Liu N et al, 2015: Iatrogenic urological triggers of autonomic dysreflexia: a systematic review.
Liu N, Zhou M, Biering-Sørensen F, Krassioukov AV.
Department of Rehabilitation Medicine, Peking University Third Hospital, Beijing, China.
Department for Spinal Cord Injuries, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark.
International Collaboration on Repair Discoveries (ICORD), Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada; GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, British Columbia, Canada.
STUDY DESIGN: This is a systematic review.
OBJECTIVE: The objective of this study was to review the literature on iatrogenic urological triggers of autonomic dysreflexia (AD).
SETTING: This study was conducted in an international setting.
METHODS: A systematic review was conducted from PubMed search using AD/ autonomic hyperreflexia and spinal cord injury (SCI). Studies selected for review involved iatrogenic urological triggers of AD in individuals with SCI, including original articles, previous practice guidelines, case reports and literature reviews. Studies that did not report AD or blood pressure (BP) assessments during urological procedures were excluded.
RESULTS: Forty studies were included for analysis and categorized into four groups: (1) urodynamics and cystometry; (2) cystoscopy and transurethral litholapaxy; (3) extracorporeal shock-wave lithotripsy (ESWL); and (4) other procedures. During urodynamics, the incidence of AD ranged from 36.7% to 77.8%. The symptomatic rate ranged from 50% to 65%, with AD symptoms seen predominantly in cervical SCI patients. The studies imply no consensus regarding the relationship between AD, neurogenic detrusor overactivity and detrusor sphincter dyssynergia. Without anesthesia, the majority of individuals develop AD during cystoscopy, transurethral litholapaxy and ESWL. The effectiveness of different anesthesia methods relies on blocking the nociceptive signals from the lower urinary tract (LUT) below the level of the neurological lesion. Other iatrogenic urological triggers were commonly associated with bladder filling.
CONCLUSION: The LUT triggers of episodes of AD are often associated with iatrogenic urological procedures. AD was more prevalent in cervical SCI than in thoracic SCI. To detect this potential life-threatening complication following cervical and high thoracic SCI, routine BP monitoring during urological procedures is highly recommended.
Spinal Cord. 2015 Mar 24. doi: 10.1038/sc.2015.39. [Epub ahead of print]
This article is an important reminder of the risk that patients with spinal cord injuries suffer of developing autonomic dysreflexia (AD) in association with urological treatment. Inasmuch as ESWL is an excellent method for treating stones in patients with spinal cord injuries, it is extremely important to be aware of this complication that might be triggered either by the ESWL treatment itself, associated transurethral manipulations or just bladder filling.
In its full developed state AD is a serious and life-threatening condition with very high systolic blood pressure and typical symptoms, but AD can also be “silent” with less marked blood pressure increase but nevertheless with an obvious risk of complications. It is of note that without anaesthesia, a majority of patients subject to cystoscopy, stone removal with URS or ESWL developed AD. Anaesthesia is one method to cope with this complication, but one of the advantages when treating patients with spinal cord injuries is that the treatment can be carried out without general anaesthesia. Careful patient monitoring is mandatory and it appears worthwhile to pre-treat these patients with nifedipine (10mg) and moreover, to be prepared for the possibility of AD.