Introduction

Spinal cord injury results not only in motor and sensory deficits but also in autonomic
dysfunctions as a result of the disruption between higher brain centers and the spinal
cord. So, what is autonomic dysfunction? Autonomic dysfunction can include
compromised cardiovascular, respiratory, urinary, gastrointestinal, thermoregulatory,
and sexual activities.
After spinal cord injury sobrang challenging ito na masustain at mamaintain ng may
mga sci na patient to mamaintain and mausstain yung optimal health and well-being
because it affects our cardiovascular, respiratory, urinary, gastrointestinal,
thermoregulatory, and sexual activities.
Additionally di lang autonomic dysfunction ang nagiging complicationg ng isang spinal
cord injury kundi may mga common secondary health conditions like pressure sores,
spasms, chronic pain, and urinary tract infections often negatively affect quality of
life and social participation. 
Autonomic Dysfunction
Autonomic dysfunction is common following a spinal cord injury, particularly in those
with a lesion at mid-thoracic levels (T6) and above.
Sa acute phase of spinal cord injury nagkakaroon ng main forms of autonomic
dysfunction wherein present ang mga neurogenic and spinal shock. Although others
think na pareho lng sila madalas however the true definitions of neurogenic and spinal
shock are hard to identify with multiple definition used. Later on we will know the
definition of neurogenic shock and spinal shock.
According to Biering-Sørensen et al (2018) suggest that while the symptoms and signs
of spinal shock and neurogenic shock may occur simultaneously, it should be noted that
these are two distinctly different clinical conditions and should be treated as such. 
While Autonomic Dysreflexia and thermoregulation dysfunction is more common in the
sub-acute and chronic spinal cord injury. Diba sabi ko ng yung iba madalas na akala
nila pareho yung neurogenic and spinal shock but they are different in clinical
conditions and kung paano ito itetreat.
We have 4 types of the autonomic dysfunction first is _____________ Remember
everyone that neurogenic and spinal shock occurs in the mid thoracic level in the t6
and above while the autonomic dysreflexia and thermoregulation dysfunction is more
common in the sub-acute and chronic spinal cord injury.
One of the autonomic shock is Spinal shcok
Spinal shock, first described by Whytt in 1750, it is a temporary loss of all neurological
activity including motor, sensory and reflex activity below the level of the spinal cord
lesion that can occur immediately following the onset of an acute spinal cord injury. 
Ang tanong natin paano yung above the level ng spinal cord na mga reflexes natin. the
Reflexes above the level of the spinal cord injury remain unaffected pero yung below
the level of injury are either depressed (hyporeflexia) or absent (areflexia). 
The extent of disruption to reflexes is variable, both in terms of reflexes involved and
timeframe for recovery, and as a result the precise definition and duration of spinal
shock is debated. There is common timeframe for recovery of the reflexes especially the
affected reflexes which is the below one. But the precise definition and durations of
spinal shock is remain to be debated.
The bulbocavernosus reflex (BCR) is a well-known somatic reflex that is useful for
gaining information about the state of the sacral spinal cord segments. When present, it
is indicative of intact spinal reflex arcs (S2–S4 spinal segments) with afferent and
efferent nerves through the pudendal nerve.
Procedure. The test involves monitoring internal/external anal sphincter contraction in
response to squeezing the glans penis or clitoris, or tugging on an indwelling Foley
catheter. This reflex can also be tested electrophysiologically, by stimulating the penis
or vulva and recording from the anal sphincter.
Ano nga bang kinalaman ng Appearance of bulbocavernosus reflex, so normally within
the first few days post injury, nakikita ito by some clinicians as the end point for spinal
shock, while others naman suggest it ends with the recovery of either deep tendon
reflexes within a few weeks or much later with the recovery of bladder reflexes within 2
months of injury.
Next is Neurogenic Shock
Neurogenic shock, sometimes referred to as vasogenic shock, can occur after damage
to the central nervous system, such as an acute spinal cord injury, typically in
individuals with a lesion at T6 or above. The difference of this neurogenic shock to
spinal shock, the neurogenic shock occur after damage to the central nervous system,
such as an acute spinal cord injury, typically in individuals with a lesion at T6 or above
while spinal shock is temporary loss of all neurological activity including motor, sensory
and reflex activity below the level of the spinal cord lesion that can occur immediately
following the onset of an acute spinal cord injury. Neurogenic shock is above and spinal
shock is below.
Consequences of neurogenic shock are loss of sympathetic stimulation to the blood
vessels and unopposed vagal activity leading to an imbalance of autonomic control,
which can mimic or co-exist with Hypovolemic.
We all know that hypovolemic results to haemodynamic triad of severe hypotension with
the systolic blood pressures of < 90 mmHg in supine position, bradycardia and
peripheral vasodilation, which nakkaapekto sa isang tao at risk sila for secondary
neurological injury and pulmonary, renal, and cerebral insults that leading sa organ
dysfunction and even death kapag di agad na-recognize and hidni na-treat.
Autonomic Dysreflexia
Autonomic dysreflexia, also referred to as autonomic hyperreflexia, is a potentially life-
threatening condition that can affect people who have had a spinal cord injury at the
level of T6 or above, and occurs more frequently in those with a complete injury over
those with an incomplete injury, presenting more commonly during the chronic phase of
spinal cord injury, around 3 - 6 months. 
This autonomic dysreflexia is a life-threatening condition to most people who have SCI
at the level of t6 or above and Us, medical professionals ay maraming di narerecgnize
yung dapat unahin natin but the autonomic dysreflexia should be considered as the first
medical emergency that requires immediate intervention. So, If not treated promptly and
correctly, it can lead to significant complications, including stroke, seizures, myocardial
ischaemia, and even death.
It is an acute syndrome characterised by a sudden excessive increase in Systolic Blood
Pressure triggered by an ascending sensory, usually "noxious” stimuli below the level of
the lesion.
SA Noxious stimuli it includes bladder infection, urinary stasis, bowel obstruction,
pressure sores, maling positioning, mahigpit na damit, catheter blockage, twisted
intercostal drainage tubes, after sudden violent hip range of motion, and extreme hot
weather with the most common causes resulting from bladder and bowel related
problems. 
The noxious stimulus send nerve impulses to the spinal cord, where they travel upward
until they are blocked by the lesion at the level of the spinal cord injury.
Since the impulses cannot reach the brain, may isang reflex na na-activated that
increases activity of the sympathetic portion of the autonomic nervous system. At dito
nagkakaroon ng resulta ng severe vasoconstriction, which causes a sudden rise in the
blood pressure of the patients who has SCI. Then, syempre alam na ng body natin yung
problem ngayon naman nagrerelease ng Baroreceptors ang ating heart and blood
vessels kasi na-detect nyang tumaas yung bp nung patient who has SCI and dito nag-
sesend ng message sa ating brain. After that, The brain sends a message to the heart,
at dito naman nagkakaroon ng pagbaba ng heartbeat and the blood vessels above the
level of injury to dilate.
However, yung utak ng patient natin ay di pwedeng mag send ng messages below the
level of injury, due to the spinal cord lesion, and therefore the blood pressure cannot be
regulated. So, The brain is unable to check the sympathetic response resulting sa
pagtaas ng systemic blood pressure. 
This overstimulation of the autonomic nervous system is characterised by sudden onset
of severe high blood pressure known as paroxysmal hypertension at least 20 to 40
mmHg above normal resting systolic level. 
This manifests itself with flushing of the skin, pounding headache, blurred vision, spots
in visual field, irritability, pilo erection (goose bumps), profuse sweating above the level
of the injury, dry and pale skin caused by vasoconstriction below the level of the injury,
blurred vision, nasal congestion, bradycardia, cardiac arrhythmias, atrial fibrillation and
often associated with anxiety and feelings of apprehension.
Remember also, Sometimes there is what we called the Silent autonomic dysreflexia na
nag-0-occur with minimal or no symptoms kahit nag-elevated yung blood pressure.
Thermoregulation is a process that allows your body to maintain its core internal
temperature, with baseline temperature normally between 37°C (98°F) and 37.8°C
(100°F). Thermoregulation mechanisms are designed to return your body to
homeostasis and maintain a state of equilibrium. 
In this part , we have sophisticated thermoregulatory center in the hypothalamus
regulates thermogenesis na inaactivate at iniinhibit nya yung sympathetic nervous
system to maintain core body temperature. Kapag yung internal temperature changes,
there is a sensors in CNS na nagsesend ng messages sa hypothalamus
In response, it sends signals to various organs and systems in the body, which respond
with a range of different mechanisms to either heat or cool the body. 
(Read the table)
Individuals with a spinal cord injury, particularly those with a cervical or high thoracic
lesion, have impaired thermoregulation and are unable to respond appropriately to the
changing temperatures of their surrounding environments. Mga patients na may SCI ay
di masyadong makarespong sa changes ng temperature sa katawan kasi nagkakaroon
ng malaking damage sa afferent and efferent pathways of the sympathetic nervous
system na nagkacause ng reduced sensory input to the thermoregulatory center and
loss of supra spinal control, which lead to dysregulation in vasomotor tone, skeletal
muscle shivering and sweating dysfunction below the level of the SCI
Cardiovascular Dysfunction
Many cardiovascular complications following a spinal cord injury occur as a result of
damage to the autonomic nervous system and in individuals with cervical and high
thoracic lesions may be life-threatening and may exacerbate the neurological
impairment due to the spinal cord injury. 
Deep Vein Thrombosis and Pulmonary Embolism
Deep vein thrombosis (DVT), which refers to the formation of one or more blood clots in
one of the body’s large veins and subsequent Pulmonary Embolism (PE), which
is blockage of an artery in the lungs by a substance that has moved from elsewhere in
the body through the bloodstream (embolism), remains a significant cause of morbidity
and mortality in individuals with spinal cord injuries and are particularly vulnerable
during the first 2-3 weeks post the injury, followed by a small peak three months after
the later. DVT is blood clots in one of the bodys large veins while PE is blockage of an
artery in the lungs.
In this case, may mga nareport na Incidences of deep vein thrombosis and pulmonary
embolism are estimated to be 15% and 5%, respectively during the first year post-injury,
while the incidence of clinically significant thromboembolism is less than 2% during the
chronic stage. There are also A case report of an individual with acute SCI and COVID-
19 showed an increased risk of deep vein thrombosis and pulmonary embolism due to
COVID-19 coagulopathy, thus calling for more cautious screening and more aggressive
management of the SCI patients with a concurrent diagnosis of COVID-19.
DVT’s tend to begin in the calf muscle. The signs of DVT are low grade fever and
localized swelling, warmth and discolouration, with pain sometimes present in
individuals with intact sensation, while loss of consciousness, shortness of breath,
hypoxia, sweating, haemoptysis, tachycardia, confusion or chest pain are more
characteristic of a PE.
Orthostatic Hypotension
Orthostatic Hypotension, also referred to as Postural Hypotension, is defined as a
decrease in systolic blood pressure of 20 mmHg or more, or a reduction in diastolic
blood pressure of 10 mmHg or more, when the body position changes from supine to
upright, regardless of whether symptoms occur and occurs both during the acute and
chronic stages of spinal cord injury. In this case, alam naman nating lahat na ang
orthostatic hypotension ay nagkakaroon ng pagbabago sa systolic bp kapag nagchange
tayo ng position in supine to upright position.
It is exacerbated by poor venous return secondary to lower limb paralysis and the loss
of the lower limb ‘muscle pump’, causing blood pooling in the legs and abdomen, na
nagreresullta sa pagbaba ng bp. Several other factors including low plasma volume,
hyponatremia, and cardiovascular deconditioning due to prolonged bed-rest may also
may predispose individuals with a spinal cord injury to orthostatic hypotension.
Ang mga Symptoms nito ay pagkahilo, light headedness, pagsakit ng ulo, pallor,
frequent yawning, pagpapawis, panghihina ng muscles, fatigue and occasionally
syncope or what we called fainting or passing out. It tends also to be more delikado
when individuals first start to sit up and mobilize after injury, so, especially if there has
been an extended period of prior bedrest and as such graduated gradual progressive
daily head-up tilt is important.
Pressure Sores
Individuals with a Spinal Cord injury are at high risk of developing pressure ulcers with
an incidence of 25 - 66%, with higher level injuries more susceptible than those with a
lower level injury. [23] The National Pressure Ulcer Advisory Panel, U.S
(NPUAP) defines a pressure ulcer as an area of unrelieved pressure over a defined
area, usually over a bony prominence, resulting in ischemia, cell death, and tissue
necrosis. MOStly nagkakroon ng mga pressure sores sa katawan ng isang tao kasi di
sila madalas makagal at sila yung mga high risk na tinatawag. Examples SCI patients,
bed-ridden, coma patients, etc.
Ang isang pressure ulcer ay localized injury sa isang skin and/or underlying tissue
usually over a bony prominence, as a result of pressure kaya nga tinawag na pressure
sore kasi usually napepressure yung isang parte ng katawan ng isang pasyente, or
pressure in combination with shear. Tingin nyo ilang hours bago magkaroon ng
pressure sores ang isang patient? So, usually ang isang pressure sore can develop in a
few hours, but the results can last for many months and even cause death, diba
pressure sores can cause death pero ibang pressure papatay satin charot. Kidding
aside.
Here is the part usually na nagkakaroon ng pressure ulcer or sores
(Read the parts of the body)
Tissue injury or pressure ulcer is related to both extrinsic and intrinsic factors. Sa
Extrinsic factors nandito na yung pressure, shear, friction, immobility, and moisture,
while Intrinsic factors pwede nating i-relate sa condition ng patient, such as sepsis, local
infection, decreased autonomic control, altered level of consciousness, increased age,
vascular occlusive disease, anemia, malnutrition, sensory loss, spasticity, and
contracture.
Respiratory Dysfunction
Impaired respiratory function is common following a spinal cord injury. Respiratory
function of people with is primarily determined by neurological level of the injury.
Paralysis or partial paralysis of key muscles has a marked impact on respiratory
function. Respiratory complications in spinal cord injury are common with complications
directly correlated with mortality, and both are related to the level of neurologic injury.
Nagreresult ito ng partial paralysis because alam naman natin na kapag di
nakapagbigay ng message yung spinal cord sa brain it can’t trigger the muscles to
function well.
Gastrointestinal Dysfunction
Gastrointestinal dysfunction including constipation, straining, diarrhea, distention,
abdominal pain, incontinence, rectal bleeding, hemorrhoids, and autonomic dysreflexia
during bowel movements occur in 27% to 62% of individuals with a spinal cord injury. 
Pagdating ng acute stage of spinal cord injury nagkakaroon ng increased risk of
gastrointestinal complications within the first few days post injury, including
gastrointestinal hemorrhage, perforation, and paralytic ileus, while neurogenic
bowel, affecting almost half of those with a spinal cord injury (46.9%) is a major problem
long term both in terms of physical and psychological wellbeing.
Paralytic Ileus
Paralytic Ileus, often associated with spinal shock post an acute spinal cord injury, is
an obstruction of the intestine secondary to paralysis of the intestinal muscles with no
evidence of mechanical obstruction, which like spinal shock can last from a few days to
a few weeks. The paralysis does not need to be complete to cause ileus, but the
intestinal muscles must be so inactive that it prevents the passage of food, and leads to
a functional blockage of the intestine, which causes abdominal distension.
Pagkatpaos magkaroon ng distended abdomen tumaaas yung work of breathing kaya
mabilis silang huminga. Nagkakaroon din ng pagsusuka na nagkacause ng pagtaas ng
risk for aspiration pneumonia and further respiratory complications. Individuals with a
paralytic ileus are typically managed Nil by Mouth (NPO) nothing per orem or mouth
with nasogastric suction para regular na maaspirate yung mga unnecessary stomach
contents .
Neurogenic Bowel
Neurogenic bowel dysfunction with changes to bowel motility, sphincter control, coupled
with impaired mobility and hand dexterity, is a major physical and psychological problem
for many individuals with a spinal cord injury, as well as major source of
morbidity. Neurogenic bowel occurs secondary to a lack of central nervous control of
the bowel resulting in dysfunction of the colon, with two distinct clinical presentations.  
SO, this two distinct clinical presentation is The UMN AND LMN.
Upper Motor Neuron (UMN) Bowel Syndrome, occurring in a spinal cord injury above
the conus medullaris results in a hyperreflexic bowel, characterised by increased
colonic wall and anal tones, with disrupted voluntary external anal sphincter control. SO,
Typically associated sya sa constipation and fecal retention
Lower Motor Neuron (LMN) Bowel Syndrome, occurring in a spinal cord injury at
the injury at the conus medullaris or cauda equina results in an areflexic bowel,
characterised by loss of spinal cord-mediated peristalsis and slow stool propulsion with
an atonic external anal sphincter. Ito naman Typically associated din sya sa
constipation and a significant risk of incontinence
The three main implications of disruption to motor, sensory and autonomic pathways
post spinal cord injury on bowel function are an inability to:
feel when the bowel is full
voluntarily control muscles to defecate
voluntarily contract muscles to prevent defecatin