Spinal autonomic dysreflexia
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Synonyms: Hyperreflexia, spinal autonomic dysreflexia
Overview
Spinal autonomic dysreflexia is a condition in which the blood pressure in a person with a spinal cord injury (SCI) above T5-6 becomes elevated due to the excess Autonomic Nervous System activity.
Pathophysiology
Autonomic Dysreflexia is usually caused when a painful stimulus occurs below the level of spinal cord injury. The stimulus is then mediated through the Central Nervous System (CNS) and the Peripheral Nervous System (PNS).
The CNS is made up of the spinal cord and brain, which control voluntary acts and end organs via their respective nerves. The PNS is made up from 12 pairs of cranial nerves, spinal nerves and peripheral nerves. The PNS also is divided into the somatic nervous system and the autonomic nervous system. The autonomic nervous system is responsible for the signs and symptoms of autonomic dysreflexia. The autonomic nervous system normally maintains body homeostasis via its two branches, the parasympathetic autonomic nervous system (PANS) and the sympathetic autonomic nervous system (SANS). These branches have complementary roles through a negative-feedback system; that is, when one branch is stimulated, the other branch is suppressed.
The SANS is associated with the flight-or-fight response, causing dilation of the pupils, increased heart rate, vasoconstriction, decreased peristalsis and tone of the gut, release of epinephrine and norepinephrine, as well as other effects. The effects of PANS stimulation are the opposite of the SANS; for the most part, these are constriction of the pupil, decreased heart rate, as well as increased peristalsis and tone of the gut.
The PANS and SANS exit at different sites in the CNS. The PANS exits via the midbrain, pons, medulla (cranial nerves [CN] III, VII, IX, and X), and the sacral level of the spinal cord. The SANS exits via the thoracic and lumbar segments of the spinal cord. There is a major sympathetic output (called the splanchnic outflow) between T5 and L2.
In someone with a high-level SCI, intact lower motor neurons sense the painful stimuli below the level of injury and transmit the message up the spinal cord (see diagram). At the level of the SCI, the pain signal is interrupted and prevented from being transmitted to the cerebral cortex. The site of the SCI also interrupts the two branches of the autonomic nervous system and disconnects the feedback loop, causing the two branches to function independently.
The ascending information reaches the major splanchnic sympathetic outflow (T5-T6) and stimulates a sympathetic response. The sympathetic response causes vasoconstriction, resulting in hypertension, pounding headache, visual changes, anxiety, pallor, and goose bumps below the level of injury. This hypertension stimulates the baroreceptors in the carotid sinuses and aortic arch. The PANS is unable to counteract these effects through the injured spinal cord, however. Instead, the PANS attempts to maintain homeostasis by slowing down the heart rate. The brainstem stimulates the heart, through the vagus nerve, causing bradycardia and vasodilation above the level of injury. The PANS impulses are unable to descend past the lesion, and therefore no changes occur below the level of injury.
Diagnosis
Symptoms
The most common symptoms include excess sweating, headache, a tingling sensation on the face and neck, blotchy skin around the neck and goose bumps. Not all the symptoms always appear at once, and their severity may vary.
There can be many stimuli that cause autonomic dysreflexia. Anything that would have been painful, uncomfortable, or physically irritating before the injury may cause autonomic dysreflexia after the injury.
The most common cause seems to be overfilling of the bladder. This could be due to a blockage in the urinary drainage device, bladder infection (cystitis), inadequate bladder emptying, bladder spasms, or possibly stones in the bladder.
The second most common cause is a bowel that is full of stool or gas. Any stimulus to the rectum, such as digital stimulation, can trigger a reaction, leading to autonomic dysreflexia.
Other causes include skin irritations, wounds, pressure sores, burns, broken bones, pregnancy, ingrown toenails, appendicitis, and other medical complications.
Differential Diagnosis of Causes of Spinal Autonomic Dysreflexia
In general, noxious stimuli (irritants, things which would ordinarily cause pain) to areas of body below the level of spinal injury. Things to consider include:
| Cardiovascular | No underlying causes |
| Chemical / poisoning | No underlying causes |
| Dermatologic | Any direct irritant below the level of injury (eg. - prolonged pressure by object in shoe or chair, cut, bruise, abrasion) • Pressure sores • Decubitus ulcer • Ingrown toenails • Burns (eg. - sunburn, burns from using hot water) • Tight or restrictive clothing or pressure to skin from sitting on wrinkled clothing |
| Drug Side Effect | No underlying causes |
| Ear Nose Throat | No underlying causes |
| Endocrine | No underlying causes |
| Environmental | No underlying causes |
| Gastroenterologic | Any condition that causes over distention or irritation of the bowel • Constipation • Impaction • Distention during bowel program (digital stimulation) • Hemorrhoids • Anal fissures • Infection or irritation (eg. appendicitis) |
| Genetic | No underlying causes |
| Hematologic | No underlying causes |
| Iatrogenic | No underlying causes |
| Infectious Disease | Urinary tract infection |
| Musculoskeletal / Ortho | No underlying causes |
| Neurologic | No underlying causes |
| Nutritional / Metabolic | No underlying causes |
| Obstetric / Gynecologic | Menstrual cramps • Labor and delivery |
| Oncologic | No underlying causes |
| Opthalmologic | No underlying causes |
| Overdose / Toxicity | No underlying causes |
| Psychiatric | No underlying causes |
| Pulmonary | No underlying causes |
| Renal / Electrolyte / Urologic | Overdistension of the bladder from any cause • Urinary retention • Blocked catheter • Overfilled collection bag • Non-compliance with intermittent categorization program |
| Rheum / Immune / Allergy | No underlying causes |
| Sexual | Over stimulation during sexual activity [stimuli to the pelvic region which would ordinarily be painful if sensation were present] |
| Trauma | Skeletal fractures |
| Miscellaneous | Heterotopic ossification such as Myositis ossificans • Heterotopic bone |
Treatment
The key strategy in treatment is to treat and/or remove any underlying precipitants of the syndrome.