Malignant autonomic dysreflexia in spinal cord injured men

Study design: Case reports. Objectives: To present a series of cases of protracted and severe autonomic dysreflexia (AD) in men with spinal cord injury(SCI), who sustained damage to their descending autonomic pathways. Settings: GF Strong Rehabilitation Centre, Sexual Health Rehabilitation Service, Vancouver Sperm Retrieval Clinic, Vancouver Coastal Health Authority, Vancouver, BC, Canada. Case report: AD is a serious complication of SCI triggered by a variety of noxious or non-noxious stimuli below the level of injury. However, we are presenting three cases of protracted, severe AD we have termed 'malignant', owing to the tendency of progressive worsening not usually seen with AD once the alleviating factor is removed. In all three individuals, AD was initially triggered by ejaculation and continued for a period of more than 1 week. Systolic blood pressure in these individuals increased above 220 mmHg and required either acute hospitalization or hospital assessment. Two of the individuals with malignant AD had American Spinal Injury Association (ASIA) B and C high cervical injury, respectively, with the third having a high thoracic ASIA A injury. In addition to detailed history and neurological examination, electrophysiological assessment of sympathetic skin responses (SSR) demonstrated a significant disruption of the descending autonomic pathways in these individuals. Conclusions: Our findings suggest that in addition to the severe injury of the motor and sensory pathway s (assessed by ASIA score), these individuals sustained severe injury to the supraspinal autonomic control. A combination of strong triggers such as ejaculation and bladder or colono-rectal irritation with total loss of descending autonomic control to the spinal sympathetic circuits could therefore contribute to the unusual manifestation of AD.