal injuries develop BPH “normally” as uninjured patients.…”

“…The higher the injury the greater the segment of intact intermediolateral nuclei and the higher the risk of autonomic dysreflexia. 16 In the proposed model, patients with cervical or high thoracic spinal injuries develop BPH "normally" as uninjured patients. In patients with low thoracic or lumbar injuries, damage to critical intermediolateral nuclei may result in paralysis of the lower part of the sympathetic nervous system and atrophy of the prostate.…”

Protocol for a phase II, open-label exploratory study investigating the efficacy of fesoterodine for treatment of adult patients with spinal cord injury suffering from neurogenic detrusor overactivity for amelioration of autonomic dysreflexia

“… 16 Furthermore, continuous ‘beat-to-beat’ recording of SBP, diastolic BP and heart rate, synchronous to the ongoing UDS, will capture even short AD episodes. 12 13 Electrocardiography and blood velocity in the left middle and right posterior cerebral arteries will be acquired. 30 Confirmation of AD during UDS: an attending physician will confirm episodes of AD, which is defined according to the ISAFSCI 3 as an increase in SBP ≥20 mmHg from baseline.…”

“… 10 Urodynamic studies (UDS), considered as the gold standard to evaluate lower urinary tract function (in order to protect the upper urinary tract, ie, preserve renal function), 11 is a frequent trigger of artificially induced AD. 12 13 Given the fact that bladder filling occurs several times a day, individuals might experience multiple episodes of AD each day. Spontaneous uninhibited contractions of the detrusor, known as neurogenic detrusor overactivity (NDO), are a leading trigger of life-threatening episodes of AD (ie, affecting more than 80% of individuals with a supraspinal SCI).…”

“…Spontaneous uninhibited contractions of the detrusor, known as neurogenic detrusor overactivity (NDO), are a leading trigger of life-threatening episodes of AD (ie, affecting more than 80% of individuals with a supraspinal SCI). 12 …”