Autonomic dysreflexia in urological practice: pathophysiology, prevention and treatment considerations.

PURPOSE: Spinal cord injury (SCI) leads to sensorimotor impairments; however, it can also be complicated by significant autonomic dysfunction, including cardiovascular and lower urinary tract (LUT) dysfunctions. Autonomic dysreflexia (AD) is a dangerous cardiovascular complication of SCI often overlooked by healthcare professionals. AD is characterized by a sudden increase in blood pressure (BP) that can result in severe cardiovascular and cerebrovascular complications. In this review, we provide an overview on the clinical manifestations, risk factors, underlying mechanisms, and current approaches in prevention and management of AD. METHODS: After conducting a literature research, we summarized relevant information regarding the clinical and pathophysiological aspects in the context of urological clinical practice CONCLUSIONS: The most common triggers of AD are those arising from LUT, such as bladder distention and urinary tract infections. Furthermore, AD is commonly observed in individuals with SCI during urological procedures, including catheterization, cystoscopy and urodynamics. Although significant progress in the clinical assessment of AD has been made in recent decades, effective approaches for its prevention and treatment are currently lacking.

Are local analgesics effective in reducing autonomic dysreflexia in individuals with spinal cord injury? A systematic review.

STUDY DESIGN: Systematic review. OBJECTIVES: To systematically review the evidence on the use of local analgesics, specifically lidocaine or bupivacaine, to prevent autonomic dysreflexia (AD) during iatrogenic procedures or bowel and bladder care routines in individuals with spinal cord injury (SCI). METHODS: A keyword search of MEDLINE, CINAHL, CENTRAL, Cochrane Reviews, PsycInfo, Embase, and Web of Science databases identified all English-language studies evaluating the efficacy of local analgesics in reducing AD. Included studies were either randomized controlled trials (RCTs) or quasi-experimental studies. Participants were adults with chronic SCI who received local analgesics prior to AD-triggering procedures or routines. Additionally, studies were required to report blood pressure values as an outcome. The methodology of this review followed the PRISMA checklist and was registered with PROSPERO (CRD42021219506). RESULTS: Four RCTs and two quasi-experimental studies met inclusion criteria. Results were narratively synthesized as meta-analysis was not possible due to heterogeneity across studies included in the review. All six studies administered lidocaine. Lidocaine was found to have a beneficial effect on AD in three studies, no effect in two studies and a detrimental effect in one study. CONCLUSIONS: Presently, RCTs and quasi-experimental studies on the use of lidocaine for reducing AD in individuals with SCI had small sample sizes and opposing findings. There is a strong need for definitive, well-monitored clinical trials with adequate sample sizes. Presently there is not enough compelling evidence to support or refute recommendations for the use of lidocaine from the AD management clinical practice guidelines.

[Efficacy of fesoterodine for prevention of autonomic dysreflexia in patients with neurogenic dysfunction of the bladder after spinal cord injury].

AIM: to evaluate the effectiveness of fesoterodine for the prevention of autonomic dysreflexia (AD) in patients with neurogenic bladder dysfunction (NBD) after spinal cord injury (SCI). MATERIALS AND METHODS: a total of 53 patients with AD were included in the study. In the main group (n=33) patients received fesoterodine 4 mg per day for 12 weeks as a treatment for neurogenic bladder dysfunction and prevention of AD. In the control group (n=20), patients were monitored for 12 weeks without specific treatment. The assessment was based on the results of ADFSCI and NBSS questionnaires, daily blood pressure monitoring with the completion of a self-observation diary, cystometry with simultaneous monitoring of blood pressure and heart rate. RESULTS: In the main group there was a significant decrease in episodes and severity of AD according to ADFSCI questionnaire and an improvement in the quality of life according to NBSS questionnaire compared to the control group (p<0.001). Also, in the main group, the number of episodes of AD and systolic blood pressure decreased. The maximum bladder capacity and bladder compliance increased (p<0.001), and the maximum detrusor pressure and systolic blood pressure when the cystometric capacity was reached, decreased significantly (p<0.001) in the main group compared in comparison with the control group. CONCLUSION: Fesoterodine at a dosage of 4 mg for 12 weeks reduced the severity of symptoms of AD in patients with SCI and NBD, which was manifested by the stabilization of blood pressure and a decrease in the number of episodes of AD, which significantly improved the quality of life. Also, the drug led to a significant improvement in urodynamic parameters during cystometry, in the form of a decrease in detrusor pressure and an increase in cystometric capacity. We can conclude that fesoterodine is effective in the prevention of AD in patients with NBD after SCI.

Clinical recommendations for use of lidocaine lubricant during bowel care after spinal cord injury prolong care routines and worsen autonomic dysreflexia: results from a randomised clinical trial.

STUDY DESIGN: Clinical trial. OBJECTIVE: Spinal cord injury (SCI) impacts autonomic function and bowel management. Bowel care is a potential trigger for autonomic dysreflexia (AD; paroxysmal hypertension elicited by sensory stimuli below the level of lesion). AD can be life threatening so strategies to minimise AD are prioritised after SCI. Lidocaine lubricant is recommended during bowel care with the rationale to minimise the sensory stimulus, reducing AD. The objective of this study was to assess whether lidocaine lubricant (Xylocaine 2%) ameliorates AD during at-home bowel care compared with standard lubricant (placebo). SETTING: Community. METHOD: Participants (n = 13; age 44.0 ± 3.3 years) with high-level SCI (C3-T4) performed their normal at-home bowel care on two days, each time using a different lubricant, with continuous non-invasive cardiovascular monitoring. Injury to spinal autonomic (sympathetic) nerves was determined from low-frequency systolic arterial pressure (LF SAP) variability. RESULTS: Participants displayed reduced autonomic function (LF SAP 3.02 ± 0.84 mmHg2), suggesting impaired autonomic control. Bowel care duration was increased with lidocaine (79.1 ± 10.0 min) compared to placebo (57.7 ± 6.3 min; p = 0.018). All participants experienced AD on both days, but maximum SAP was higher with lidocaine (214.3 ± 10.5 mmHg) than placebo (196.7 ± 10.0 mmHg; p = 0.046). Overall, SAP was higher for longer with lidocaine (6.5 × 105 ± 0.9 × 105 mmHg • beat) than placebo (4.4 × 105 ± 0.6 × 105 mmHg • beat; p = 0.018) indicating a higher burden of AD. Heart rate and rhythm disturbances were increased during AD, particularly with lidocaine use. CONCLUSIONS: At-home bowel care was a potent trigger for AD. Our findings contradict recommendations for lidocaine use during bowel care, suggesting that anaesthetic lubricants impair reflex bowel emptying, resulting in longer care routines with an increased burden of AD.

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.

Testing for boosting at the Paralympic games: policies, results and future directions.

BACKGROUND: 'Boosting' is defined as the intentional induction of autonomic dysreflexia (AD) by athletes with a spinal cord injury (SCI) at or above the level of T6 for the purpose of improving sports performance. Boosting has been shown to confer up to a 9.7% improvement in race time. Additionally, to compete in a hazardous dysreflexic state, whether intentional or unintentional, would present an extreme health risk to the athlete. For these reasons, the International Paralympic Committee strictly bans the practice of boosting, and has developed a protocol to test for its presence. METHODS: Testing was performed at three major international Paralympic events. Education regarding the dangers of AD was provided to athletes and team staff. Testing was conducted on athletes from the relevant sport classes: Athletics (wheelchair racing classes T51/T52/T53) and Handcycling (H1). Key parameters included the athlete's demographics (gender, country of origin), classification and blood pressure measurements. An extremely elevated blood pressure was considered to be a proxy maker for AD, and a systolic blood pressure of ≥180 mm Hg was considered a positive test. RESULTS: A total of 78 tests for the presence of AD were performed during the three games combined. No athlete tested positive. The number of athletes tested, by classification, was: 6 in Athletics T51, 47 in Athletics T52, 9 in Athletics T53 and 16 in Handcycling H1. Of those tested, the average systolic and diastolic blood pressures were 135 mm Hg (range 98-178) and 82 mm Hg (range 44-112), respectively. All athletes were compliant with testing. No athletes were withdrawn from competition due to the presence of AD. DISCUSSION: Testing for the presence of AD in paralympic athletes with SCI prior to competition has been carried out for the first time at three major international paralympic competitions. There have been no positive tests thus far. Knowledge gained during these early testing experiences will be used to guide ongoing refinement of the testing protocol and the development of further educational initiatives.

Autonomic dysreflexia: recognizing a common serious condition in patients with spinal cord injury.

OBJECTIVE: To raise family physicians' awareness of autonomic dysreflexia (AD) in patients with spinal cord injury (SCI) and to provide some suggestions for intervention. SOURCES OF INFORMATION: MEDLINE was searched from 1970 to July 2011 using the terms autonomic dysreflexia and spinal cord injury with family medicine or primary care. Other relevant guidelines and resources were reviewed and used. MAIN MESSAGE: Family physicians often lack confidence in treating patients with SCI, see them as complex and time-consuming, and feel undertrained to meet their needs. Family physicians provide a vital component of the health care of such patients, and understanding of the unique medical conditions related to SCI is important. Autonomic dysreflexia is an important, common, and potentially serious condition with which many family physicians are unfamiliar. This article will review the signs and symptoms of AD and offer some acute management options and preventive strategies for family physicians. CONCLUSION: Family physicians should be aware of which patients with SCI are susceptible to AD and monitor those affected by it. Outlined is an approach to acute management. Family physicians play a pivotal role in prevention of AD through education (of the patient and other health care providers) and incorporation of strategies such as appropriate bladder, bowel, and skin care practices and warnings and management plans in the medical chart.

Pharmacological Inhibition of Soluble Tumor Necrosis Factor-Alpha Two Weeks after High Thoracic Spinal Cord Injury Does Not Affect Sympathetic Hyperreflexia.

After a severe, high-level spinal cord injury (SCI), plasticity to intraspinal circuits below injury results in heightened spinal sympathetic reflex activity and detrimentally impacts peripheral organ systems. Such sympathetic hyperreflexia is immediately apparent as an episode of autonomic dysreflexia (AD), a life-threatening condition characterized by sudden hypertension and reflexive bradycardia following below-level sensory inputs; for example, pressure sores or impacted fecal matter. Over time, plasticity within the spinal sympathetic reflex (SSR) circuit contributes to the progressive intensification of AD events, as the frequency and severity of AD events increase greatly beginning ∼2 weeks post-injury (wpi). The neuroimmune system has been implicated in driving sympathetic hyperreflexia, as inhibition of the cytokine soluble tumor necrosis factor-alpha (sTNFα) using the biological mimetic XPro1595 beginning within days post-SCI has been shown to attenuate the development of AD. Here, we sought to further understand the effective therapeutic time window of XPro1595 to diminish sympathetic hyperreflexia, as indicated by AD. We delayed the commencement of continuous intrathecal administration of XPro1595 until 2 weeks after a complete, thoracic level 3 injury in adult rats. We examined the severity of colorectal distension-induced AD biweekly. We found that initiation of sTNFα inhibition at 2 wpi does not attenuate the severity or intensification of sympathetic hyperreflexia compared with saline-treated controls. Coupled with previous data from our group, these findings suggest that central sTNFα signaling must be targeted prior to 2 weeks post-SCI in order to decrease sympathetic hyperreflexia.

Effects of early exercise training on the severity of autonomic dysreflexia following incomplete spinal cord injury in rodents.

Hemodynamic instability and cardiovascular (CV) dysfunction are hallmarks of patients living with cervical and high thoracic spinal cord injuries (SCI). Individuals experience bouts of autonomic dysreflexia (AD) and persistent hypotension which hamper the activities of daily living. Despite the widespread use of exercise training to improve health and CV function after SCI, little is known about how different training modalities impact hemodynamic stability and severity of AD in a model of incomplete SCI. In this study, we used implantable telemetry devices to assess animals with T2 contusions following 3.5 weeks of exercise training initiated 8 days post-injury: passive hindlimb cycling (T2-CYC, n = 5) or active forelimb swimming (T2-SW, n = 6). Uninjured and non-exercised SCI control groups were also included (CON, n = 6; T2-CON, n = 7; T10-CON, n = 6). Five weeks post-injury, both T2-CON and T2-CYC presented with resting hypotension compared to uninjured CON and T10-CON groups; no differences were noted in resting blood pressure in T2-SW versus CON and T10-CON. Furthermore, pressor responses to colorectal distention (AD) were larger in all T2-injured groups compared to T10-CON, and were not attenuated by either form of exercise training. Interestingly, when T2-injured animals were re-stratified based on terminal BBB scores (regardless of training group), animals with limited hindlimb recovery (T2-LOW, n = 7) had more severe AD responses. Our results suggest that the spontaneous recovery of locomotor and autonomic function after severe but incomplete T2 SCI also influences the severity of AD, and that short periods (3.5 weeks) of passive hindlimb cycling or active forelimb swimming are ineffective in this model.

Sevoflurane concentrations required to block autonomic hyperreflexia during transurethral litholapaxy in patients with complete spinal cord injury.

BACKGROUND: Autonomic hyperreflexia (AHR) is a potentially life-threatening hypertensive condition that occurs in patients with high spinal cord injury (SCI). The current study was aimed to determine sevoflurane concentrations that block AHR in SCI patients. METHODS: The study involved 28 patients with chronic, complete SCI scheduled to undergo transurethral litholapaxy during general anesthesia. Nine patients without SCI served as controls post hoc. Anesthesia was induced with thiopental, and sevoflurane concentrations in 50% nitrous oxide were adjusted to maintain a Bispectral Index of 40-50. When a patient developed AHR during bladder distension, the target sevoflurane concentration was maintained for at least 10 min, and then the procedure was resumed. Systolic blood pressure, heart rate, and Bispectral Index as well as plasma concentrations of catecholamines and arginine vasopressin were measured before and during the bladder distension. Each target concentration was determined by the up-and-down method based on changes (15% increase or more) of systolic blood pressure in response to bladder distension. RESULTS: In SCI, systolic pressure increased by 67 +/- 33 mmHg, whereas heart rate decreased by 13 +/- 8 beats/min during the first trial (P < 0.01). The hypertensive event was associated with increases of norepinephrine concentrations, but not of epinephrine or vasopressin concentrations. Systolic pressure, heart rate, and norepinephrine concentrations did not change significantly in the control patients. The end-tidal concentrations of sevoflurane to prevent AHR were EC50 of 3.12% and EC95 of 3.83%. CONCLUSION: The EC95 for sevoflurane in 50% nitrous oxide to block AHR during transurethral litholapaxy in patients with SCI was 3.83%.

Blood pressure changes during sexual stimulation, ejaculation and midodrine treatment in men with spinal cord injury.

OBJECTIVES: To explore the effectiveness of various sources of self-stimulation, including oral midodrine, in triggering ejaculation in men with spinal cord injury (SCI), and to document the systematic variations in blood pressure at ejaculation and consider a revised definition of autonomic dysreflexia. PATIENTS AND METHODS: The study included 62 men with SCI lesions from C2 to L2. Ejaculation potential was assessed with various sources of stimulation, beginning with natural stimulation, followed, if the test was negative, by penile vibrator stimulation (PVS) followed, if the test was again negative, by PVS combined with oral midodrine, started at 5 mg and increased in 5 mg steps up to 25 mg. The success rate of ejaculation was recorded, as were blood pressure (BP) changes measured at baseline and at ejaculation (or on the last trial if the test was negative). Reported sensations were also recorded and compared during positive and negative tests. RESULTS: Overall, 89% of the patients reached ejaculation with one mode or another of stimulation. When patients had a negative result with natural stimulation, 56% were salvaged by PVS, and when PVS was negative, another 22% were salvaged by midodrine combined with PVS. The mean systolic BP increased by 35 mmHg at ejaculation during PVS and by 11 mmHg after midodrine, and a subsequent 29 mmHg at ejaculation during PVS combined with midodrine. By contrast, negative tests showed a relatively stable BP; the difference in changes in BP during positive and negative tests was significant (P < 0.01). Increases in BP during positive tests declined significantly more often within the limits of autonomic dysreflexia than negative tests (P < 0.01). CONCLUSION: These results support the view that most men with SCI can obtain an ejaculation when a wide spectrum of stimulation is used, including natural stimulation, PVS, and PVS combined with oral midodrine. Positive tests were associated with significant increases in BP, in contrast to negative tests, where BP was relatively stable. This suggests that significant changes in BP are required for ejaculation and that insignificant changes are predictive of future failure. As most changes in BP during positive tests also fall within the criterion of autonomic dysreflexia, a revised definition of autonomic dysreflexia should be considered to encourage safe experiences with ejaculation and safe use of midodrine.

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.

[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.

The downside of ileocystoplasty for persons with cervical spinal cord injury and an indwelling urinary catheter.

PURPOSE: To explore the lived experience of persons with cervical spinal cord injury with a urinary catheter in situ, managing mucus in urine following ileocystoplasty METHOD: Descriptive qualitative methodology was employed. Semi-structured, one-to-one, audiotaped interviews with men (n=6) and a woman (n=1) with cervical-level spinal cord injuries (C4-C6). Analyses of transcribed verbatim transcripts was undertaken using thematic analysis. FINDINGS: There was a mean of 3.6 years since ileocystoplasty. Six major themes emerged from the data. All participants perceived the surgery had adversely affected their life, in part because regular intervention was needed to manage the significant problem of mucus. There was also an increase in autonomic dysreflexia episodes experienced due to mucus blocking bladder drainage. CONCLUSION: Consequences of mucus production have impacted negatively upon participants' health and their ability to participate in life situations, as well as increasing their dependence on others.

[Clinical specificities of spinal cord injury patients (pressure ulcers, autonomic hyperreflexia, spasticity)]. / Spécificités cliniques du blessé médullaire (escarres, HRA, spasticité).

The management of spinal cord injury patients requires a knowledge of several non-urological aspects associated with a risk of particular complications in these patients: pressure ulcers, spasticity and autonomic hyperreflexia. Spinal cord injury patients present a high risk of pressure ulcer, as almost all patients develop at least one pressure ulcer during their lifetime. During a stay in hospital, the medical team must be particularly attentive to prevent these problems, as, once they develop, they can take several months or even years to heal. Autonomic hyperreflexia and spasticity can be due to a urological cause. These two diseases can cause major discomfort for the patient and, in these patients, must be considered to be equivalent to the pain that they can no longer feel due to sensory disorders. The management of spinal cord injury patients must take into account these three particular risk factors: pressure ulcers, spasticity and autonomic hyperreflexia.

A therapeutic time window for anti-CD 11d monoclonal antibody treatment yielding reduced secondary tissue damage and enhanced behavioral recovery following severe spinal cord injury.

OBJECT: The purpose of this study was to investigate the therapeutic time window for antiinflammatory treatment within the first 24 hours of spinal cord injury (SCI). The authors have shown that an anti-CD11d antibody treatment attenuates leukocyte infiltration and improves neurological function when administered beginning 2 hours after SCI. A more clinically relevant time for the initiation of treatment after SCI, however, is 6 or more hours postinjury. METHODS: In Study 1, the T-4 vertebrae in four groups of rats were injured by a 50-g clip-induced compression method, and the anti-CD11d antibody (1 mg/kg) was intravenously administered starting 2, 6, 12, or 24 hours postinjury. All groups received subsequent doses at 24 and 48 hours, and animals were killed at 72 hours. The anti-CD11d antibody treatment starting at 6 hours postinjury caused significant attenuation of leukocyte infiltration, reactive oxygen species-associated enzymes, and secondary tissue damage. Based on these findings, Study 2 included two groups of rats receiving the aforementioned injury and treatment beginning at 6 hours postinjury (with subsequent treatments at 24 and 48 hours) with the anti-CD11d or a control antibody (1B7); these rats were then observed for 5 weeks. Basso-Beattie-Bresnahan (BBB) scores were significantly higher in anti-CD11d-treated rats (mean BBB score 8.9 +/- 0.1) than controls (mean BBB score 7.7 +/- 0.1) 5 weeks postinjury. Increases in mean arterial pressure during colon distension were smaller in anti-CD11d-treated rats (19.5 +/- 3.7 mm Hg) than in controls (37.4 +/- 4.7 mm Hg). CONCLUSIONS: These findings suggest that antiinflammatory treatments that reduce secondary tissue damage after SCI may be delayed until 6 hours postinjury and still be effective.

Autonomic dysreflexia in a parturient with spinal cord injury.

Autonomic dysreflexia (ADR) is a syndrome of imbalanced reflex sympathetic discharge occurring in patients with spinal cord injury (SCI) at or above the level of splanchnic sympathetic outflow (T6). We present the case of a 29 year-old, gravida 3, para 1 Caucasian female at 28 weeks gestation, with a history of T3 SCI secondary to a gunshot wound 9 years prior, who developed ADR during preterm labor and received epidural anesthesia during 6 days of labor followed by spinal anesthesia for cesarean section. Spinal anesthesia may be superior to epidural anesthesia for providing hemodynamic protection against ADR during cesarean section.

[Labor management using epidural anesthesia in a gravida patient with high spinal injury].

Since autonomic hyperreflexia (AH) is a serious complication during labor in a gravida with spinal cord injury, anesthetic measures should be taken for the suppression of AH even in a sensory-loss condition. Several reports have described various methods for the suppression of AH, in which epidural anesthesia has been advocated as a useful means for the prevention or amelioration of AH. However, it is difficult to evaluate the efficacy of epidural anesthesia due to the lack of sensory and motor functions. We report a primipara who had spinal cord injury below the T 3 level at the age of 17 due to a traffic accident and underwent successful vaginal delivery twice under epidural anesthesia at the ages of 30 and 32. For the first delivery, we placed two epidural catheters. We controlled the rate and the content of epidural infusion through the two different injection sites so as to meet delivery process. For the second delivery we did epidural anesthesia in the same way. Tubal-ligation was also performed under epidural anesthesia after the second delivery. No major obstetric complication including AH occurred in either of delivery. The woman with high spinal injury could have two healthy children without major complications during labor by the cooperation of gynecologists and anesthesiologists.

Reconstructive surgery and patients with spinal cord injury: Perioperative considerations for the plastic surgeon.

BACKGROUND: Patients with spinal cord injury (SCI) requiring reconstructive surgery, particularly for pressure ulcers, are ubiquitous in Plastic and Reconstructive Surgery practices. Much of the current literature focuses on operative techniques, antibiotic indications, sitting protocols, and dressing and bedding choices. METHODS: This paper reviews normal neuroanatomy, outlines changes in neurophysiology observed in spinal cord injury, and addresses concepts related to perioperative care that are highly relevant but often under-emphasised. RESULTS: Vascular disturbances such as autonomic dysreflexia and orthostatic hypotension are dangerous phenomena occurring in this patient population that, if not properly recognised and treated, may result in complications such as haematoma, flap loss, inadequate tissue perfusion, and death. The management of spasticity, deep venous thrombosis, and perioperative pain are also relevant and discussed in this paper. CONCLUSION: A basic understanding of these concepts is essential for the Plastic Surgeon involved in the care of patients with SCI and pressure ulcers, particularly before and after debridement or reconstruction.