Autonomic Dysreflexia with Concurrent Orthostatic Hypotension: A Clinical Approach Dilemma

Zafefe bin Abd Rahman, Wong Yean Tzeh, Muhammad Nizamuddin bin Arbain, Sharon Anne Khor Keat Sim
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Abstract

Background and aim: Autonomic dysreflexia (AD) commonly occurs in high cervical spinal cord injury (SCI) patients. However, concurrent orthostatic hypotension (OH) makes the management of this condition more difficult. This case report highlighted the complicated condition that creates a dilemma for clinicians to prioritise the management. Methods: A 26-year-old man presented with traumatic cervical SCI C4 ASIA B secondary to C3 – C5 vertebral body fracture underwent anterior corpectomy and fusion. He had frequent episodes of AD in the rehabilitation clinic, presenting with sweating, headache, and high blood pressure (BP) while he was in a wheelchair. No other precipitating factors were identified except for his chronic sacral and ischial wounds. These AD episodes also happened multiple times daily at home with intermittent presyncope attacks. He was given stat doses of Nifedipine during the clinic visits but was never prescribed antihypertensive as no proper BP monitoring was done at home. Nonpharmacological measures for OH were already established. The rehabilitation team educated him on a side-lying position to alleviate his AD symptoms and preventive strategies such as optimal pressure relief with wheelchair cushions and using the reclining function on his motorised wheelchair. Results: He had difficulty achieving independent mobility because he could not tolerate upright sitting without having AD and intermittent OH. Conclusion: OH as a precipitating factor for AD should be considered. The lowest possible dose of antispastic medications for optimum spasm control and consideration of mineralocorticoid drugs for OH management may be helpful. Antihypertensives are commonly used for prophylaxis of chronic recurrent AD. However, its usage may be limited in patients with OH. Prazosin may be an option as studies have shown that it did not excessively lower baseline BP. Pressure mapping and surgical intervention to facilitate chronic non-healing wound closure also should be considered. Chronic recurrent AD with intermittent OH remains a challenging condition in high SCI.
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自主神经反射障碍并发直立性低血压:一个临床困境
背景与目的:自主神经反射障碍(AD)常见于高位颈脊髓损伤(SCI)患者。然而,并发体位性低血压(OH)使这种情况的管理更加困难。本病例报告强调了复杂的条件,创造了一个两难的临床医生优先管理。方法:一名26岁男性因C3 - C5椎体骨折继发的外伤性颈椎脊髓损伤C4 ASIA B行前椎体切除术和融合术。他在康复诊所经常发作阿尔茨海默病,当他坐在轮椅上时,表现为出汗、头痛和高血压。除了他的慢性骶骨和坐骨伤口外,没有发现其他促发因素。这些阿尔茨海默病发作也发生多次,每天在家中间歇性发作晕厥前。在门诊就诊时,他被给予两剂硝苯地平,但由于家中没有进行适当的血压监测,从未开过降压药。OH的非药物测量方法已经建立。康复小组教他侧躺的姿势,以减轻他的AD症状和预防策略,如使用轮椅垫和使用电动轮椅的斜倚功能来最佳缓解压力。结果:患者在没有AD和间歇性OH的情况下无法忍受直立坐姿,因此难以实现独立活动。结论:OH是AD的诱发因素之一。尽可能使用最低剂量的抗痉挛药物以达到最佳的痉挛控制,并考虑使用矿化皮质激素治疗OH可能会有所帮助。抗高血压药物通常用于预防慢性复发性AD。然而,它在OH患者中的使用可能受到限制。哌唑嗪可能是一种选择,因为研究表明它不会过度降低基线血压。还应考虑压力测绘和外科干预,以促进慢性不愈合伤口愈合。慢性复发性AD伴间歇性OH仍然是高脊髓损伤患者的一个挑战。
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