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Paper text:
a patient with incomplete cervical cord injury , taken up for cervical spine decompression and fusion surgery , developed hypertensive crisis in operation theatre which was refractory to routine antihypertensive measures .
anaesthesia and surgery proceeded when she reasonably responded to intravenous ( iv ) dexmedetomidine only to have a rebound hypertension in the post - operative period which finally responded dramatically to rectal evacuation of impacted stool .
autonomic dysreflexia ( ad ) , a potentially dangerous clinical syndrome occurs in spinal cord injury at or above the sixth thoracic vertebral level ( t6 ) resulting in acute uncontrolled hypertension due to over activity of sympathetic nervous system below the level of injury , triggered by an ascending sensory ( noxious ) stimulus usually an over distended bladder in almost 85% of cases and bowel distension due to impacted stools .
a 35 year old female weighing 45 kg was having complaints of pain in the neck and weakness of all 4 limbs for 1 week . there were quadriparesis and a swelling on the left side of the neck along with tenderness in the cervical spine .
neurological examination revealed a power of 3/5 in bilateral upper and lower limbs and a sensory loss below c5 level with no bladder and bowel involvement .
rest of the clinical examination and baseline investigations were within normal limits . based on fine needle aspiration cytology report of a caseating tubercular lesion ,
magnetic resonance imaging of spine showed osseous destruction of c4 , c6 , c7 , t2 vertebral bodies , pre- and para - vertebral abscess and mild tracheal compression at the level of c6c7 [ figures 1 and 2 ] pre- and para - vertebral abscess with extension into b / l paraspinal muscles , anterior and posterior epidural space leading to significant compression of thecal sac and cervical spinal cord osseous destruction of c4 , c6 , c7 , t2 vertebral bodies an awake fiberoptic bronchoscopy ruled out any airway compromise .
she was planned for an elective cervical spine decompression and fusion surgery under the american society of anesthesiologists grade 1 . however , a sudden bladder and bowel involvement called for immediate surgery .
the patient was extremely anxious , agitated , was sweating and complained of headache with pain in the neck even after a premedication of midazolam 1 mg iv .
monitors showed a heart rate ( hr ) of 150/min and a blood pressure ( bp ) of 188/110 mmhg .
after 5 min bp was 196/120 mmhg with hr 158/min and continued to rise to 200/124 mmhg with a hr 156/min .
the progressing neurological deficit , aggressive haemodynamic optimization was attempted with a loading dose of esmolol 1 mg / kg iv was followed by an infusion 0.2 mg / kg / min after securing an arterial line .
remaining parameters such as percentage saturation of oxygen ( spo2 ) remained within normal limits .
a peripheral central catheter was inserted for central venous pressure monitoring . despite continuing esmolol infusion for 15 min
snp was not readily available with us , and a trial of esmolol had already been given .
the persistent anxiety factor prompted us to utilise the 2 agonist dexmedetomidine in a loading dose of 1 g / kg over 10 min followed by infusion of 0.2 g / kg / h .
the hr dropped to 120/min over 10 min , and the bp came down to 140/94 mmhg and patient became anxiety free . having achieved a relatively stable haemodynamics it was decided to proceed with the case .
while maintaining a manual inline stabilisation , mask ventilation was assured and vecuronium bromide 5 mg iv administered .
although a difficult intubation trolley was kept ready , trachea could be easily intubated with a 7.5 mm cuffed endotracheal tube .
extubation was planned in a deeper plane of anaesthesia . to obtund the haemodynamic reflexes at extubation ,
extubation was smooth and uneventful , and the patient shifted to high dependency unit ( hdu ) . in the hdu ,
a per rectal examination revealed impacted hard stools which was then evacuated . in the next 60 - 90 min ,
the patient was observed for the next 48 h with strict instructions of bowel care by enema .
our patient presented with incomplete cervical cord injury without any associated comorbidity but developed rapid neurological deficit with bladder and bowel involvement . on the operation table , she developed hypertensive crisis which was refractory to the conventional treatment , but responded somewhat to the cocktail of 2 agonist dexmedetomidine , opioid , beta blocker , diuretic and inhalation anaesthetic which helped us to tide over the intraoperative period only to have a rebound hypertension in the immediate post - operative period .
since we were dealing with a lesion at the cervical level with relatively intractable hypertension in a young patient with no previous history of hypertension , ad was considered as a possible cause , which led us to search for a focus of stimulation .
the urinary bladder was already catheterised so any stimulus arising from bladder was ruled out .
ad is a potentially dangerous clinical syndrome that develops in spinal cord injury at or above the t6 vertebra , resulting in acute , uncontrolled hypertension due to widespread reflex activity of sympathetic nervous system below the level of injury , triggered by an ascending sensory ( usually noxious ) stimulus either an over distended bladder , in almost 85% of cases , or bowel distension due to impacted stools , due to isolation of spinal cord below the injury from normal regulation by vasomotor centres in the brainstem .
pressure sores , ingrowing toenails , pregnancy and labour are also known to trigger ad .
release of catecholamines causes severe vasoconstriction with skin pallor , piloerection and a sudden rise in bp usually accompanied by a headache . rise in bp
is sensed by baroreceptors in the aortic arch and carotid bodies resulting in parasympathetic activity and compensatory bradycardia ( via the vagus nerve ) . our patient had a unique presentation for several reasons .
firstly , though it is a known occurrence in spinal cord injury , very few cases have been reported in non - traumatic causes .
however , causes like spinal cord tumours or post - neurosurgery above t6 , secondary to medical conditions such as multiple sclerosis are also known . secondly , our patient presented with tachycardia contrary to the much common presentation of bradycardia in these patients .
however , it has been observed that tachycardia is not an uncommon finding especially in patients with cervical lesion as was our patient .
thirdly , only 27% of patients with incomplete lesions present with ad ( in comparison to 91% of complete lesions ) as was in our patient . because of all the above factors , we considered it wise to rule out all other possibilities of such a presentation before concluding on ad as the cause . to rule out common causes of hypertension in a young female ,
a thorough history and examination were followed by a repeat routine laboratory tests along with special tests such as fundoscopy , thyroid profile , renal doppler , ultrasound kidney , ureter , bladder , echocardiography , serum cortisol and vanillylmandelic acid .
since all were within normal range , we zeroed down to a diagnosis of ad .
we want to emphasize that while dealing with a cervical cord injury , traumatic or atraumatic , complete or incomplete , the element of ad should be kept in mind , which should prompt us to eliminate any focus of stimulus below the level of injury .
catheterization of the urinary bladder and bowel evacuation with enema are the pearls of the preoperative preparation of such cases .
a young female having complaints of quadriparesis along with bladder and bowel involvement , diagnosed to have osseous destruction of c4 , c6 , c7 , t2 vertebral bodies with pre- and para - vertebral abscess , was taken up for anterolateral decompression and fusion of cervical spine . 
 she presented with anxiety , agitation , sweating and headache and was in hypertensive crisis which was refractory to antihypertensives , anxiolytics and analgesics but showed a reasonable response to intravenous dexmedetomidine and finally responded dramatically to rectal evacuation . 
 autonomic dysreflexia was suspected with stimulus arising from distended rectum as all other causes of hypertension were ruled out .