Published in “Charting a New Course:
The Guide to Independent Living after Spinal Cord Injury
By The University of Michigan Model Spinal Cord Injury Care System

A medical condition known as Autonomic Dysreflexia can occur in anyone with SCI at levels T6 and above, either complete or incomplete. This medical problem can happen at any time after SCI, even several years. Autonomic dysreflexia is a reaction of the body to a stimulus below the level of injury that results in a sudden increase in blood pressure. Symptoms may include a pounding headache, flushing of the skin, or a greatly slowed heartbeat.

Autonomic dysreflexia is a serious problem that can be life threatening. Promptly recognizing the condition and getting emergency medical attention is critical. Your family, friends and any caregivers should be able to recognize autonomic dysreflexia’s symptoms.

Autonomic dysreflexia is a very rapid increase in blood pressure that results as a response to a strong stimulation (such as a full bladder, pressure sore or other condition) below a person’s level of injury. The body’s normal inhibitory responses are blocked causing constriction of the blood vessels. This causes a rapid increase in blood pressure. The body may try to compensate resulting in a decrease in the heart rate and flushing above the level of the injury.

Sometimes, autonomic dysreflexia takes place following another serious medical condition such as a burn, fracture or pressure sore, or a minor event such as a medical exam, menstrual period or, even, overly tight clothing. In any case, the person must get medical care immediately.

Note: People with SCI often have a normally low systolic blood pressure (the higher number) of about 90-110. An increase of just 20-40 may be a sign of autonomic dysreflexia!

The sudden increase in blood pressure results in many other symptoms, which may include:

• Pounding headache,
• Slow heart rate relative to the normal rate,
• Sweating and flushing above the person’s injury level,
• Pale skin,
• Nasal Congestion,
• Anxiety, or
• Heartbeat irregularity (skipping heartbeats).

Occasionally, silent autonomic dysreflexia will occur where there are no symptoms besides elevated blood pressure.

Causes of Autonomic Dysreflexia

Bladder Distension

This is the most common cause of autonomic dysreflexia in people with SCI. This can be due to a kinked or clogged indwelling catheter or a full bladder in a patient who self catheterizes or reflex voids to empty their bladder. Other problems can include bladder or kidney stones, urinary tract infections or even a medical procedure such as insertion of a catheter or an endoscope examination of the bladder. For women, pregnancy, labor or menstruation can trigger autonomic dysreflexia.

Bowel

A distended bowel or bowel impaction can also bring on autonomic dysreflexia, as can digital stimulation or a rectal examination. Conditions such as appendicitis, a ruptured bowel and abdominal infections are other risk factors.

Skin

Skin problems such as ulcers, burns, trauma, tight clothing or equipment or ingrown toenails can cause autonomic dysreflexia.

Other Systems

Undiagnosed fractures, bone overgrowth, blood clots and medical or surcgical procedures put people with SCI at a higher risk for autonomic dysreflexia.

Treatment of Autonomic Dysreflexia

A medical provider will check a person’s blood pressure if autonomic dysreflexia is suspected or symptoms are present. A non-professional can also check blood pressure and take these steps:

If blood pressure is not elevated, refer to a physician as other causes of symptoms are possible. If blood pressure is elevated and the systolic blood pressure (the top number) is 15-20 above their usual level do the following:

• Call a doctor if the person appears very ill
• Sit person upright, if possible, to encourage pooling of blood in legs
• Loosen any clothing or restrictive devices (such as belts or ties)
• Recheck blood pressure
• People who catheterize should do so at once. An overly full bladder is the most common cause of autonomic dysreflexia. Place lidocaine jelly* in the urethra and wait 2-5 minutes, if possible. Then, recheck blood pressure.
• For people who use an indwelling catheter, check the tubing for kinks or blockages. Flush the tubing gently with several tablespoons of sterile water. Then use lidocaine jelly* solution. If there is blockage, change the catheter using lidocaine jelly, if available. Let the doctor know if there is difficulty passing a catheter.
• If the cause is not identified as urinary, a bowel problem may be suspected, such as possible fecal impaction (overly full bowel).
• Check for presence of stool and gently remove if it is in the rectum. It is possible that the person’s blood pressure will increase with this stimulation.
• Contact the doctor, then place a generous amount of lidocaine jelly* in the rectum and wait 2-5 minutes, then check the blood pressure.
• If the systolic blood pressure is over 150, treatment with drugs may be required.
• If no urinary or bladder source is identified and the autonomic dysreflexia persists, consult a doctor. The person should then be stripped down and inspected for other possible causes, such as tight clothing, a pressure ulcer, local trauma or musculoskeletal or skin problems.

If autonomic dysreflexia is severe, management with prescription drugs may be necessary and your blood pressure will need to be carefully watched. If the autonomic dysreflexia is severe and resistant to treatment, you may need to be monitored. After an episode of autonomic dysreflexia, your blood pressure should be checked every 15 minutes for 2 hours. A doctor needs to document the episode of autonomic dysreflexia and its cause.

- William Scelza, M.D.

*Lidocaine jelly is both a lubricant and a mild anesthetic. If it is not available, another lubricant can be used, such as KY jelly.

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As published in “The University of Michigan Spinal Cord Injury Rehabilitation Guide for Health Professionals”
By The University of Michigan Health System

Spinal cord injury (SCI) is a relatively rare occurrence. Improved medical techniques and knowledge about the condition have resulted in better survival for those individuals with acute or chronic SCI. There are identifiable trends regarding the etiology of injuries and other injury characteristics, although statistics regarding SCI have been collected and analyzed only in the last 35 years. The vast majority of statistical data has been collected by Model SCI Systems.

Incidence and Prevalence
The statistics reported here regarding the incidence (new cases) and prevalence (existing cases) of SCI are based on data from several studies, not from the National SCI Database. In the U.S., an estimated 11,000 new spinal cord injuries occur each year, or about 40 cases for every one million in population. These numbers include people who experience a traumatic SCI, but not cases due to disease or those who die at the scene of an accident. New studies on the occurrence of SCI have not been conducted since the 1970s, so it is unknown if the incidence has changed. The number of people in the United States living with a spinal cord injury as of June 2006 is about 253,000. This prevalence estimate is between 225,000 and 296,000 individuals.

Etiology
The causes of SCI among Model System participants are dominated by motor vehicle crashes which cause nearly half of all injuries. The next most common causes, in order of occurrence are: falls, violence, diving, sports, medical/surgical complications, and others. During the 1990s, violence was an increasingly frequent contributor to SCI, peaking at 24.8% in the time period 1990-1999, and then declining 13.8% since 2000.

Diving as a cause of spinal cord injury has dramatically declined, from causing 9.5% of SCIs between 1973 and 1979 to only 3.9% between 2000 and 2003. This may be due to new safety practices (e.g., the removal of diving boards at pools and safer pool designs) as well as public education.

Demographic Trends
Based on information provided by Model SCI Systems to the National SCI Database, the average age of injury is now 33.0 years. Most people who acquire an SCI are younger adults, with those 16-30 years of age accounting for the greatest percentage of people with a new SCI. The age of onset has been increasing, in part due to an aging U.S. population. Another factor is that people over the age of 60 are experiencing an increased rate of SCI: 10.9% of injuries were in this age group since the year 2000, compared with 4.7% in 1980. A disproportionate number of those injured are male; the ratio of males to females in 4:1.

The percentage of people with SCI representing minority groups have risen. For injuries that occurred in the years 1973-1976, 76.9% were white, 14.1% African American, 6% Hispanic, and 3% from other groups. Since 2000, the percentages have shifted to 67.5% white, 19% African American, 10.4% Hispanic, and 3.1% other. The reasons for these shifts in race-linked rates are not clear. Such changes could be due to Model SCI System data collection and referral patterns, actual differences in race-specific incidence rates, or shifts in overall U.S. demographics.

Neurological Level and Extent of Lesion
People with tetraplegia have sustained an injury to the cervical segments of the spinal cord while those with paraplegia have sustained damage to the thoracic, lumbar and sacral regions of the spinal cord. Injuries are also classified by extent of lesion: complete or incomplete. Complete SCI is defined as an injury with no sensation or motor strength below the level of injury. With incomplete SCI there continues to be some sensation or motor strength below the level of injury. When discharged from acute rehabilitation, about 34.3% of SCI patients have a diagnosis of incomplete tetraplegia, 25.1% have complete paraplegia, 22.1% have complete tetraplegia, and 17.5% have incomplete paraplegia.

Occupational Status
More than half (63%) of people with SCI are employed when admitted to a Model System at the time of injury. Ten years after their injury, more people with paraplegia are employed versus those with tetraplegia (31.7% versus 26.4%). Employment is complicated by many factors, including loss of medical insurance and other benefits, discrimination against people with disabilities, inaccessible workplaces, secondary health conditions, and personal issues.

Life Expectancy
In years past, the leading cause of death for people with an SCI was renal failure. Respiratory infections and infections related to the skin also contributed to mortality. The development of antibiotics, modern materials such as plastic and latex, and better procedures for dealing with the everyday issues of living with SCI have resulted in much lower rates of death and complications. Since 1973, the most frequent causes of death related to SCI are pneumonia, pulmonary embolism, and septicemia. Pulmonary complications are more common in individuals with cervical injuries, particularly those on a ventilator. If those with higher lesions are excluded, cardiovascular disease is the most common cause of death for people with SCI. Life expectancy has significantly improved so that the life-span estimates for people with paraplegia approach U.S. population norms.

Most of the above information is from the National Spinal Cord Injury Association website, located at www.spinalcord.uab.edu. Further information concerning these topics can also be found in special issues of the journal Archives of Physical Medicine and Rehabilitation published in November 1999 and November 204.

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The first of several spine injury patients is undergoing treatment, which has helped rodents regain the ability to walk and run. Doctors’ hopes are high.

By Amina Khan, Los Angeles Times
October 12, 2010

Researchers announced Monday that they had injected stem cells into a patient with a spinal cord injury on Friday, kicking off the world’s first clinical trial of a therapy derived from human embryonic stem cells.

The patient was treated at Shepherd Center, a spinal cord and brain injury center in Atlanta.

Though the trial, run by Geron Corp. of Menlo Park, Calif., is in its earliest stages — aimed primarily at testing the treatment for safety — the event stands as a landmark one for embryonic stem cell researchers, who for years have studied the cells’ potential to treat spinal cord injuries, diabetes and a variety of neurodegenerative diseases.

“All of that work, all of that money sent to the ivory towers is manifesting something. It’s a real shot in the arm for the field,” said Hans Keirstead, a neurobiologist at the Reeve-Irvine Research Center at UC Irvine who led a team that pioneered the treatment in rats and licensed the technology to Geron.

Keirstead’s team managed first to turn human embryonic stem cells into oligodendrocytes, the cells that insulate nerve fibers with coatings of fatty myelin. Growing the “tubing” that protects nerve cells could in many cases be enough to allow signals to travel up and down the spine again, Keirstead said. That’s because, in the vast majority of spinal cord injuries, the cord is not completely severed — rather, the myelin sheath that protects the nerve cells is damaged or destroyed.

In the animal trials, rats with spinal cord damage that had lost control of their hind limbs regained at least the partial ability to walk and run after treatments with the stem cells.

The human trial is a so-called Phase I trial, meant to test the safety of the treatment for people. It will enroll up to 10 patients who have suffered spinal cord injuries between the third and 10th thoracic vertebrae, injecting the cells within 14 days of the injury. If the treatment is shown to be safe and well tolerated, researchers will move on to test the treatment’s effectiveness.

In addition to the Shepherd Center, Northwestern University near Chicago has been announced as a site for this phase of the trial, and up to seven centers ultimately may be involved. The trial will last for two years after the last of the patients is enrolled.

Dr. Robert Watkins IV, an orthopedic spine surgeon and co-director of the Marina Spine Center at Marina Del Rey Hospital, said even the start of a Phase I trial in this area of medicine is encouraging.

“We know a lot about rehabilitation … but right now we have no treatment,” Watkins said. “It’s one of the most frustrating aspects of being a doctor.”

Keirstead said that even if the therapy ultimately did not permit people to walk and run again, it might greatly improve their quality of life by giving them more control over bowel, bladder and sexual functions.

He said he would be “waiting with bated breath every day” of the trial, watching for any side effects, such as signs of tumor growth or pain.

“I’ve got a couple of years of waking up and looking at the news every day, hoping and praying we’re doing good for people and not bad,” he said.

amina.khan@latimes.com
Copyright © 2010, Los Angeles Times

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University of Michigan researchers have created their first human embryonic stem cell line and one of only a handful in the nation made without potential contamination from other animal material, the lead scientist said Sunday.

The work was made possible by a 2008 Michigan constitutional amendment that lets scientists create embryonic stem cell lines using surplus embryos slated for disposal by fertility clinics, the university said.

The announcement came on the eve of a three-day global conference on stem cell research and commercialization in Detroit. The event, organized by the Genetics Policy Institute, is expected to draw more than 1,200 business, academic and government leaders from 25 countries.

“This historic achievement opens the door on a new era for U-M researchers, one that holds enormous promise for the treatment of many seriously debilitating and life-threatening diseases,” university President Mary Sue Coleman said in a statement.

The new stem cell line, called UM-4-6, is one of about 76 known to have been created nationwide and the first in Michigan, project leader Gary Smith told The Associated Press.

The line itself should be useful to researchers at the Ann Arbor school and elsewhere, Smith said, particularly because no animal products were used in its development. That increases researchers’ confidence that non-human protein material isn’t skewing the findings, he said.

In addition, the success gives Michigan research confidence of their ability to develop embryonic stem cell lines that carry genetic illnesses such as Huntington’s Disease and diabetes, he said.

“It’s really setting a pattern for deriving other embryonic stem cell lines,” Smith said.

Embryonic stem cells can become virtually any tissue in the body, and scientists say they believe they could one day lead to treatments for Parkinson’s disease, spinal-cord injuries and other serious illnesses.

They were first isolated at the University of Wisconsin in 1998.

Stem cell research has been a matter of heated dispute between advocates who promote its potential to find cure for disease and opponents who say fertilized human eggs are a form of human life that deserves legal protection.

“Ours is not the first country or culture to selectively pursue a moral calculus that justifies taking a life to enable scientific experiments,” Roman Catholic Archbishop Allen Vigneron of Detroit said Sunday in a written statement about the upcoming conference.

Vigneron criticized what he called the disconnect between state laws making it a crime to harm a fetus being carried in a woman’s womb and “what occurs in a laboratory when a human life is destroyed.”

The stem cell line that Smith and his colleagues created was derived from a cluster of about 30 cells from a five-day-old embryo. It was from a couple that underwent infertility treatments and “no longer wanted to use it for reproductive purposes,” Smith said.

Had it not been used to create a stem cell line, it would have been discarded, he said.

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