The Successful Management of Neurogenic Failure: A Case Report

Case Diagnosis: A patient with a traumatic cervical spinal cord injury experienced neurogenic failure requiring many medications to maintain adequate blood pressures.

Case Description or Program Description: This patient suffered a complete SCI after a motor vehicle incident, with an ISNCSCI classification of C5 AIS A. She transferred to rehab on QID fluid boluses, which was an unrealistic plan for discharging home, so as we weaned down on these, we uncovered her unique presentation. She experienced symptomatic hypotensive episodes coupled with tachycardia, headaches, presyncope, and feelings of malaise without obvious triggers up to multiple times per day. These episodes were always positionally responsive, pharmacologically responsive, or IV fluid responsive, but never oral fluid responsive. These episodes occurred at different times throughout a 24 hour period – never with an identified trigger.

Setting: Inpatient Rehabilitation Hospital

Assessment/Results: Her workup was very thorough, involving cardiology, endocrinology, gastroenterology, neurology, and internal medicine consults. All imaging, laboratory, and stimulation tests proved non-contributory, leading us to the conclusion of pure neurogenic failure with a spinal cord etiology. These episodes were prevented only on a regimen of droxidopa TID, midodrine QID, caffeine BID, atomoxetine BID, desvenlafaxine nightly, pyridostigmine TID, and fludrocortisone BID, and she was able to discharge home 3 months after her injury.

Discussion (relevance): This is the first reported case of total autonomic failure without an identifiable trigger, as well as the successful management with this regimen of medications.

Conclusions: Neurogenic failure is much lesser known sequela of spinal cord injuries, and it needs to be managed differently than dysautonomia and autonomic dysreflexia, which can present similarly. Life threatening sequela following complete cervical spinal cord injuries require quick identification and appropriate management, as well as deeper research to better understand and possibly prevent these episodes of autonomic failure.