Sam C. Colachis

Autonomic hyperreflexia with spinal cord injury.

Autonomic hyperreflexia occurs in up to 85 percent of individuals with spinal cord injuries above the major splanchnic sympathetic outflow. In such cases, paroxysmal reflex sympathetic activity develops in response to noxious stimuli below the level of the neurologic lesion. The clinical features of autonomic hyperreflexia are due largely to reflex sympathetic adrenergic and cholinergic discharges with dysfunctional supraspinal regulatory control. Cephalgia, diaphoresis, flushing, tachycardia or bradycardia, and paroxysmal hypertension are most commonly observed. Although a variety of stimuli can provoke autonomic responses of variable magnitudes, bladder and bowel distention continue to account for most episodes. Removal of the offending stimulus is important to restoring the autonomic nervous system to its baseline activity. Current understanding of the pathophysiology, clinical features, and medical management of this fascinating but potentially serious complication of spinal cord injury are reviewed.

Autonomic hyperreflexia associated with recurrent cardiac arrest : Case Report

Autonomic hyperreflexia is a condition which may occur in individuals with spinal cord injuries above the splanchnic sympathetic outflow. Noxious stimuli can produce profound alterations in sympathetic pilomotor, sudomotor, and vasomotor activity, as well as disturbances in cardiac rhythm. A case of autonomic hyperreflexia in a patient with C6 tetraplegia with recurrent ventricular fibrillation and cardiac arrest illustrates the profound effects of massive paroxysmal sympathetic activity associated with this condition.

Surveillance With Duplex Ultrasound In Traumatic Spinal Cord Injury On Initial Admission To Rehabilitation

Abstract Objective: To determine the prevalence of deep vein thrombosis (DVT) by surveillance duplex ultrasound in the traumatic spinal cord injury (SCI) population on admission to rehabilitation. Design: Retrospective sequential case series. Setting: Midwest regional, university-based, Commission on Accreditation of Rehabilitation Facilities-accredited acute rehabilitation center. Methods: Charts of all patients with traumatic SCI admitted and discharged from january 1, 1996 through December 31, 1998 were reviewed. Preadmission data were collected on demographics, severity of injury, and DVT prophylaxis information, along with rehabilitation duplex ultrasound results and incidence of thromboembolic events. Results: Ninety-two participants met the inclusion criteria. There were 68 men and 24 women with a mean age on admission of 3 2.4 years. On admission, 45 participants (49%) were classified as tetraplegic and 47 (51%) were classified as paraplegic; 63 (69%) had motor-complete lesions and 29 (31 %) had motor-incomplete lesions. Of all the participants, 8 (8.7%) were found to have DVT on admission to rehabilitation. There were no statistically significant differences among participants with regard to age, sex, level of injury, or completeness of injury, when comparing those participants with DVT on admission, those without DVT on admission, and those with thromboembolic events diagnosed later in their hospitalization. Of the 84 participants who had negative duplex ultrasounds on admission, 4 individuals (4.8%) were found to have DVT and 4 (4.8%) had pulmonary emboli subsequently. In these 84 participants, DVT prophylaxis with low-molecular-weight heparin was found to be more effective than was adjusted-dose heparin in preventing thromboembolic phenomenon. Conclusion: Incidence of DVT remains high despite prophylaxis in traumatic SCI patients. Two thirds of DVT diagnosed in rehabilitation was identified on admission and one third was diagnosed later. Duplex ultrasound is an effective and valuable tool that assists in the diagnosis of asymptomatic DVT in patients with traumatic SCI who are initiating in -patient rehabilitation.

Occurrence of fever associated with thermoregulatory dysfunction after acute traumatic spinal cord injury.

The medical records of 156 patients with acute traumatic Spinal Cord Injury (SCI), admitted for inpatient SCI rehabilitation during the period from January 1, 1990 through December 31, 1992, were retrospectively reviewed. Seventy-one patients with acute traumatic SCI were identified at risk for thermoregulatory dysfunction (50 patients with cervical SCI and 21 with upper thoracic level SCI). A total of 713 days were documented in which febrile events occurred in 60 of 71 patients during the study period. Over 39% of these fevers measured 101 degrees F (38.3 degrees C) or greater. There were 71 days of documented febrile episodes occurring in 17 patients for which an etiology could not be determined. Fifteen of these individuals had fewer than five such febrile days each during their entire rehabilitation hospitalization. Study results indicate that in a population of patients with acute traumatic SCI at risk for thermoregulatory dysfunction, the occurrence of fever is quite high. Fever not attributable to infectious or inflammatory etiologies is uncommon. Fever attributable to thermoregulatory dysfunction in this setting should be considered only after other etiologies have been carefully excluded.

The association between deep venous thrombosis and heterotopic ossification in patients with acute traumatic spinal cord injury

The medical records of 209 patients with acute traumatic spinal cord injury (SCI) admitted to the SCI rehabilitation unit from 7/1/88 through 12/31/92 were reviewed. Whereas the incidence of heterotopic ossification (HO) and deep venous thrombosis (DVT) in this population were 16.7% and 14.3%, respectively, 36.6% of the individuals with DVT had HO. 31.4% of those with HO developed DVT at some time during their acute or rehabilitation hospitalization. The overall incidence of coexistent DVT and HO was 5.3%. The correlation between the occurrence of HO and DVT in this SCI population reached statistical significance (X2 = 9.97; p < 0.005). The results of this study suggest that there exists an association between the occurrence of DVT and HO following traumatic SCI. We hypothesize that venous compression from expanding heterotopic bone can result in lower limb DVT following traumatic SCI.

A preventable cause of foot drop during childbirth

Compression of the peroneal nerve is an uncommon complication of labor and delivery. We describe a case of common peroneal nerve injury associated with positioning the knees in hyperflexion during delivery. The pathophysiologic mechanisms, clinical course, and possible prevention of this uncommon complication are discussed.

Neurovascular complications of heterotopic ossification following spinal cord injury

Compression of neurovascular structures from heterotopic ossification can result in neurological and vascular sequelae. Three cases of neurovascular compression due to heterotopic ossification illustrate the potential for neurovascular compression resulting from this condition and underscore the importance of recognising this uncommon, but notable complication following spinal cord injury.

Early recognition of neuroleptic malignant syndrome during traumatic brain injury rehabilitation.

Neuroleptic malignant syndrome is a rare disorder that manifests with hyperthermia, muscle rigidity and autonomic instability. Presented is a case series of individuals with traumatic brain injury and agitation who, when treated with neuroleptics, developed neuroleptic malignant syndrome. Although the incidence of this syndrome is rare, it is associated with significant morbidity and mortality. The onset of symptoms inconsistent with the patients current level of recovery should alert the clinician to consider other possible diagnosis and failure to distinguish the features of neuroleptic malignant syndrome from post-traumatic agitation will delay appropriate intervention for this potentially life-threatening disorder.

Hypothermia associated with autonomic dysreflexia after traumatic spinal cord injury.

Individuals with traumatic upper thoracic and cervical spinal cord injuries are at increased risk for the development of both thermoregulatory dysfunction and autonomic dysreflexia. It is unclear, however, what effect reflex autonomic sympathetic outflow has on thermoregulatory dysfunction during episodes of autonomic dysreflexia. The following case of an individual with C5 tetraplegia and both thermoregulatory dysfunction and autonomic dysreflexia illustrates the profound effects that the autonomic nervous system may have on body temperature in individuals at risk for this complication.

Incidence of fever in the rehabilitation phase following brain injury.

There appears to be a high incidence of fever after brain injury. The most common cause for fever is infection. The incidence of fever occurring as a result of hypothalamic thermoregulatory dysfunction after brain injury is less clear. This study retrospectively reviewed the charts of 286 subjects with brain injuries. Subject subpopulations were divided into traumatic brain injuries, anoxic brain injuries, and brain injuries resulting from aneurysmal subarachnoid hemorrhage. Fever events were described as any core temperature greater than 99.9 degrees F. Most subjects suffered a severe brain injury and had an average acute hospital length of stay ranging from 35.4 to 60 days. The average rehabilitation length of stay ranged from 38.4 to 45.1 days. Twenty-four percent of subjects experienced fevers, with each of the populations having similar occurrence rates. Unexplained fever events were found in the traumatic brain injury (7%) and aneurysmal subarachnoid hemorrhage (8%) subpopulations only. No unexplained fever event was associated with a temperature greater than 100.8 degrees F.