title: Spinal fusion and antibiotic treatment illustrating lumbar osteomyelitis and spinal instability as a previously unrecognized and surgically treatable cause of autonomic dysreflexia.
abstract: Autonomic dysreflexia (AD) following spinal cord injury can lead to a physiologic state where there is unopposed sympathetic tone and subsequent hypertension, bradycardia, hyperhidrosis and anxiety. It is known to be triggered by nociceptive stimuli below the level of injury-most commonly constipation and bladder retention. We present a case of a C6-7 tetraplegic who developed AD 20 years after his injury with the unusual trigger of positional spinal instability due to osteomyelitis and discitis. The patient's clinical course began when he was diagnosed with L2-3 and L3-4 osteomyelitis, discitis and myositis of the bilateral paraspinous muscles. The infection did not respond well to an attempted course of medical management and degenerated into an unstable spinal segment. This instability in the vertebral column led to positional AD with symptom onset in extension (lying supine) and relieved with flexion (patient sitting up and bending forward). Once the trigger for his AD was determined, he was successfully treated with spinal fusion to stabilize the mobile segment and further antibiotic treatment. He had complete resolution of his AD after surgery and eradication of his infection.
authors.affiliation: Department of Neurosurgery, Penn State Hershey Medical Center , Hershey, PA, USA.
authors.forename: Emily P
authors.initials: EP
authors.lastname: Sieg
authors.affiliation: Department of Neurosurgery, Penn State Hershey Medical Center , Hershey, PA, USA.
authors.forename: Joseph C
authors.initials: JC
authors.lastname: Zacko
authors.affiliation: Department of Neurosurgery, Penn State Hershey Medical Center , Hershey, PA, USA.
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Hudson
keywords: Chronic pain; Disability; Trauma