Prevention of recurrent autonomic dysreflexia: a survey of current practice

No pain, no strain: Targin® mitigates pain and constipation following spinal cord injury

BACKGROUND

Opioids effectively reduce chronic pain, but present significant side effects including opioid-induced constipation. Oxycodone/naloxone decreases pain and constipation in cancer patients, however its effect on spinal cord injury population remains understudied.

METHODS

We assessed whether oxycodone/naloxone reduces pain, constipation, and severity of autonomic dysreflexia in an individual with spinal cord injury. A 55-year-old male with C5 lesion presented with chief complaint of chronic pain received 5/2.5 mg and 20/10 mg oxycodone/naloxone for 6 and 2 weeks, respectively.

RESULTS

Oxycodone/naloxone improved pain, bowel function, and autonomic dysreflexia severity.

INTERPRETATION

Oxycodone/naloxone was effective in managing chronic pain and constipation in the studied case.

Autonomic Dysfunction and Management after Spinal Cord Injury: A Narrative Review

The autonomic nervous system (ANS), composed of the sympathetic and parasympathetic nervous systems, acts to maintain homeostasis in the body through autonomic influences on the smooth muscle, cardiac muscles, blood vessels, glands and organs of the body. The parasympathetic nervous system interacts via the cranial and sacral segments of the central nervous system, and the sympathetic nervous system arises from the T1–L2 spinal cord segments. After a spinal cord injury (SCI), supraspinal influence on the ANS is disrupted, leading to sympathetic blunting and parasympathetic dominance resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions and uncontrolled bowel, bladder, and sexual dysfunction. Further, afferent signals to the sympathetic cord elicit unabated reflex sympathetic outflow in response to noxious stimuli below the level of SCI. This article outlines the pathophysiology of SCI on the ANS, clinical ramifications of autonomic dysfunction, and the potential long-term sequelae of these influences following SCI.

Autonomic Dysreflexia following Spinal Cord Injury

Autonomic dysreflexia (AD) is a potentially life-threatening condition of the autonomic nervous system following spinal cord injury at or above T6. One of the most common symptoms is a sudden increase in blood pressure induced by afferent sensory stimulation owing to unmodulated reflex sympathetic hyperactivity. Such episodes of high blood pressure might be associated with a high risk of cerebral or retinal hemorrhage, seizures, heart failure, or pulmonary edema. In-depth knowledge is, therefore, crucial for the proper management of the AD, especially for spine surgeons, who encounter these patients quite often in their clinical practice. Systematical review of the literature dealing with strategies to prevent and manage this challenging condition was done by two independent reviewers. Studies that failed to assess primary (prevention, treatment strategies and management) and secondary outcomes (clinical symptomatology, presentation) were excluded. A bibliographical search revealed 85 eligible studies that provide a variety of preventive and treatment measures for the subjects affected by AD. As these measures are predominantly based on noncontrolled trials, long-term prospectively controlled multicenter studies are warranted to validate these preventive and therapeutic proposals.

Guideline No. 416: Labour, Delivery, and Postpartum Care for People with Physical Disabilities

OBJECTIVE

To describe evidence-based practice for managing the labour, delivery, and postpartum care of people with physical disabilities in Canada.

TARGET POPULATION

This guideline addresses the needs of people with physical disabilities, with a focus on conditions that affect strength and mobility, as well as those that affect neurological or musculoskeletal function or structure. Although aspects of this guideline may apply to people with solely intellectual, developmental, or sensory disabilities (e.g., hearing and vision loss), the needs of this population are beyond the scope of this guideline.

OUTCOMES

Safe and compassionate care for people with physical disabilities who are giving birth.

BENEFITS, HARMS, AND COSTS

Implementation of this guideline will improve health care provider awareness of specific complications people with physical disabilities may experience during labour, delivery, and the postpartum period and therefore increase the likelihood of a safe birth.

EVIDENCE

A literature review was conducted using MEDLINE (474), Embase (36), and the Cochrane Central Register of Controlled Trials (CENTRAL; 28) databases. The results have been filtered for English language, publication date of 2013 to present, observational studies, systematic reviews, meta-analyses, and guidelines and references in these publications were also reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Maternal-fetal medicine specialists, obstetricians, family physicians, nurses, midwives, neurologists, physiatrists, and those who care for people with physical disabilities.

RECOMMENDATIONS

Critical Care Management of Acute Spinal Cord Injury-Part II: Intensive Care to Rehabilitation

Spinal cord injury is devastating to those affected due to the loss of motor and sensory function, and, in some cases, cardiovascular collapse, ventilatory failure, and bowel and bladder dysfunction. Primary trauma to the spinal cord is exacerbated by secondary insult from the inflammatory response to injury. Specialized intensive care of patients with acute spinal cord injury involves the management of multiple systems and incorporates evidence-based practices to reduce secondary injury to the spinal cord. Patients greatly benefit from early multidisciplinary rehabilitation for neurologic and functional recovery. Treatment of acute spinal cord injury may soon incorporate novel molecular agents currently undergoing clinical investigation to assist in neuroprotection and neuroregeneration.

Autonomic dysreflexia after spinal cord injury: Systemic pathophysiology and methods of management

Traumatic spinal cord injury (SCI) has widespread physiological effects beyond the disruption of sensory and motor function, notably the loss of normal autonomic and cardiovascular control. Injury at or above the sixth thoracic spinal cord segment segregates critical spinal sympathetic neurons from supraspinal modulation which can result in a syndrome known as autonomic dysreflexia (AD). AD is defined as episodic hypertension and concomitant baroreflex-mediated bradycardia initiated by unmodulated sympathetic reflexes in the decentralized cord. This condition is often triggered by noxious yet unperceived visceral or somatic stimuli below the injury level and if severe enough can require immediate medical attention. Herein, we review the pathophysiological mechanisms germane to the development of AD, including maladaptive plasticity of neural circuits mediating abnormal sympathetic reflexes and hypersensitization of peripheral vasculature that collectively contribute to abnormal hemodynamics after SCI. Further, we discuss the systemic effects of recurrent AD and pharmacological treatments used to manage such episodes. Contemporary research avenues are then presented to better understand the relative contributions of underlying mechanisms and to elucidate the effects of recurring AD on cardiovascular and immune functions for developing more targeted and effective treatments to attenuate the development of this insidious syndrome following high-level SCI.