Abstract

Introduction: Traumatic Spinal Cord Injury (TSCI) causes a constellation of interrelated autonomic and cardiovascular abnormalities. One of them is Autonomic Dysreflexia (AD) which could appear when the TSCI is at or above the sixth thoracic (T6) spinal cord segment, resulting from a parasympathetic imbalance. It is clinically defined as acute hypertension generated by unmodulated sympathetic reflexes below the injury level. In response to hypertension, the baroreflex system lowers blood pressure by reducing heart rate and decreasing the activity of vasoconstrictor Sympathetic Preganglionic Neurons (SPN) located in the thoracolumbar spinal cord. While vagal parasympathetic innervation of the heart remains intact after TSCI, the disruption of descending vasomotor pathways to SPN produces an incomplete compensatory decrease in peripheral vascular resistance so that hypertension persists until the triggering stimulus is removed. The objective of this report is to describe a clinical case that suddenly triggered AD after an uncommon cause, that of T2 AIS A (ASIA/ISCoS) (1) A in which AD harmed the life of the patient but also the rehabilitation program.
Case report: A male 55 years with a prior history of TSCI, paraplegia AIS A, neurological level T2, was admitted to the Northern Rehabilitation Center (NRC) for optimization of the neuromotor rehabilitation, improving autonomy in daily life activities, and reducing joint limitations. The patient, after one weekend moving home 3 days after that suddenly start with AD symptoms during the rehabilitation program, triggered in the sitting position. Besides persistent hypertension, palpitations, diaphoresis, shivering, and tachycardia. The patient was diagnosed after finding out from the clinical history that the cause of the AD was a fracture of the left iliopubic and ischiopubic branches that would have arisen from a small accident that occurred over the weekend patient had not even appreciated. The cause of AD is concluded after being excluded from the most common AD triggers and conservatively treated.
Discussion: This cause draws attention even in low-energy injuries plus the prolonged immobilization known in TSCI resulting in bone loss and osteoporosis could easily develop a fracture which could trigger an AD and compromise all the rehabilitation programs, and the importance of anti-osteoporotic treatment whenever is necessary. AD is a medical emergency that can put the patient at risk of life, so the medical team should always be aware of this clinical entity.

Keywords: Dysreflexia; Parasympathetic imbalance; Clinical entity; Baroreflex system; Hypertension; Rehabilitation program