Silent Autonomic Dysreflexia During Voiding in Men with Spinal Cord Injuries

Linsenmeyer, Todd A.; Campagnolo, Denise I.; Chou, I.-Hsin

doi:10.1016/s0022-5347(01)66438-3

Cited by 83 publications

(8 citation statements)

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“…Sympathetic pre-ganglionic neurons (SPNs) are regarded as the pivotal spinal neurons for central cardiovascular control [ 30 ]. It is commonly believed that AD occurs in patients with SCI at or above T6 [ 31 , 32 ], and most studies have only presented data in this selected cohort [ 9 , 27 , 29 , 33 ]. However, AD can also occur in patients with a lesion level below T6, as the sympathetic outflow originates from T1 to L2 [ 34 ] and supplies various regions, such as the heart (T1–T5) and urinary bladder (L1–L2) [ 35 ].…”

Section: Discussionmentioning

confidence: 99%

Prediction of autonomic dysreflexia during urodynamics: a prospective cohort study

Walter

Knüpfer

Cragg

et al. 2018

BMC Med

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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.

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Section: Discussionmentioning

confidence: 99%

Prediction of autonomic dysreflexia during urodynamics: a prospective cohort study

Walter

Knüpfer

Cragg

et al. 2018

BMC Med

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“…Although the impact of AD on the prevalence of cardiovascular and cerebrovascular diseases is not fully clarified, considering the report that cardiovascular instability in patients with SCI increased the frequency of heart disease and ischemic stroke occurrence [ 23 ], appropriate BP control and evaluation of cardiovascular instability are important. In addition, inappropriate activation of the sympathetic nervous system, which is associated with AD, occurs several times a day and could be asymptomatic in spite of the significantly elevated arterial BP [ 9 , 24 ]. Thus, it is necessary to diagnose such asymptomatic AD earlier on and apply appropriate treatment interventions.…”

Section: Discussionmentioning

confidence: 99%

“…However, the chronic group showed no significant differences in nocturnal BP dipping and HR. Considering the report that significant morphological changes such as atrophy of sympathetic preganglionic neurons and loss of dendritic arbors were observed in the acute phase [ 30 ], it is believed that neural regeneration-mediated recovery of the autonomic nervous system by passage of time or acclimatization of patients to the stimuli and symptoms, which cause AD and acquisition of self-control ability [ 9 ], influenced the above results.…”

Section: Discussionmentioning

confidence: 99%

Prevalence of Autonomic Dysreflexia in Patients with Spinal Cord Injury above T6

Lee

Joo

2017

BioMed Research International

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Objective To investigate the prevalence of autonomic dysreflexia (AD) using ambulatory blood pressure monitoring (ABPM) and the autonomic dysfunction following spinal cord injury (ADFSCI) questionnaire in patients with spinal cord injury (SCI) above T6. Methods Twenty-eight patients diagnosed with SCI above T6 were enrolled. ABPM and ADFSCI were utilized to assess AD. Using ABPM, systolic blood pressure (SBP), diastolic blood pressure, and heart rate (HR) were measured at 30-minute intervals. AD was defined as SBP 20 mmHg higher than basal SBP, and the number of AD events was counted. The ADFSCI questionnaire evaluates the severity and frequency of the AD symptoms. Results According to the ABPM, AD occurred in 26 patients and AD events occurred 5.8 ± 4.7 times. Average daytime and nighttime SBP were 119.9 ± 18.8 mmHg and 123.8 ± 21.2 mmHg, respectively, and the nighttime mean SBP appeared to be 4 mmHg higher than daytime mean SBP. These findings suggest the loss of nocturnal BP dipping in SCI patients. ADFSCI results revealed that 16 of the patients evaluated were symptomatic while 12 were asymptomatic. Conclusion AD following SCI above T6 was highly prevalent and several patients seemed asymptomatic. These results suggest the necessity of proper diagnostic and therapeutic interventions for managing AD.

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“…However, there is no correlation between the magnitude of the hypertensive response and the headache (Teasell et al, 2000). Moreover, by definition, subclinical episodes go undetected, and this syndrome of silent dysreflexia is of increasing concern, particularly for those living with SCI in the community (Linsenmeyer et al, 1996). …”

Section: Autonomic Dysreflexiamentioning

confidence: 99%

Somatosympathetic Vasoconstrictor Reflexes in Human Spinal Cord Injury: Responses to Innocuous and Noxious Sensory Stimulation below Lesion

Macefield¹,

Burton²,

Brown³

2012

Front. Physio.

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It is known that the sudden increases in blood pressure associated with autonomic dysreflexia in people with spinal cord injury (SCI) are due to a spinally mediated reflex activation of sympathetic vasoconstrictor neurons supplying skeletal muscle and the gut. Apart from visceral inputs, such as those originating from a distended bladder, there is a prevailing opinion that autonomic dysreflexia can be triggered by noxious stimulation below the lesion. However, do noxious inputs really cause an increase in blood pressure in SCI? Using microelectrodes inserted into a peripheral nerve to record sympathetic nerve activity we had previously shown that selective stimulation of small-diameter afferents in muscle or skin, induced by bolus injection of hypertonic saline into the tibialis anterior muscle or the overlying skin, evokes a sustained increase in muscle sympathetic nerve activity and blood pressure and a transient increase in skin sympathetic nerve activity and decrease in skin blood flow in able-bodied subjects. We postulated that these sympathetic responses would be exaggerated in SCI, with a purely noxious stimulus causing long-lasting increases in blood pressure and long-lasting decreases in skin blood flow. Surprisingly, though, we found that intramuscular or subcutaneous injection of hypertonic saline into the leg caused negligible changes in these parameters. Conversely, weak electrical stimulation over the abdominal wall, which in able-bodied subjects is not painful and activates large-diameter cutaneous afferents, caused a marked increase in blood pressure in SCI but not in able-bodied subjects. This suggests that it is activation of large-diameter somatic afferents, not small-diameter afferents, that triggers increases in sympathetic outflow in SCI. Whether the responses to activation of large-diameter afferents reflect plastic changes in the spinal cord in SCI is unknown.

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Silent Autonomic Dysreflexia During Voiding in Men with Spinal Cord Injuries

Abstract: Urodynamics are helpful to detect symptomatic and asymptomatic autonomic dysreflexia. Significant elevations in blood pressure can occur without the symptoms of autonomic dysreflexia.

Cited by 83 publications

References 13 publications

Prediction of autonomic dysreflexia during urodynamics: a prospective cohort study

Prediction of autonomic dysreflexia during urodynamics: a prospective cohort study

Prevalence of Autonomic Dysreflexia in Patients with Spinal Cord Injury above T6

Somatosympathetic Vasoconstrictor Reflexes in Human Spinal Cord Injury: Responses to Innocuous and Noxious Sensory Stimulation below Lesion

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