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Practice Practice Pointer

Autonomic dysreflexia in spinal cord injury

BMJ 2020; 371 doi: (Published 02 October 2020) Cite this as: BMJ 2020;371:m3596

This article has a correction. Please see:

  1. Helen Cowan1,
  2. Celine Lakra, registrar in rehabilitation medicine2,
  3. Manish Desai, consultant in rehabilitation medicine2
  1. 1No affiliation
  2. 2London Spinal Cord Injury Centre, Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK
  1. Correspondence to C Lakra celine.lakra{at}

What you need to know

  • Patients with a spinal cord injury above T6 are at risk of developing autonomic dysreflexia, an uncoordinated autonomic response to a noxious stimulus that occurs below the level of the spinal cord lesion.

  • Serious complications can occur if autonomic dysreflexia is not recognised and treated early, including cerebrovascular haemorrhage, seizures, and cardiac arrest

  • Bladder or bowel distension are the most common triggers

  • Sitting the patient upright and eliminating triggers is the first line management

  • Patients and their carers will likely have experience of the condition and should help to guide management, in the acute and long term setting

Autonomic dysreflexia is a potentially life threatening complication of spinal cord injury. It carries a mortality rate of 22%1 and increases the risk of stroke by 300% to 400%.2 Clinicians working in emergency or urgent care may not see patients with this condition often, but when they do, prompt recognition and treatment are required. This practice pointer gives a brief overview of autonomic dysreflexia and how to identify it.

What is autonomic dysreflexia?

Autonomic dysreflexia is the product of dysregulation of the autonomic system, leading to an uncoordinated response to a noxious stimulus below the level of a spinal cord injury,2 usually in individuals with a spinal cord injury above the level of T6 (fig 1). It is three times more prevalent in those with complete spinal cord injury than in those with incomplete injury (91% versus 27%, respectively).3 Autonomic dysreflexia is clinically defined as an acute episode of systolic blood pressure elevated 25 mm Hg or above the patient’s normal measurements. …

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