From the Guidelines
Autonomic dysfunction following spinal cord infarction significantly increases the risk of morbidity and mortality, particularly due to cardiac complications, and thus requires immediate and comprehensive management. The effects of autonomic dysfunction following spinal cord infarction are multifaceted, impacting various bodily systems and necessitating a tailored approach to management.
Orthostatic Hypotension Management
For orthostatic hypotension, non-pharmacological measures such as compression stockings, abdominal binders, and gradual position changes should be initiated first 1. If these measures are insufficient, medications like midodrine (2.5-10mg three times daily) or fludrocortisone (0.1-0.2mg daily) may be necessary. The definition and management of orthostatic hypotension have been outlined in the ACC/AHA/HRS and ESC guidelines, with a focus on a drop in systolic BP of ≥20 mm Hg or diastolic BP of ≥10 mm Hg with assumption of an upright posture 1.
Neurogenic Bladder and Bowel Management
For neurogenic bladder, intermittent catheterization every 4-6 hours is recommended, along with anticholinergics like oxybutynin (5mg three times daily) to reduce detrusor overactivity. Bowel management should include a high-fiber diet, adequate hydration, and scheduled bowel programs using bisacodyl suppositories or digital stimulation. These measures aim to prevent further complications such as urinary tract infections and constathing.
Temperature Dysregulation and Sexual Dysfunction
Temperature dysregulation may require environmental modifications and careful monitoring, while sexual dysfunction can be addressed with medications like sildenafil (25-100mg as needed) for erectile dysfunction. The underlying cause of these autonomic complications is the disruption of communication between higher brain centers and peripheral autonomic neurons due to the spinal cord infarct, affecting both sympathetic and parasympathetic functions.
Overall Management Approach
A multifaceted management approach is crucial, focusing on addressing specific symptoms while supporting overall autonomic regulation. Regular monitoring and adjustment of treatments based on symptom changes are essential, as autonomic dysfunction can evolve over time following spinal cord injury. The management strategy should be guided by the most recent and highest quality evidence, prioritizing interventions that improve morbidity, mortality, and quality of life outcomes.
From the Research
Effects of Autonomic Dysfunction
The effects of autonomic dysfunction following spinal cord infarction can be severe and potentially life-threatening. Some of the key effects include:
- Disrupted blood pressure regulation, which can lead to episodes of high blood pressure 2, 3, 4
- Impaired thermoregulation, resulting in temperature dysregulation 2, 5, 3
- Cardiovascular problems, such as cardiac dysrhythmias and orthostatic hypotension 5, 3
- Urinary and gastrointestinal issues, including bladder and bowel dysfunction 3
- Sexual dysfunction 3
- Autonomic dysreflexia, a potentially life-threatening condition characterized by sudden increases in blood pressure 5, 3, 4
Autonomic Dysfunctions
The autonomic dysfunctions that occur following spinal cord injury can be categorized into several areas, including:
- Cardiovascular dysfunction, which can lead to disordered hemodynamics and episodic hypertension 3
- Respiratory dysfunction, which can result in compromised respiratory function 3
- Urinary dysfunction, which can lead to bladder storage and emptying problems 3
- Gastrointestinal dysfunction, which can result in gastric dilation, delayed gastric emptying, and diminished propulsive transit 3
- Thermoregulatory dysfunction, which can lead to temperature dysregulation 2, 5, 3
Management and Prevention
Management and prevention of autonomic dysfunctions following spinal cord injury are crucial to prevent secondary complications. Some of the strategies that have been proposed include:
- Recognition and assessment of autonomic dysfunction, including the use of standardized assessment criteria 5
- Prevention and treatment of autonomic dysreflexia, including the use of preventive measures and treatment strategies 4
- Management of cardiovascular, respiratory, urinary, and gastrointestinal issues, including the use of medications and other interventions 3