Feasibility and safety of 4 weeks of blood flow-restricted exercise in an individual with tetraplegia and known autonomic dysreflexia: a case report.

INTRODUCTION: Blood flow-restricted exercise (BFRE) appears to hold considerable potential in spinal cord injury (SCI) rehabilitation, due to its ability to induce beneficial functional changes and morphological alterations from low-intensity, low-load exercise. However, it remains unclear if this training approach is feasible and safe in individuals with autonomic dysreflexia (AD). CASE PRESENTATION: A 23-year-old male with traumatic, cervical (C6), motor-complete (AIS: B) SCI and diagnosed AD completed eight sessions of BFRE for the upper extremities over 4 weeks. Blood pressure and heart rate recordings and perceptual pain responses were collected repeatedly during exercise. Blood samples were drawn pre- and post-training. Training was carried out in a neurorehabilitation hospital setting with appertaining medical staff readiness, and was supervised by a physiotherapist with expertise in AD in general as well as prior knowledge of the present patient's triggers and symptoms. Four incidences of AD (defined as systolic blood pressure increase >20 mmHg) were recorded across all training sessions, of which one was symptomatic. The patient's blood profile did not change considerably from pre- to post-training sessions. Self-reported average pain during training corresponded from "mild" to "moderate". DISCUSSION: The patient was able to perform 4 weeks of BFRE, but encountered episodes of AD. Similarly, two AD episodes were registered during a single conventional, free-flow resistance training session. Evidence from clinically controlled safety studies is needed in order to establish if and how BFRE can be applied in a rehabilitation strategy in SCI individuals with neurological level of injury at or above T6 level.

[A rare complication of transrectal electrostimulation for sperm retrieval]. / Das ist doch kein Beinbruch?! Eine seltene Komplikation der transrektalen Elektrostimulation zur Spermagewinnung.

In men who wish to have children after a spinal cord injury, assisted ejaculation is frequently needed for sperm retrieval. Transrectal electrostimulation (TES) is often used for this purpose. Typical side effects of TES are autonomic dysreflexia or pain. In a 33-year old man with complete tetraplegia below C6 since 2004, TES caused massive leg spasticity, leading to transcervical fracture of the femoral neck. This previously unreported complication of TES demonstrates that, in men with long-term chronic tetraplegia, spasticity and osteoporosis, TES in anesthesia should be taken into consideration.

An investigation of the relationship between autonomic dysreflexia and intrathecal baclofen in patients with spinal cord injury.

OBJECTIVE: To study the relationship between autonomic dysreflexia and intrathecal baclofen in patients with spinal cord injury. DESIGN: Retrospective chart review. SETTING: Inpatient and outpatient acute rehabilitation facility. PARTICIPANTS: Thirty-four subjects. INTERVENTIONS: We reviewed patients' medical records to ascertain the presence of symptomatic autonomic dysreflexia (AD) prior to and after implantation of an intrathecal baclofen (ITB) pump for spasticity in spinal cord injury patients. We recorded risk factors for autonomic dysreflexia including kidney and bladder stones, heterotopic ossification (HO), and ischial / sacral pressure ulcers. OUTCOME MEASURES: Presence of autonomic dysreflexia pre and post-intrathecal baclofen pump placement, presence of risk factors associated with autonomic dysreflexia including (1) kidney or bladder stones, (2) heterotopic ossification, and (3) pressure ulcers. RESULTS: Of the 34 subjects, 25 (73.5%) experienced AD prior to ITB pump placement and only 2 (5.9%) after placement. Four subjects (11.8%) had kidney or bladder stones, of which, all had AD prior to placement and none had AD afterwards. Twenty-six subjects (76.5%) had pressure ulcers, of which, all experienced AD prior to placement and only one (0.02%) afterwards. Six patients (17.6%) had HO, of which 5 (83%) had AD prior to placement and none afterwards. Additionally, three patients (8.8%) had at least 2 of the above risk factors, of which, all had AD prior to ITB placement and none afterwards. CONCLUSION: This study showed a significant reduction of symptomatic episodes of autonomic dysreflexia after spinal cord injury, even in those with additional risk factors for development of autonomic dysreflexia.

Complications of Spinal Cord Injury Over the First Year After Discharge From Inpatient Rehabilitation.

OBJECTIVES: To describe the prevalence and cumulative incidence of secondary complications of spinal cord injury (SCI) in the first year after discharge from inpatient rehabilitation (IR); and to evaluate potential associations between risk of complications and sociodemographic and injury-specific factors. DESIGN: Secondary analysis of data collected for a single-site, single-blind, randomized controlled trial comparing telephone follow-up with usual care. SETTING: Inpatient rehabilitation units. PARTICIPANTS: Adults ages ≥18 years (N=169) within 1 year of discharge from IR after SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-report of 10 secondary complications of SCI. RESULTS: Participants experienced a mean of 4.7 complications over 12 months. The most frequently reported complications were urinary tract infection (UTI), autonomic dysreflexia (AD), and pressure ulcers, with cumulative incidences of 62%, 43%, and 41%, respectively. Bone and soft tissue injuries (cumulative incidence, 35%) and bowel problems, including impaction or severe constipation (cumulative incidence, 33%), were also common. Cumulative incidences of AD, decubitus ulcers, UTI, and problems with bladder were greater in participants with higher level and more complete injuries, and some recurrent complications were common. Age at injury and impairment level significantly affected rates of complications, and subjects developed an average of 2.33 distinct complications during the study period. CONCLUSIONS: People with SCI are at high risk for a number of secondary complications over the first year after discharge from IR. Although these data offer some insight into who with SCI is at highest risk for first time and recurrent complications, further study is needed to refine this understanding and to develop effective educational and prevention strategies.

Risk factors to develop autonomic dysreflexia during urodynamic examinations in patients with spinal cord injury.

AIMS: The risk factors for developing autonomic dysreflexia (AD) during urodynamic (UD) examination in patients with spinal cord injury (SCI) above Th6 still remain unclear. The main goal of our study is to investigate the risk factors that could be associated with AD in these particular patients. DESIGN: Cross sectional survey. SUBJECT AND METHODS: The study was carried out in 83 patients with SCI above Th6 who were submitted to our center for a UD examination. AD was defined as a rise in systolic blood pressure above 15 mm Hg with a pulse rate below 60 beats per minute. RESULTS: The prevalence rate of AD among our patients was 54%. Univariate analysis of our study showed the following risk factors: patient's age, SCI completeness, traumatic etiology, indwelling catheter, presence of chills or sweating, anticholinergic treatment, maximum detrusor voiding pressure, detrusor pressure at maximum flow rate, detrusor external sphincter dyssynergia, and bladder outlet obstruction. Using multivariate logistic regression, we found that there are only two independent risk factors: patient's age equal to or above 45 years of age (OR = 10.995) and maximum detrusor voiding pressure equal to or above 31 cm H2 O (OR = 3.879). CONCLUSIONS: According to our results, the patient's age and maximum detrusor voiding pressure should be considered at the time of performing a UD examination in order to prevent the sudden onset of AD in patients with SCI above Th6. Neurourol. Urodynam. 36:171-175, 2017. © 2015 Wiley Periodicals, Inc.

Characterizing the Severity of Autonomic Cardiovascular Dysfunction after Spinal Cord Injury Using a Novel 24 Hour Ambulatory Blood Pressure Analysis Software.

Cardiovascular disease is one of the leading causes of morbidity and mortality in the spinal cord injury (SCI) population. SCI may disrupt autonomic cardiovascular homeostasis, which can lead to persistent hypotension, irregular diurnal rhythmicity, and the development of autonomic dysreflexia (AD). There is currently no software available to perform automated detection and evaluation of cardiovascular autonomic dysfunction(s) such as those generated from 24 h ambulatory blood pressure monitoring (ABPM) recordings in the clinical setting. The objective of this study is to compare the efficacy of a novel 24 h ABPM Autonomic Dysfunction Detection Software against manual detection and to use the software to demonstrate the relationships between level of injury and the degree of autonomic cardiovascular impairment in a large cohort of individuals with SCI. A total of 46 individuals with cervical (group 1, n = 37) or high thoracic (group 2, n = 9) SCI participated in the study. Outcome measures included the frequency and severity of AD, frequency of hypotensive events, and diurnal variations in blood pressure and heart rate. There was good agreement between the software and manual detection of AD events (Bland-Altman limits of agreement = ±1.458 events). Cervical SCI presented with more frequent (p = 0.0043) and severe AD (p = 0.0343) than did high thoracic SCI. Cervical SCI exhibited higher systolic and diastolic blood pressure during the night and lower heart rate during the day than high thoracic SCI. In conclusion, our ABPM AD Detection Software was equally as effective in detecting the frequency and severity of AD and hypotensive events as manual detection, suggesting that this software can be used in the clinical setting to expedite ABPM analyses.

Online training improves paramedics' knowledge of autonomic dysreflexia management guidelines.

STUDY DESIGN: Single-group pre-/post-test with 3- and 6-month follow-ups. OBJECTIVES: To test the effects of the 'ABCs of AD' educational module on immediate and longer-term changes in paramedics' knowledge and beliefs about using the autonomic dysreflexia clinical practice guidelines (AD-CPGs). SETTING: Canada. METHODS: A total of 119 paramedics completed an AD knowledge test and measures of attitudes, perceived control, self-efficacy, social pressure from patients and health-care professionals, and intentions to use the AD-CPGs before and 1 week, 3 months and 6 months after viewing 'ABCs of AD'. RESULTS: There were significant improvements in AD knowledge, attitudes and social pressure from patients to use the AD-CPGs from baseline to 1 week, 3 months and 6 months post viewing (all P<0.001). Self-efficacy and intentions increased 1 week post viewing (P<0.001), but returned to baseline levels at 3 and 6 months (P>0.05). There was no change in perceived control or social pressure from health-care professionals. AD knowledge and beliefs explained 50-61% of the variance in intentions to use the AD-CPGs. Attitudes, social pressure from patients and perceived behavioural control were significant unique predictors of intentions at all time points (P<0.05); AD knowledge was a significant predictor at 6 months only (P=0.048). No other predictors were significant. CONCLUSION: 'ABCs of AD' has immediate and sustained effects on paramedics' knowledge of attitudes toward and perceived pressure from patients to use the AD-CPGs. Updates to paramedic patient care guidelines and standards are needed to increase paramedics' perceived control and self-efficacy to implement the guidelines, and their intentions to use the AD-CPGs. SPONSORSHIP: Canadian Institutes of Health Research (2011-CIHR- 260877).

Cardiovascular response during urodynamics in individuals with spinal cord injury.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To establish the frequency and severity of autonomic dysreflexia (AD) during urodynamics among individuals with chronic spinal cord injury (SCI) and to investigate the possible effect of the number of years since SCI on the severity of AD. SETTING: SCI outpatient clinic. METHODS: A retrospective chart review was undertaken of individuals with SCI who were seen at an outpatient clinic and could potentially develop an episode of AD (T6 and above). Data regarding age, gender, urodynamic examination, lower urinary tract function, cardiovascular parameters and SCI were collected. In addition, information on signs and symptoms of AD were retrieved. RESULTS: A total of 76 individuals with SCI were examined with blood pressure (BP) monitoring. The majority had cervical SCI (79%). The mean age was 47.8±13.9 years. The median duration after SCI was 51.5 months. During urodynamics, a total of 48 (63.2%) individuals showed an increase in systolic BP>20 mm Hg, meeting the criteria for AD. Indicators for higher incidences of AD were cervical SCI, being >2 years after SCI, the presence of detrusor sphincter dyssynergia (DSD) and low bladder compliance. AD was more severe in individuals with complete (American Spinal Cord Association (ASIA) impairment scale (AIS) A) injuries, worse with greater time after SCI. CONCLUSION: Individuals with cervical SCI, DSD, poor bladder compliance or >2 years after SCI were associated with a higher possibility of developing AD during urodynamics. Furthermore, AD was more severe in complete (AIS A) individuals and was exacerbated with time after injury.

Prevention of recurrent autonomic dysreflexia: a survey of current practice.

OBJECTIVE: There is a dearth of literature on the treatment of chronic recurrent autonomic dysreflexia (AD), a well-known complication of spinal cord injury that can have life-threatening implications. This study sought to identify clinical practices regarding the treatment of AD, both acute and recurrent, in patients with spinal cord injury (SCI). METHODS: Online survey regarding AD management in SCI composed of 11 questions designed to obtain information on respondent characteristics, AD treatment options, and causes of AD. SETTING: Veterans Administration health care system. PARTICIPANTS: Veterans Health Administration National SCI Staff Physicians were sent an electronic email to participate in the anonymous web-based survey. INTERVENTION: None applicable. RESULTS: The response rate was 52%. The most commonly prescribed medications for minor and severe acute manifestations of AD were nitrates. For recurrent AD, clonidine was the most commonly prescribed medication. INTERPRETATION: Anti-hypertensive medications continue to be the mainstay in the management of both acute and chronic recurrent AD. Current literature is lacking in prospective randomized controlled trials investigating the relative efficacy of AD interventions. Evidence-based practice guidelines are necessary to improve clinical care.

Iatrogenic urological triggers of autonomic dysreflexia: a systematic review.

STUDY DESIGN: This is a systematic review. OBJECTIVE: The objective of this study was to review the literature on iatrogenic urological triggers of autonomic dysreflexia (AD). SETTING: This study was conducted in an international setting. METHODS: A systematic review was conducted from PubMed search using AD/ autonomic hyperreflexia and spinal cord injury (SCI). Studies selected for review involved iatrogenic urological triggers of AD in individuals with SCI, including original articles, previous practice guidelines, case reports and literature reviews. Studies that did not report AD or blood pressure (BP) assessments during urological procedures were excluded. RESULTS: Forty studies were included for analysis and categorized into four groups: (1) urodynamics and cystometry; (2) cystoscopy and transurethral litholapaxy; (3) extracorporeal shock-wave lithotripsy (ESWL); and (4) other procedures. During urodynamics, the incidence of AD ranged from 36.7% to 77.8%. The symptomatic rate ranged from 50% to 65%, with AD symptoms seen predominantly in cervical SCI patients. The studies imply no consensus regarding the relationship between AD, neurogenic detrusor overactivity and detrusor sphincter dyssynergia. Without anesthesia, the majority of individuals develop AD during cystoscopy, transurethral litholapaxy and ESWL. The effectiveness of different anesthesia methods relies on blocking the nociceptive signals from the lower urinary tract (LUT) below the level of the neurological lesion. Other iatrogenic urological triggers were commonly associated with bladder filling. CONCLUSION: The LUT triggers of episodes of AD are often associated with iatrogenic urological procedures. AD was more prevalent in cervical SCI than in thoracic SCI. To detect this potential life-threatening complication following cervical and high thoracic SCI, routine BP monitoring during urological procedures is highly recommended.

Autonomic dysreflexia during urodynamics in children and adolescents with spinal cord injury or severe neurologic disease.

INTRODUCTION: Autonomic dysreflexia (AD) is a well-established association of high spinal cord injury (SCI), particularly in those occurring above T6. When a noxious stimulus is encountered, the body responds by stimulating an increase in blood pressure, which is then countered by vasodilation. In patients with autonomic dysreflexia, the patient is unable to vasodilate below the level of spinal injury due to interruption of the autonomic innervation below the injury. This then leads to persistently elevated blood pressure causing uncoordinated autonomic responses such as headache, flushing, sweating, and even hypertensive crisis. The noxious stimulus most commonly reported is bladder or bowel distention [1]. This potential trigger is especially important since many patients with SCI require catheterization and repeated urodynamic testing, both of which predispose them to bladder distention. In response to an incident during which a patient developed severe hypertension during UDS, institutional concern was raised about the potential risk of AD in other patients with SCI ≥ T8 and other severe neurological disease undergoing urodynamic testing, and a protocol was initiated in 2007 for monitoring for AD during UDS. Although no long-term complication was encountered in this incident, the need for improvement in our understanding of the detection and treatment of AD during urodynamic testing was highlighted. However, due to the potential of UDS to trigger AD and possible subsequent severe cardiovascular crisis, a protocol was established at our institution. Because of reports documenting episodes of AD for patients with severe, non-SCI neurologic disease and the unknown risk, these patients also were historically monitored at our institution as well. OBJECTIVE: Autonomic dysreflexia (AD) is an uncoordinated autonomic response seen in patients with spinal cord injury (SCI). AD is often triggered by bladder distention, which may occur during urodynamic studies (UDS), and has potentially life-threatening consequences. Our purpose is to determine the prevalence and associated factors of AD in children undergoing UDS with either SCI or other neurological disease. METHODS: We identified 13 pediatric patients with SCI at the eighth thoracic vertebrae or above (SCI ≥ T8) or other severe neurological disorder with urodynamic evaluations between 2007 and 2011 at our institution. We retrospectively reviewed these patients for age, gender, bladder volume, bladder compliance, detrusor instability, symptoms of AD, blood pressure, and urinary infection. RESULTS: There were a total of 13 patients with SCI ≥ T8 (9), transverse myelitis (2), and encephalomyelitis (2). There were a total of 41 urodynamic studies with an average of 3.2 studies per patient. One adolescent with C1/2 injury and a prepubertal child with T2/3 injury developed AD. AD was not observed in non-SCI patients. The patients who developed AD had multiple subsequent episodes with follow up UDS. No statistical associations were found for the variables evaluated. No major complications occurred, and AD was successfully managed conservatively. CONCLUSIONS: With appropriate monitoring and education, AD is easily recognized and managed conservatively. We found an increased risk of patients developing subsequent AD episodes after an initial episode. Patients who did not have autonomic dysreflexia during initial UDS did not experience autonomic dysreflexia on subsequent UDS. We did not observe autonomic dysreflexia occurring in children with transverse myelitis or encephalomyelitis.

Longitudinal changes in medical complications in adults with pediatric-onset spinal cord injury.

OBJECTIVES: To determine longitudinal changes in the occurrence of medical complications in adults with pediatric-onset spinal cord injury (SCI). DESIGN: Longitudinal study of long-term outcomes. SETTING: Community. PARTICIPANTS: Individuals who had sustained an SCI before age 19, were 23 years of age or older at initial interview, and followed annually between 1996 and 2011. They were classified into four American Spinal Injury Association (ASIA) Impairment Scale (AIS) severity groups: C1-4 AIS ABC, C5-8 AIS ABC, T1-S5 AIS ABC, AIS D. OUTCOME MEASURES: Generalized estimating equation (GEE) models were formulated to obtain the odds ratio (OR) of having a medical complication over time. RESULTS: A total of 1793 interviews were conducted among 226 men and 125 women (86% Caucasian; age at baseline, 26.7 ± 3.6 years; time since injury at baseline, 12.9 ± 5.2 years). Odds of complication occurrence over time varied among severity groups, with increased ORs of severe urinary tract infection (1.05, confidence interval (CI) 1.02-1.09), autonomic dysreflexia (AD) (1.09, CI 1.05-1.14), spasticity (1.06, CI 1.01-1.11), pneumonia/respiratory failure (1.09, CI 1.03-1.16), and hypertension/cardiac disease (1.07, CI 1.01-1.15) in the C1-4 ABC group; AD (1.08, CI 1.04-1.13) and pneumonia/respiratory failure (1.09, CI 1.02-1.16) in the C5-8 ABC group; and hypertension/cardiac disease (1.08, CI 1.02-1.14) in the T1-S5 ABC group. Upper extremity joint pain had increased odds of occurrence in all injury severity groups. CONCLUSION: The significantly increased odds of having medical complications over time warrants awareness of risk factors and implementation of preventive measures to avoid adverse consequences of complications and to maintain independence in individuals with pediatric-onset SCI.

A prospective report on the prevalence of heart rate and blood pressure abnormalities in veterans with spinal cord injuries.

OBJECTIVE: Decentralized autonomic cardiovascular regulation may lead to increased prevalence of heart rate (HR) and blood pressure (BP) abnormalities in veterans with SCI. In addition, comorbid medical conditions and prescription medication use may increase HR and BP abnormalities. These abnormalities include bradycardia, and tachycardia, hypotension, hypertension as well as autonomic dysreflexia and orthostatic hypotension; the prevalence of which is unknown. DESIGN: HR and BP data were measured during a routine annual physical examination in 64 veterans with SCI. Measurements of HR and BP were recorded in the seated and supine positions to document the influence of body position and to document intra-subject variability in these assessments. RESULTS: All subjects were chronically injured (20 ± 14 years), 33 subjects were tetraplegic (T: C3-C8), nine had high paraplegia (HP: T1-T6), and 22 had low paraplegia (LP: T7-L2). Regardless of position, the prevalence of bradycardia was increased in the T group, whereas prevalence of tachycardia was increased in the HP and LP groups. Systolic hypotension was more common in the T and HP groups than the LP group and positional effects were most evident in the T group. Systolic hypertension was comparable in the T and HP groups but was twice as prevalent in the LP group. Increased prevalence of individuals with three or more medical conditions and prescribed three or more medications which might influence HR and BP was observed. CONCLUSION: Decentralized autonomic regulation, comorbid medical conditions, and prescription medication use in veterans with SCI result in HR and BP abnormalities; our data suggest that these abnormalities vary depending on the level of injury and orthostatic positioning.

A retrospective chart review of heart rate and blood pressure abnormalities in veterans with spinal cord injury.

OBJECTIVE: Autonomic impairment may lead to increased prevalence of heart rate (HR) and blood pressure (BP) abnormalities in veterans with spinal cord injury (SCI). In addition, comorbid medical conditions and prescription medication use may influence these abnormalities, including bradycardia, and tachycardia, hypotension, hypertension as well as autonomic dysreflexia (AD), and orthostatic hypotension (OH). DESIGN: A retrospective review of clinical and administrative datasets in veterans with SCI and compared the prevalence rates between clinical values and ICD-9 diagnostic codes in individuals with tetraplegia (T: C1-C8), high paraplegia (HP: T1-T6), and low paraplegia (LP: T7 and below). RESULTS: The prevalence of clinical values indicative of a HR ≥ 80 beats per minute was higher in the HP compared to the LP and T groups. A systolic BP (SBP) ≤ 110 mmHg was more common in the T compared to the HP and LP groups, whereas the prevalence of a SBP ≥ 140 mmHg was increased in the LP compared to the HP and T groups. Diagnosis of hypertension was 39-60% whereas the diagnosis of hypotension was less than 1%. Diagnosis of AD and OH was highest in the T group, but remained below 10%, regardless of categorical lesion level. Antihypertensive medications were commonly prescribed (55%), and patients on these medications were less likely to have high BP. The odds ratio of higher SBP and DBP increased with age and body mass index (BMI). CONCLUSION: In veterans with SCI, the prevalence of HR and BP abnormalities varied depending on level of lesion, age, BMI, and prescription medication use.

Autonomic cardiovascular dysfunction and vitamin D deficiency in pediatric spinal cord injury.

OBJECTIVE: The purpose of this manuscript is to present a general overview and preliminary results of pilot projects of two complications in pediatric spinal cord injury (SCI): autonomic cardiovascular dysfunction and vitamin D deficiency. METHODS: Retrospective cross-sectional investigations of blood pressures (BP), heart rates (HR), and vitamin D levels were performed. RESULTS: Among 279 children with SCI, it was observed that baseline BP increases and HR decreases with increasing age. Boys had higher systolic BP and girls had higher HR, but a gender difference in diastolic BP did not emerge. There were no significant associations of baseline BP or HR as a function of injury level, severity, or duration. Among 82 youth with SCI, 79% had vitamin D deficiency or insufficiency. There were no differences in vitamin D status as a function of gender or level of injury. Adolescents, however, were more likely to exhibit deficiency compared to children. IMPLICATIONS: Because of the clinical significance of autonomic dysreflexia and orthostatic hypotension, baseline BP and HR need to be routinely assessed in youth with SCI. In view of the high prevalence of vitamin D insufficiency in youth with SCI and the risk of complications such as pathological fractures, serum 25-hydroxycholecalciferol levels should be routinely monitored.

Blood pressure and age associated with silent autonomic dysreflexia during urodynamic examinations in patients with spinal cord injury.

STUDY DESIGN: An observational study. OBJECTIVES: To investigate the factors associated with silent autonomic dysreflexia (AD) during urodynamics (UD) in spinal cord injury (SCI) patients. SETTING: Taichung city, Taiwan, ROC. METHODS: Blood pressure (BP) and symptoms of AD were continuously monitored during UD, and systolic blood pressure (SBP) elevations >20 mmHg was considered an AD reaction. AD patients were divided into a symptomatic group and a silent group (without AD symptoms), and variables (basic demographic data, hemodynamic data and UD parameters) were compared. RESULTS: A total of 42 patients, 21 in symptomatic and 21 in silent AD groups, were analyzed. Symptomatic group had significantly greater diastolic blood pressure (DBP) increment and rates of SBP/DBP changes (change of BP divided by duration) as compared to the silent group (29.5 vs 21.7 mmHg; 4.8 vs 2.3 mmHg min(-1) and 2.8 vs 1.4 mmHg min(-1)) (P<0.05). The cutoff points of these three variables, determined by receiver operating characteristic analysis, are: DBP increment of 21 mmHg and rates of SBP/DBP change of 2.27 and 1.16 mmHg min(-1). Age had a weak negative correlation with DBP change (Pearson's r=-0.377, P=0.048) and the silent group was significantly older than the symptomatic group (49.4 vs 40.1 years, P<0.05). CONCLUSION: Patients with more symptomatic AD tended to have significant DBP elevation and more rapid SBP/DBP increments, and this was negatively correlated with age. Aging decreases AD symptoms and the magnitude of DBP elevation, possibly through the mechanism of decreased baroreceptor sensitivity. BP monitoring during UD and other invasive procedures is strongly recommended, especially for elderly SCI patients.

Incidence of symptomatic autonomic dysreflexia varies according to the bowel and bladder management techniques in patients with spinal cord injury.

STUDY DESIGN: A retrospective, multicenter study. OBJECTIVES: To investigate the relationship between bowel and bladder management methods and symptomatic autonomic dysreflexia (AD) during hospitalization in patients with spinal cord injury (SCI). SETTING: Twenty-eight Rosai hospitals in Japan. METHODS: The study subjects were 571 patients with SCI who had been admitted to 28 Rosai hospitals between April 1997 and March 2007 for rehabilitation therapy and fulfilled the following criteria: (1) SCI at or above sixth thoracic level, (2) discharged from hospital after more than 4 months of admission for initial injury and (3) lack of pressure ulcers, deep venous thrombosis, ureteral and renal stones or heterotopic ossification throughout hospitalization to exclude possible influence of these complications on cardiovascular reflexes. The study subjects were examined for the incidence of symptomatic AD according to age, sex, ASIA Impairment Scale, injury level, bowel and bladder management techniques at discharge. RESULTS: The Rosai Hospital registry included 3006 persons with SCI during 1997-2007, and 571 patients fulfilled the above criteria. The highest incidence of symptomatic AD was diagnosed in subjects using reflex voiding and in those using manual removal of stool. By contrast, the lowest incidence of symptomatic AD was in those on continent spontaneous voiding and continent spontaneous defecation. CONCLUSION: Medical staff should evaluate the presence of AD in patients with SCI at or above the T6 level under bladder and bowel management such as reflex voiding and manual removal of stool.

The incidence of trigeminocardiac reflex in endovascular treatment of dural arteriovenous fistula with onyx.

This paper reports the incidence of tri-geminocardiac reflex (TCR) in endovascular treatment of dural arteriovenous fistulas (DAVFs) with Onyx. The consecutive case histories of 45 patients with DAVFs, treated with Onyx transarterially and transvenously, from February 2005 to February 2008 at Beijing Tiantan Hospital, China, were retrospectively reviewed. The time period was limited as the anesthetic and intravascular procedure was performed under the same standardized anesthetic protocol and by the same team. The TCR rate was subsequently calculated. Of the 45 patients, five showed evidence of TCR during transarterial Onyx injection and transvenous DMSO injection. Their HR fell 50% during intravascular procedures compared with levels immediately before the stimulus. However, blood pressure values were stable in all cases. The TCR rate for all patients was 11.1% (95% CI, 4 to 24%), 7.7% (95% CI, 2 to 21%) in patients treated intraarterially and 33.3% (4 to 78%) in patients treated intravenously. Once HR has fallen, intravenous atropine is indicated to block the depressor response and prevention further TCR episodes. TCR may occur due to chemical stimulus of DMSO and Onyx cast formation under a standardized anesthetic protocol and should be blunted by atropine.

Obstetric management following traumatic tetraplegia: case series and literature review.

OBJECTIVE: Pregnancy in tetraplegia is a rare event, with only sporadic cases reported. This case series describes seven pregnancies in five tetraplegic women, all with spinal cord injuries in the region of C6. DESIGN: Retrospective case series. SETTING: Sydney, Australia. POPULATION: All tetraplegic women presenting to the obstetric service of a university teaching hospital, which also provides a regional spinal injury service, between 1981 and 2006. METHODS: Hospital records of all patients were examined and information extracted regarding demographics, pregnancies and their complications, labour and delivery and neonatal data. MAIN OUTCOME MEASURES: Course, complications, management and outcomes of pregnancy in tetraplegic women. RESULTS: Mean age at the time of injury was 22 years, and, at the time of pregnancy, 33 years. All patients suffered recurrent, and sometimes severe, urinary tract infections and episodes of autonomic dysreflexia during pregnancy. Frequent and sometimes lengthy hospital admissions were required for these and other reasons. Only two pregnancies required caesarean section and all entered labour spontaneously, at a mean of 37.9 weeks of gestation. Episodes of autonomic dysreflexia were aggressively managed using pre-emptive epidural anaesthesia and sublingual nifedipine. All pregnancies resulted in normal, near-term babies with no serious perinatal problems. CONCLUSIONS: Pregnancy and childbirth in tetraplegic women can be undertaken safely, usually with spontaneous onset of labour and vaginal delivery. However, hospitalisation for intercurrent problems is common. Management requires a multidisciplinary approach and is best undertaken in major centres with both obstetric and spinal cord injuries medical expertise.

Secondary health complications in an aging Canadian spinal cord injury sample.

OBJECTIVES: This study describes self-reported incidence of secondary health complications (SHCs) and their associations with age, years postinjury (YPI), and impairment among a Canadian spinal cord-injured (SCI) cohort. DESIGN: Cross-sectional telephone survey methods were used to collect data on (1) sociodemographics, (2) impairment, (3) health status, and (4) self-reported SHCs on 781 adults >or=1 yr post-SCI living in Ontario, Canada. RESULTS: Logistic regression analyses were used to determine associations between self-reported incidences of SHCs with the following covariates: (1) age, (2) YPI, and (3) impairment. The odds ratios for cardiac complications, high blood pressure (HBP), and respiratory complications increased per year with age, whereas autonomic dysreflexia (AD), bladder infections, heterotopic ossification, psychological distress, and drug addiction decreased. The odds ratios for pressure ulcers, AD, and heterotopic ossification increased per YPI, whereas HBP, bowel problems, psychological distress, and depression decreased. Complete injuries were associated with bladder infections, pressure ulcers, and AD. Paraplegia was associated with HBP and bowel problems, and tetraplegia was associated with AD. CONCLUSIONS: The findings provide some clarification on factors associated with the occurrence of SHCs after SCI and are useful for informing health-promotion planners, clinicians, and stakeholders regarding the odds of SHCs with aging or among specific impairment groups.