Kofler Markus, Poustka Katharina, Saltuari Leopold
Department of Neurology, Hospital Hochzirl, Austria.
Auton Neurosci. 2009 Mar 12;146(1-2):106-10. doi: 10.1016/j.autneu.2008.12.003. Epub 2009 Jan 20.
Autonomic dysreflexia may occur following spinal cord injury above mid-thoracic level, commonly developing in the early posttraumatic period. Cardiovascular dysregulation is the most prominent feature, characterized by paroxysmal high blood pressure attacks, which are precipitated by distension of urinary bladder or bowels, skin wounds, or increased spastic muscle tone. Severe drops in blood pressure may occur in orthostatic conditions. Baclofen is effective for treating spasticity. While orally administered baclofen often fails to alleviate severe spasticity adequately, intrathecal baclofen (ITB) is more effective and thus is being used increasingly. A 61-year-old male sustained a cervical spinal cord injury, subsequently developing severe spastic tetraparesis, predominantly in the legs. Some 30 years later he experienced marked spasms of the muscles of the abdominal wall, leading to extreme fluctuations of blood pressure. After positive evaluation with ITB the patient underwent implantation of a pump-catheter-system for continuous ITB application. Abdominal wall spasms ceased entirely with a daily dose of 190 microg ITB, accompanied by a sustained normotensive blood pressure profile. However, spasms reoccurred after inadvertent reduction of ITB flow when increasing the pump's ITB concentration but subsided again when the optimal antispastic dose was reestablished. Baclofen per se has the potential of lowering blood pressure. In this patient, however, ITB treatment enabled permanent stabilization of insidious blood pressure fluctuations. It would appear that suppression of abdominal spasms prevented the triggering of dysautonomic crises. This case demonstrates that ITB administration may help to stabilize autonomic dysreflexia and orthostatic hypotension in patients with spinal cord lesions.
自主神经反射异常可能发生在胸中段以上脊髓损伤后，通常在创伤后早期出现。心血管调节功能紊乱是最突出的特征，表现为阵发性高血压发作，由膀胱或肠道扩张、皮肤伤口或痉挛性肌张力增加引发。在直立位时可能会出现严重的血压下降。巴氯芬对治疗痉挛有效。虽然口服巴氯芬常常不能充分缓解严重痉挛，但鞘内注射巴氯芬（ITB）更有效，因此使用越来越多。一名61岁男性发生颈髓损伤，随后出现严重的痉挛性四肢轻瘫，主要累及腿部。约30年后，他出现腹壁肌肉明显痉挛，导致血压剧烈波动。经ITB阳性评估后，患者接受了泵-导管系统植入以持续应用ITB。每日剂量190微克ITB时腹壁痉挛完全停止，同时血压持续维持在正常水平。然而，在增加泵内ITB浓度时意外减少ITB流量后痉挛复发，但重新建立最佳抗痉挛剂量后痉挛再次缓解。巴氯芬本身有降低血压的可能。然而，在该患者中，ITB治疗使隐匿性血压波动得以永久稳定。似乎抑制腹壁痉挛可防止自主神经危象的触发。该病例表明，ITB给药可能有助于稳定脊髓损伤患者的自主神经反射异常和直立性低血压。
