Autonomic Dysreflexia – a Serious Complication of Spinal Cord Injury

Authors: J. Kříž 1;  M. Rejchrt 2
Authors‘ workplace: 2. LF UK a FN v Motole, Praha Spinální jednotka při Klinice rehabilitace a tělovýchovného lékařství 1;  2. LF UK a FN v Motole, Praha Urologická klinika 2
Published in: Cesk Slov Neurol N 2014; 77/110(2): 168-173
Category: Review Article


Autonomic dysreflexia is a serious complication found in more than half of patients with spinal cord injury above the T6 level. In case of an autonomic system disorder, a trigger below the level of injury causes severe vasoconstriction with paroxysmal hypertension. Presenting symptoms include bradycardia, pounding headache, sweating and flushing above the level of lesion, and anxiety. However, AD can sometimes occur without symptoms. The causes of AD include bladder and bowel distension, urological surgeries as well as burning, pressure sores and fractures. Uncontrolled hypertension can lead to hemorrhagic stroke, retinal he­morrhage, respiratory or cardiac problems and even death. Management involves placing the patient in an upright position to take advantage of orthostatic reduction in blood pressure. As the first line of treatment, the cause of irritation has to immediately be eliminated; this usually leads to blood pressure stabilization. If hypertension continues, rapid onset antihypertensive drugs should be used.

Key words:
spinal cord injury – autonomic dysreflexia – tetraplegia

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manu­script met the ICMJE “uniform requirements” for biomedical papers.


1. Alexander MS, Biering‑ Sorensen F, Bodner D, Brackett NL, Cardenas D, Charlifue S et al. International standards to document remaining autonomic function after spinal cord injury. Spinal Cord 2009; 47(1): 36– 43.

2. Bowlby A. On the Condition of the Reflexes in Cases of Injury to the Spinal Cord; with special reference to the Indications for Operative Interference. Med Chir Trans 1890; 73: 313– 325.

3. Guttmann L, Whitteridge D. Effects of bladder distension on autonomic mechanisms after spinal cord injuries. Brain 1948; 70(4): 361– 404.

4. Curt A, Nitsche B, Rodic B, Schurch B, Dietz V. Assessment of autonomic dysreflexia in patients with spinal cord injury. J Neurol Neurosurg Psychiatry 1997; 62(5): 473– 477.

5. Bycroft J, Shergill I, Choong E, Arya N, Shah P. Autonomic dysreflexia: a medical emergency. Postgrad Med J 2005; 81(954): 232– 235.

6. Furusawa K, Tokuhiro A, Sugiyama H, Ikeda H, Tajima F, Genda E et al. Incidence of symptomatic autonomic dysreflexia varies according to the bowel and bladder management techniques in patients with spinal cord injury. Spinal Cord 2011; 49(1): 49– 54.

7. Krassioukov AV, Karlsson AK, Wecht JM, Wuermser LA, Mathias CJ, Marino RJ et al. Assessment of autonomic dysfunction following spinal cord injury: rationale for additions to International Standards for Neurological Assessment. J Rehabil Res 2007; 44(1): 103– 112.

8. Vaidyanathan S, Soni BM, Sett P, Watt JW, Oo T, Bingley J. Pathophysiology of autonomic dysreflexia: long‑term treatment with terazosin in adult and paediatric spinal cord injury patients manifesting recurrent dysreflexic episodes. Spinal Cord 1998; 36(11): 761– 770.

9. Karlsson AK. Autonomic dysreflexia. Spinal Cord 1999; 37(6): 383– 391.

10. Krhut J, Doležel J, Doležil D, Zachoval R, Ženíšek J. Neurourologie. 1. ed. Praha: Galén 2005: 73– 74.

11. Novotný T, Lukeš M, Bittner L, Heráček J, Urban M, Sobotka V et al. Urologické komplikace poranění míchy. Postgraduální medicína 2007; 9(9): 957– 964.

12. Linsenmeyer TA, Campagnolo DI, Chou IH. Silent autonomic dysreflexia during voiding in men with spinal cord injuries. J Urol 1996; 155(2): 519– 522.

13. Huang YH, Bih LI, Liao JM, Chen SL, Chou LW, Lin PH.Blood pressure and age associated with silent autonomic dysreflexia during urodynamic examinations in patients with spinal cord injury. Spinal Cord 2013; 51(5): 401– 405.

14. Shergill IS, Arya M, Hamid R, Khastgir J, Patel HR, Shah PJ. The importance of autonomic dysreflexia to the urologist. BJU Int 2004; 93(7): 923– 926.

15. Courtois F, Rodrigue X, Côté I, Boulet M, Vézina JG, Charvier K et al. Sexual function and autonomic dysreflexia in men with spinal cord injuries: how should we treat? Spinal Cord 2012; 50(12): 869– 877.

16. Skowronski E, Hartman K. Obstetric management following traumatic tetraplegia: case series and literature review. Aust N Z J Obstet Gynaecol 2008; 48(5): 485– 491.

17. McGarry J, Woolsey RM, Thompson CW. Autonomic hyperreflexia following passive stretching to the hip joint. Phys Ther 1982; 62(1): 30– 31.

18. Ho CP, Krassioukov AV. Autonomic dysreflexia and myocardial ischemia. Spinal Cord 2010; 48(9): 714– 715.

19. Vallès M, Benito J, Portell E, Vidal J. Cerebral hemorrhage due to autonomic dysreflexia in a spinal cord injury patient. Spinal Cord 2005; 43(12): 738– 740.

20. Eltorai I, Kim R, Vulpe M, Kasravi H, Ho W. Fatal cerebral hemorrhage due to autonomic dysreflexia in a tetraplegic patient: case report and review. Paraplegia 1992; 30(5): 355– 360.

21. Silver JR. Early autonomic dysreflexia. Spinal Cord 2000; 38(4): 229– 233.

22. Krassioukov AV, Furlan JC, Fehlings MG. Autonomic dysreflexia in acute spinal cord injury: an under‑ recognized clinical entity. J Neurotrauma 2003; 20(8): 707– 716.

23. Elliott S, Krassioukov A. Malignant autonomic dysreflexia in spinal cord injured men. Spinal Cord 2006; 44(6): 386– 392.

24. Mills PB, Krassioukov A. Autonomic function as a missing piece of the classification of Paralympic athletes with spinal cord injury. Spinal Cord 2011; 49: 768– 776.

25. Steinberg LL, Lauro FA, Sposito MM, Tufik S, Mello MT, Naffah‑ Mazzacoratti MG et al. Catecholamine response to exercise in individuals with different levels of paraplegia. Braz J Med Biol Res 2000; 33(8): 913– 918.

26. Burnham R, Wheeler G, Bhanbhani Y, Belanger M,Eriksson P, Steadward R. Intentional induction of autonomic dysreflexia among quadriplegic athletes for performance enhancement: efficacy, safety and mechanism of action. Clin J Sport Med 1994; 4: 1– 10.

27. International Paralympic Committee. Position statement on autonomic dysreflexia and boosting. Chapter 4.3 IPC Handbook. International Paralympic Committee, Bonn, Germany, 2010.

28. Krassioukov A, Warburton DE, Teasell R, Eng JJ, Spinal Cord Injury Rehabilitation Evidence Research Team. A systematic review of the management of autonomic dysreflexia after spinal cord injury. Arch Phys Med Rehabil 2009; 90(4): 682– 695.

29. Vaidyanathan S, Soni B, Selmi F, Singh G, Esanu C,Hughes P et al. Are urological procedures in tetraplegic patients safely performed without anesthesia? A report of three cases. Patient Saf Surg 2012; 6: 2– 8.

30. Cosman BC, Vu TT. Lidocaine anal block limits autonomic dysreflexia during anorectal procedures in spinal cord injury: a randomized, double‑blind, placebo‑ controlled trial. Dis Colon Rectum 2005; 48(8): 1556– 1561.

31. Hughes SJ, Short DJ, Usherwood MM, Tebbutt H.Management of the pregnant woman with spinal cord injuries. Br J Obstet Gynaecol 1991; 98(6): 513– 518.

32. Steinberger RE, Ohl DA, Bennett CJ, McCabe M, Wang SC. Nifedipine pretreatment for autonomic dysreflexia during electroejaculation. Urology 1990; 36(3): 228– 231.

33. Consortium for Spinal Cord Medicine. Acute management of autonomic dysreflexia: individuals with spinal cord injury presenting to health‑ care facilities. J Spinal Cord Med 2002; 25 (Suppl 1): S67–S88.

34. Thyberg M, Ertzgaard P, Gylling M, Granerus G. Effect of nifedipine on cystometry‑induced elevation of blood pressure in patients with a reflex urinary bladder after a high level spinal cord injury. Paraplegia 1994; 32(5): 308– 313.

35. Ishikura F, Beppu S, Hamada T, Khandheria BK, Seward JB, Nehra A. Effects of sildenafil citrate (Viagra) combined with nitrate on the heart. Circulation 2000; 102(20): 2516– 2521.

36. Vaidyanathan S, Soni BM, Sett P, Watt JW, Oo T, Bingley J. Pathophysiology of autonomic dysreflexia: long‑term treatment with terazosin in adult and paediatric spinal cord injury patients manifesting recurrent dysreflexic episodes. Spinal Cord 1998; 36(11): 761– 770.

37. Krum H, Louis WJ, Brown DJ, Howes LG. A study of the alpha‑ 1 adrenoceptor blocker prazosin in the prophylactic management of autonomic dysreflexia in high spinal cord injury patients. Clin Auton Res 1992; 2(2): 83– 88.

Paediatric neurology Neurosurgery Neurology

Article was published in

Czech and Slovak Neurology and Neurosurgery

Issue 2

2014 Issue 2

Most read in this issue

This topic is also in:

Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.


Don‘t have an account?  Create new account