1. Results Introduction Objective Methodology Conclusion
Unusual Presentation of Autonomic Dysreflexia in Patient with Cervical Spinal Cord Injury- Is Myocardial Infarction a Cause or an Effect? 1Ohnmar Htwe(Htwe O),1Trevor chan,2Khin Nyein Yin, 3Rizuana Iqbal Hussain,1Amaramalar Selvi Naicker 1 Rehabilitation Unit, Department of Orthopaedic and Traumatology, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia 2 Faculty of Medicine and Health Sciences, Universiti Malaysia Saba 3 Department of Radiology, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
Introduction
Autonomic Dysreflexia (AD) is not an uncommon clinical condition and it is usually detected in patient with complete spinal cord injury at or above thoracic 6th (T6) vertebrae, with an incidence of 48-60%. This is a case report of a patient with cervical spinal cord injury (CSCI), with unusual presentation of autonomic dysreflexia (AD) associated with acute myocardial infarction (AMI) and myoclonic jerk.
Objective
To further describe the unusual presentation of AD and highlights the possibility of cardiac event as a cause or an effect especially in mentally challenged patient with cervical spinal cord injury.
Methodology
Figure 2 . T2-weighted MRI (Saggital view) of Cervical spine.
Red arrow shows posterior disc bulge at the level of C3/C4 and C4/C5 which causes significant spinal canal stenosis and cord compression at the levels of C3/C4 and C4/C5 (worse at C3/C4). There is associated abnormal T2 hyperintense cord signal from level of C2/C3 until C4/C5 consistent with cord oedema.
This case was reported in Tertiary hospital, Kuala Lumpur, Malaysia. A-52-year-old mentally challenged male patient presented with all 4 limbs weakness especially on the right side after he fell down from the stairs in sitting position. Magnetic resonance imaging (MRI) of cervical spine showed cervical OPLL (Ossified Posterior Longitudinal Ligament), worst at C3/C4 level, causing significant spinal cord compression and edema (Figure 1,2). He underwent anterior cervical corpectomy and fusion with removal of OPLL.
Results
On post-operation day 9, patient developed sudden onset of myoclonic jerk in both upper limbs and lower limbs associated with profuse sweating at face, neck and shoulder. His blood pressure was 172/104 mmHg and pulse rate was 88/ min. Distended bladder was noted with over 1 L of urine. CT brain was normal. Mild hyponatremia (129 mmol/l) was noted. ECG showed inferior myocardial infarction with right bundle branch block (Figure. 3) .
Figure 3 . ECG showing inferior myocardial infarction with right bundle branch block
Conclusion
Acute myocardial infarction is noted to be one of the complications of AD, however it could be the precipitating cause of AD. Myocardium pain can precipitate overactive spinal stretch reflex activity and lead to myoclonic jerky movement. Thus, ECG is recommended in all adult CSCI patients who present with signs and symptoms of AD, to get early diagnosis of AMI and reduce morbidity and mortality.
Fig 1: T1 Weighted axial image of Cervical spine.
Red arrow shows OPLL with posterior disc bulge causing significant spinal canal stenosis of 4mm. There is associated flattening of the spinal cord.
References
1. Colachis SC. Autonomic hyperreflexia with spinal cord injury.Top Spinal Cord Inj Rehabil 1997; 3:71-81.
2. Wan D, Krassioukov AV. Life-threatening outcomes associated with autonomic dysreflexia: a clinical review. J Spinal Cord Med. Jan 2014;37(1):2-10.