Autonomic dysreflexia is a dangerous clinical condition in patients with severe spinal cord injury at or above the level of the sixth thoracic vertebra (T6). It causes sudden uncontrolled and life-threatening hypertension because of inadequate physiological balancing by the two parts of the autonomic nervous system – the sympathetic and parasympathetic pathways.
Patients usually present with one of several symptoms –
- blurred vision or spots in front of the eyes;
- nasal congestion;
- a sense of ‘impending doom’ or apprehension.
Above the level of the injury the skin reflects unopposed parasympathetic activity with -
while below the lesion there is sympathetic activity but no inhibition by descending parasympathetic activity–
- pale, cool skin,
A range of underlying problems can induce attacks. These include (but are not limited to) – 
- Urinary tract problems - bladder distension, urinary tract infection, calculus;
- Gastrointestinal tract disturbances - Bowel distension or impaction, gastritis, gastric reflux or ulcers, gallstones, gastrocolic irritation, anal fissures, hemorrhoids or appendicitis;
- Reproductive tract stimulation – menstruation, pregnancy (especially labour and delivery), vaginitis, sexual intercourse, ejaculation, epididymitis, scrotal compression;
- Invasive investigations - cystoscopy, colonoscopy, surgery;
- Vascular conditions - deep vein thrombosis, pulmonary emboli;
- Skin problems – blisters, burns or sunburn, contact with hard or sharp objects, constrictive clothing, shoes, or appliances, pressure ulcers, ingrowing toenail, insect bites;
- Temperature fluctuations;
- Bone disease or damage – fractures, arthritis.
Entire Body System
Fractures Heterotopic Ossification Spasticity Urinary Tract Infections Autonomic Dysreflexia Deep Vein Thrombosis Pulmonary Embolism Orthostatic Hypotension Cardiovascular Disease Syringomyelia Neuropathic / Spinal Cord Pain Medication Problems Hyperthermia Hypothermia [spinal-injury.net]
Hypothermia may occur in hypothalamic disorders and in the elderly, in whom such lesions have been postulated. [jnnp.bmj.com]
MRI disclosed C2–7 cord swelling. The intramedullary region of the swelling cord was low on T1 weighted images and high signal intensity on T2 weighted images. [jnnp.bmj.com]
Regional Pain Syndrome (CRPS) ), is a posttraumatic chronic neurological syndrome Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome (CRPS) symptoms -Severe persistent burning pain -Pathological changes in bone and skin -Excessive sweating -Tissue swelling [quizlet.com]
- Constitutional Symptom
- Treatment: - non operative treatment includes adequate calcium intake and avoidance of Vit D; - w/ vague constitutional symptoms such as fatigue, weakness, and/or constipation associated w/ mild hypercalcemia then surgery is not indicated; - note [wheelessonline.com]
- Nasal Congestion
Signs and symptoms of autonomic dysreflexia Helping Hands carers are trained to look out for the signs of an imminent attack: Pounding headache (caused by the elevation in blood pressure) Goose pimples Sweating above the level of injury Nasal congestion [helpinghandshomecare.co.uk]
Clinical examination reflects the split nature of the condition -there is bradycardia, constriction off the pupils and nasal congestion. [symptoma.com]
Autonomic dysreflexia (AD) is a syndrome that consists of facial flushing, excessive sweating, nasal congestion, throbbing headache and paroxysmal hypertension which may occur in response to bladder distension in patients with spinal cord lesions above [ncbi.nlm.nih.gov]
congestion slow pulse blotching of the skin restlessness hypertension (blood pressure greater than 200/100) flushed (reddened) face red blotches on the skin above level of spinal injury sweating above level of spinal injury nausea slow pulse ( cold, [allnurses.com]
[…] the level of injury Nasal congestion Slow pulse Blotching of the skin Restlessness Hypertension (blood pressure greater than 200/100) Flushed (reddened) face Red blotches on the skin above level of spinal injury Sweating above level of spinal injury Nausea [helpinghandshomecare.co.uk]
[…] the level of injury nasal congestion slow pulse blotching of the skin restlessness hypertension (blood pressure greater than 200/100) flushed (reddened) face red blotches on the skin above level of spinal injury sweating above level of spinal injury nausea [allnurses.com]
They include headache, nausea and vomiting, problems with vision, nasal congestion, and feelings of anxiety and doom. [msdmanuals.com]
Nausea. A slow heart rate ( bradycardia ). Goose bumps below the level of spinal injury. Cold, clammy skin below the level of spinal injury. [myhealth.alberta.ca]
Tagged with: autonomic dysreflexia, bowel program, digital stimulation, flaccid, hydration, menu planning, neurogenic, reflex, sphincter Posted in ...what to know if I'm recently injured, autonomic dysreflexia, bowel problems (accidents, constipation, diarrhea [sci-u.ca]
Definition Term Definition drowsy, dizzy, diarrhea, tremor Term Definition Term carbemazepine metabolism key fact Definition Term Definition blocks Na channels, blocks Ca channels Term Definition Term gen fxn of mesocortical path Definition affect, emotion [flashcardmachine.com]
Diarrhea? Nausea? Vomiting? Quickly do a rectal check for any stool in the rectal vault. If the problem is with the bowel and you can’t resolve it – call 911 and go to the ER immediately! [craighospital.org]
Manifestations include HYPERTENSION; TACHYCARDIA (or reflex bradycardia); FEVER; FLUSHING; and HYPERHIDROSIS. Extreme hypertension may be associated with a STROKE. [fpnotebook.com]
Conclusions: AD may commonly occur with relative tachycardia. [doi.org]
AD may commonly occur with relative tachycardia. [ncbi.nlm.nih.gov]
- Orthostatic Hypotension
Treatment of orthostatic hypotension with fludrocortisone acetate relieved these symptoms. [ncbi.nlm.nih.gov]
Orthostatic intolerance with posturally induced tachycardia Orthostatic intolerance may occur without orthostatic hypotension. [jnnp.bmj.com]
Signs and symptoms – Clinical Features Hypertension: Greater than 20mmHg above baseline for both systolic and diastolic (Typical BP in tetraplegia patient is 90-110/60-70mmHg supine BP is commonly lower when patient is sitting due to orthostatic hypotension [rnoh.nhs.uk]
- Muscle Spasm
This reaction may include: Change in heart rate Excessive sweating High blood pressure Muscle spasms Skin color changes (paleness, redness, blue-gray skin color) The most common cause of autonomic dysreflexia (AD) is spinal cord injury. [nlm.nih.gov]
This reaction may include: Change in heart rate Excessive sweating High blood pressure Muscle spasms Skin color changes (paleness, redness, blue-gray skin color) The central nervous system is comprised of the brain and spinal cord. [mountsinai.org]
[…] home so everyday tasks like dressing and cooking are easier medicines to relieve problems such as pain, stiffness and muscle spasms For more information about the help and support available, see: Living with a disability Your guide to care and support [nhs.uk]
Slow pulse Blotching of the skin Restlessness Hypertension (blood pressure greater than 200/100) Flushed (reddened) face Red blotches on the skin above level of spinal injury Sweating above level of spinal injury Nausea Slow pulse (less than 60 beats [helpinghandshomecare.co.uk]
STUDY DESIGN: Measurement of haemodynamic responses, cutaneous blood flow and sweat release during penile vibratory stimulation (PVS) in spinal cord-injured men. [ncbi.nlm.nih.gov]
↑ in BP, sweating, and other autonomic reflexes in reponse to various stimuli–eg, bowel impaction. [medical-dictionary.thefreedictionary.com]
[…] above the level of injury nasal congestion slow pulse blotching of the skin restlessness hypertension (blood pressure greater than 200/100) flushed (reddened) face red blotches on the skin above level of spinal injury sweating above level of spinal injury [allnurses.com]
Above the level of the spinal lesion the skin is sweating and blotchy, while below it the skin is cool and pale with piloerection and goosebumps. [symptoma.com]
Profuse sweating, flushing, and piloerection occur above the level of spinal cord injury; vasoconstriction with dry, pale skin occurs below the level of injury. [msdmanuals.com]
Less serious effects include severe headache; changes in heart rate; sweating, flushing, and “goose bumps” or piloerection above the level of the spinal cord injury; and pallor below that level. Patient Care. [medical-dictionary.thefreedictionary.com]
This results in vasodilation, flushing, pupillary constriction and nasal stuffiness above the spinal lesion, while there's piloerection, pale and cool skin below the lesion due to the prevailing sympathetic outflow. [en.wikipedia.org]
Clinical Manifestations of AD in Patients with Spinal Cord Injuries Moderate to severe headache Flushing and piloerection above the injury Dry and pale skin due to vasoconstriction below the level of injury Blurred vision Anxiety Nasal congestion Profuse [cureus.com]
Manifestations include HYPERTENSION; TACHYCARDIA (or reflex bradycardia); FEVER; FLUSHING; and HYPERHIDROSIS. Extreme hypertension may be associated with a STROKE. [fpnotebook.com]
Three patients with chronic traumatic cervical myelopathy had severe orthostatic hyperhidrosis. Orthostatic challenge revealed that hypotension preceded hyperhidrosis, hypertension, and chills, all manifestations of autonomic dysreflexia. [ncbi.nlm.nih.gov]
Manifestations include hypertension; tachycardia (or reflex bradycardia); fever; flushing; and hyperhidrosis. Extreme hypertension may be associated with a stroke. [icd9data.com]
- Blurred Vision
Blood pressure rises often resulting in chronic headaches, blurred vision, blotchy skin and sweating. [streetsie.com]
Patients usually present with one of several symptoms – headaches; blurred vision or spots in front of the eyes; nasal congestion; a sense of ‘impending doom’ or apprehension. [symptoma.com]
- Retinal Hemorrhage
As a result, the autonomous (involuntary) nervous system is out of whack, and the sudden elevated blood pressure can lead to stroke, heart attack, retinal hemorrhage, pulmonary edema, or even death. [study.com]
In some incidences, autonomic dysreflexia can be life-threatening, as it can lead to stroke, retinal hemorrhage, cardiac arrest, and pulmonary edema. [belmarrahealth.com]
The severity of the syndrome during labor ranges from unpleasant symptoms to hypertensive encephalopathy, cerebrovascular accidents, intraventricular and retinal hemorrhages, and death. [acog.org]
Without treatment, the high blood pressure can cause cerebral hemorrhage and retinal hemorrhage, meaning both the eyes and the brain can start bleeding uncontrollably. It can be fatal. [gizmodo.com]
Sustained hypertension can lead to a wide range of secondary hypertensive problems including brain and retinal hemorrhages, myocardial infarction or seizures, and some of these can prove fatal. [symptoma.com]
Horner's syndrome (ptosis, miosis, anhidrosis, and absence of facial flushing) may be seen in cervical cord transection above the level of T1 owing to disruption of descending sympathetic fibers. [casemed.case.edu]
A variety of pupillary abnormalities may occur in autonomic disease: miosis in Horner’s syndrome and dilated myotonic pupils in Holmes-Adie syndrome. Night vision may be impaired in sympathetically denervated pupils. [jnnp.bmj.com]
By JEN GUNTER Photo Credit iStock Doctors Treating a Patient With a Nightmarish Condition She had lost all of her skin and I feared I had helped make her last weeks an unrelenting horror show, until our chance reunion. By ALESSANDRA COLAIANNI, M.D. [nytimes.com]
[…] changes or disturbances Bradycardia or tachycardia (Bradycardia at onset, tachycardia may follow) Pallor or gooseflesh below the level of the spinal cord lesion Respiratory distress or bronchospasms Anxiety (Apprehension over impending physical problem to fear [rnoh.nhs.uk]
Fear and depression are not uncommon in patients who have frequent episodes of AD. Talk with your loved one about his or her feelings. [fairview.org]
[…] changes or disturbances Bradycardia or tachycardia Bradycardia at onset, tachycardia may follow Pallor or gooseflesh below the level of the spinal cord lesion Respiratory distress or bronchospasms Anxiety Apprehension over impending physical problem to fear [eprimarycare.onf.org]
Symptoms include hypertension, bradycardia, severe headaches, pallor below and flushing above the cord lesion, and convulsions. Synonym(s): autonomic hyperreflexia. [medical-dictionary.thefreedictionary.com]
However, clinicians need to be aware of other headache features and the variety of potential triggers associated with the headache attributed to autonomic dysreflexia. [ncbi.nlm.nih.gov]
If a muscle tear or fracture has occurred, then the headaches may continue after stimulation has ceased. [karmanhealthcare.com]
[…] illegal stimulant drugs such as cocaine and amphetamines Signs and symptoms of autonomic dysreflexia include: Anxiety Irregular or racing heart beat Nasal congestion High blood pressure Pounding headache Flushing of skin Profuse sweating Lightheadedness Dizziness [belmarrahealth.com]
You are too dizzy to stand or have trouble walking or moving. You are not urinating at all. You have severe abdominal pain and have not had a bowel movement in a while. Care Agreement You have the right to help plan your care. [drugs.com]
[…] include: anxiety and apprehension irregular or racing heartbeat nasal congestion high blood pressure with systolic readings often over 200 mm Hg a pounding headache flushing of the skin profuse sweating, particularly on the forehead lightheadedness dizziness [healthline.com]
Subarachnoid hemorrhage (a form of brain bleeding) Use of illegal stimulant drugs such as cocaine and amphetamines Symptoms can include any of the following: Anxiety or worry Bladder or bowel problems Blurry vision, widened (dilated) pupils Lightheadedness, dizziness [nlm.nih.gov]
- Guillain-Barré Syndrome
Other causes include: Guillain-Barré syndrome (disorder in which the body's immune system mistakenly attacks part of the nervous system) Side effects of some medicines Severe head trauma and other brain injuries Subarachnoid hemorrhage (a form of brain [nlm.nih.gov]
[…] paralysis in the legs that spreads to the arms and face over a few days or weeks – Guillain-Barré syndrome paralysis from birth – cerebral palsy, spina bifida or spinal muscular atrophy paralysis that starts in the weeks, months or years after a tick [nhs.uk]
- Intracranial Hemorrhage
It can precipitate severe acute hypertension, acute myocardial failure or intracranial hemorrhage. We reviewed clinical features, etiologies, pathophysiology, treatment and prophylaxis. [ncbi.nlm.nih.gov]
Hypertension may result in hypertensive crisis, with pulmonary edema, intracranial hemorrhage, seizures, retinal detachment, myocardial infarction, and death. [msdmanuals.com]
Spinal cord injury leading to intracranial hemorrhage. Crit Care Med 1988; 16 : 911–912. 14 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. [nature.com]
Nopea haku ICD-10 Tautiluokituksen Alku> Jakso VI> G90-G99> G90 Sponsored ads G90.0 - Idiopaattinen autonomisten ääreishermojen sairaus G90.1 - Suvuittainen dysautonomia (Riley-Day) G90.2 - Hornerin oireyhtymä G90.3 - Usean järjestelmän rappeuma G90.4 [icd-codes.info]
Alimentary system Reduced salivation and a dry mouth (xerostomia) may occur in autonomic disease, especially in acute dysautonomias and in pure cholinergic dysautonomia. It may result in dysphagia when eating dry food. [jnnp.bmj.com]
[…] related pain (acute) (chronic) G89.4 Chronic pain syndrome G90 Disorders of autonomic nervous system G90.0 Idiopathic peripheral autonomic neuropathy G90.01 Carotid sinus syncope G90.09 Other idiopathic peripheral autonomic neuropathy G90.1 Familial dysautonomia [icd10data.com]
Clinical examination should identify the distribution of skin signs;
- Bowel Distention
Although the majority of cases are known to be induced by either bladder or bowel distention. there does exist a small number of cases in which the inciting stimulus is more obscure. [ncbi.nlm.nih.gov]
Background: Although any painful, irritating, or strong stimulus below the level of injury may cause increased blood pressure, the most common causes are bladder or bowel distention. [aapmr.org]
His symptoms are triggered by bowel distention, excitement, a bumpy car ride, or a simple turning of the neck to the left. Physical examination and laboratory studies ruled out other possible differentials (e.g., migraines, pheochromocytoma). [cureus.com]
The second most common cause of autonomic dysreflexia is bowel distention, usually due to fecal impaction. [emedicine.medscape.com]
Treatment depends on early diagnosis of the condition by all those involved with the patient, including the family, to enable ots prompt implementation.
Patients should never be left alone since this is a medical emergency.
Elevate the patient’s head, lower his/her feet to reduce the blood pressure and loosen clothing.
Correction relies upon prompt removal of the underlying cause – ask the patients for their suggestion as to the cause.
Short-acting antihypertensive drugs may be administered but care must be taken onrecent or intercurrent administration of medication for erectile dysfunction e.g. (Viagra), Vardenafil (Levitra) or Tadalafal (Cialis) .
Oral mediations may include glyceryl trinitrate or (spray or tablets) or nifedipine (Adalat) tablets.
Parenteral agents may be used in an appropriate hospital setting potentially with adequate analgesia (e.g morphine) or local epidural anaesthesia.
The severity of the underlying spinal lesion makes autonomic dysreflexia a constant threat to such patients. Sustained hypertension can lead to a wide range of secondary hypertensive problems including brain and retinal hemorrhages, myocardial infarction or seizures, and some of these can prove fatal .
Autonomic dysreflexia is caused by a lesion in the spinal cord at, or above, the level of the thoracic vertebra 6 (T6) that affects neural pathway and the flow of impulses to and from the brain. This means that the sympathetic nervous system is dominant below the level of the spinal and neurological injury while the parasympathetic system is dominant above it. Trauma is the most likely cause of such an injury .
The autonomic nervous system is that part of the peripheral nervous system which carries motor information to the visceral organs and glands of the body. Its sympathetic fibres control the body’s ‘fight-or-flight’ response by increasing bronchodilation and blood flow to skeletal muscles and the lungs while diverting blood flow away from the less important gastrointestinal tract and skin. It also increases the heart rate and the contractility of cardiac muscle. Conversely the parasympathetic fibres (mainly through cranial nerves X - the vagus nerve - and sacral nerves S1, S2 and S3) act in opposition to the sympathetic system through a negative feedback control. The parasympathetic action is the preservation of energy and recovery from ‘fight-or-flight’. Mechanisms include reducing heart rate and blood pressure, encouraging digestion and absorption of food and excreting waste products .
The level of T6 is of great significance because the great splanchnic vasculature derives its innervation from T5 – T9. Lesions below T6 usually allow enough descending parasympathetic pathways to exert adequate inhibition of the sympathetic activity.
With autonomic dysreflexia, the body’s physiological response is not balanced correctly. A strong input from sensory nerves originating below the spinal lesion will enter the spinal cord and rise towards the brain. However, passage beyond the site of the spinal injury is limited or non-existent. As a result the influence of the sympathetic reflex is far greater than any counterbalance by the parasympathetic part of the system. Common sources of this sensory input are the bladder or the bowels.
The pathophysiology of autonomic dysreflexia has not been fully identified yet. It has been suggested that peripheral alpha-adrenergic receptors develop increased responsivity below the spinal lesion and that this is linked with a low basal catecholamine levels as a result of the spinal injury. These receptors potentially have a lowered threshold for adrenergic stimulation, as well.
Large sensory input stimulates a massive reflex discharge in the thoracolumbar sympathetic nervous system and the paraspinal sympathetic ganglia. This results in direct vasoconstriction by nerve stimulation of perivascular receptors and indirect vasoconstriction by the epinephrine and norepinephrine released into circulation by the adrenal medulla. This in turn results in widespread vasoconstriction, mainly in the splanchnic (subdiaphragmatic) vasculature. The result is hypertension mainly through peripheral and splanchnic vasoconstriction .
Baroreceptors in the neck detect the pressure changes and transmit information to the brain through the glossopharyngeal and vagal nerves (cranial nerves IX and X). In response, the brain carries out two activities:
- it sends descending inhibitory impulses to shut down the sympathetic surge;
- it attempts to reduce peripheral blood pressure by slowing the heart rate via the vagus nerve.
In autonomic dysreflexia, the spinal lesion prevents all, or most, brain impulses from reaching the sympathetic outflow levels. In this situation the compensatory bradycardia alone is inadequate to reduce the hypertension.
The absence of spinal cord integrity means that hypertension remains uncontrolled.
All those involved with the patient, including the patient and family, should be trained in the importance of effective management to prevent development of underlying causes, especially constipation or bladder distension .
Care of the patient is critical to preventing episodes of this condition. Correct bladder and bowel care is most important to prevent faecal impaction or distension of the bladder. In general, strict hygiene must be maintained during regular bladder routines whether using intermittent catheterisation or in-dwelling Foley catheters. Routines should include regular urological follow-up to monitor the status of the bladder.
Similarly, a routine to maintain appropriate and adequate bowel activity should be developed to prevent constipation.
The prophylactic use of local anaesthetic creams and gels, e.g. dibucaine or lidocaine, for any catheterisation or ano-rectal procedures will reduce the likelihood of autonomic dysreflexia episodes .
Autonomic dysreflexia is a medical emergency that affects a large percentage of patients with a spinal cord injury at the level of the sixth thoracic vertebra (T6) or above. The more extensive the injury the more likely the patient is to suffer from episodes of this condition .
Episodes occur because of the inability of the two components of the autonomic nervous system - the sympathetic and parasympathetic – to act together as they should. The sympathetic dominates and creates chronic hypertension that leads to potentially severe results such as myocardial infarcts and brain hemorrhages.
Definition: Acute hypertension in patients suffering from aspinal cord lesion at the level of thoracic vertebra 6 or above, due to the inability of the body’s autonomic nervous system to work effectively because of the spinal lesion itself.
Cause: Normally the sympathetic and parasympathetic parts of the autonomic nervous system work in tandem in a balanced system. A lesion in the spinal cord at T6 or above creates a massive spinal reflex activity by the sympathetic pathways but prevents instruction from the brain through the parasympathetic system from counteracting them. The net result is major vasoconstriction of the splanchnic vessels and massive hypertension.
Symptoms: The symptoms in a patient already experiencing the problems of a damaged spinal cord are commonly headaches, blurred vision or spots before the eyes with constricted pupils, nasal congestion, a feeling of impending doom or apprehension, bradycardia and associated skin changes. Above the level of the spinal lesion the skin is sweating and blotchy, while below it the skin is cool and pale with piloerection and goosebumps. There is an inevitable clinical problem causing an overload of sensory input from the lower half of the body, most commonly from bladder distension or bowel overload.
The blood pressure is significantly raised above baseline levels in both systolic and diastolic phases.
Diagnosis: Diagnosis is primarily based on the patients having a spinal cord lesion and showing the relevant changes in blood pressure and other signs of sympathetic and parasympathetic imbalance, with sweating and blotchy skin above the lesion and pale, cold skin with piloerection and goosebumps below it.
Treatment: Effective treatment requires removal of the underlying cause, e.g distension of the bladder or bowel. Medication may be needed to lower the hypertension but care must be taken to prevent any adverse effects with concomitant medications.
Prevention: Autonomic dysreflexia is prevented by having a well-practised routines for control of potential causes such as impairment of urine or fecal flow and the prevention of pain or discomfort such as ulcers, insect bites, sunburn or infections. All investigations and procedures should be carried out with strict asepsis and adequate analgesia. Labour and childbirth are highly likely to induce episodes of the condition and so adequate preventative measures should be implemented.
- Cormier CM, Mukhida K, Walker G, Marsh DR. Development of autonomic dysreflexia after spinal cord injury is associated with a lack of serotonergic axons in the intermediolateral cell column. J Neurotrauma. Oct 2010;27(10):1805-18.
- Teasell RW, Arnold JM, Krassioukov A, Delaney GA. Cardiovascular consequences of loss of supraspinal control of the sympathetic nervous system after spinal cord injury. Arch Phys Med Rehabil. Apr 2000;81(4):506-16.
- Cardenas DD, Hoffman JM, Kirshblum S, McKinley W. Etiology and incidence of rehospitalization after traumatic spinal cord injury: a multicenter analysis. Arch Phys Med Rehabil 2004; 85:1757.
- Roatta S, Farina D. Sympathetic actions on the skeletal muscle. Exerc Sport Sci Rev. Jan 2010;38(1):31-5.
- Kirshblum SC, Priebe MM, Ho CH, et al. Spinal cord injury medicine. 3. Rehabilitation phase after acute spinal cord injury. Arch Phys Med Rehabil 2007; 88:S62.
- Lindan R, Joiner F, Freechafer A, Hazel C. Incidence and clinical features of autonomic dysreflexia in patients with spinal cord injury. Paraplegia. 1980;18:285-292.
- Wan D, Krassioukov AV. Life-threatening outcomes associated with autonomic dysreflexia: a clinical review.J Spinal Cord Med. Jan 2014;37(1):2-10
- McMahon D, Tutt M, Cook AM. Pharmacological management of hemodynamic complications following spinal cord injury. Orthopedics. May 2009;32(5):331.
- Glickman S, Kamm MA. Bowel dysfunction in spinal-cord-injury patients. Lancet 1996; 347:1651.
- Chiodo AE, Scelza WM, Kirshblum SC, et al. Spinal cord injury medicine. 5. Long-term medical issues and health maintenance. Arch Phys Med Rehabil 2007; 88:S76.