Am Heart Hosp J. 2010;8(1):63–5
Lozenge Reference
Case Report
Cardiac Bradyarrhythmias in a Patient with Cervical Spine Injury
Avneet Singh, MD, MRCP,1 Rajeev Garg, MD2 and Richard Weachter, MD2
T
he interaction between the heart and the brain has been well established. A tragic example is the frequently seen symptomatic bradycardia following cervical spinal cord injury (CSCI). We present a case report and review of the limited literature on this subject.
Case Study
A 45-year-old male without significant past medical history was admitted to the University of Missouri hospital after falling from a height of 35–40 feet. There was no history of any prodromal symptoms prior to the fall. The patient subsequently lost consciousness and was brought to the hospital. Magnetic resonance imaging (MRI) of the cervical spine revealed a C5–6 dislocation.
Despite an urgent discectomy and anterior cervical arthrodesis, he developed partial quadriplegia. He subsequently developed respiratory failure requiring mechanical ventilation. On hospital day seven, his heart rate decreased to 30 beats per minute (bpm) and his blood pressure (BP) to 90/60mmHg without any symptoms. This episode resolved spontaneously after one minute. Telemetry revealed sinus bradycardia, followed by sinus arrest, a ventricular escape rhythm, and, subsequently, restoration to normal sinus rhythm.
On hospital day 10, he developed asystole lasting 20 seconds with loss of consciousness. This episode resolved spontaneously with restoration of sinus bradycardia at 50–55bpm. Due to severe hemodynamic collapse caused by this event, a transvenous pacemaker was placed. The patient required continuous ventricular pacing at a rate
of 60bpm for the next four days, after which his intrinsic rate increased to 60–70bpm without further episodes of asystole. He did not require any more pacing support over the next three days and on hospital day 17 the pacemaker was discontinued.
The patient did well from a cardiac standpoint at follow-up four weeks after the injury, with no further documented episodes of bradyarrythmias, syncope, or pre-syncope.
Discussion
There are an estimated 10,000–12,000 spinal cord injuries every year in the US. A quarter of a million Americans are currently living with spinal cord injuries. Cervical spine injuries constitute nearly half of all these injuries. Fifty-five percent of spinal cord injury victims are between 16 and 30 years of age.1
Most of these patients
have a prolonged rehabilitation course. Cardiovascular complications are a leading cause of death in patients with CSCI.2,3
Neural pathways play an important role in the dynamics of cardiovascular physiology. The heart receives both sympathetic and parasympathetic innervation. The parasympathetic fibers travel from the pre-ganglionic neurons in the medulla (nucleus ambiguus and dorsal motor nucleus of the vagus) with the vagus nerve to supply the heart. The sympathetic fibers travel from neurons in the intermediolateral columns of the spinal cord at the T1–T4 levels and synapse in the (stellate) cervical ganglia, and from here the post- ganglionic sympathetic neurons reach the heart.
• 1. Division of Cardiology, North Shore University Hospital, Manhasset, New York; 2. Division of Cardiology, University of Missouri-Columbia
• Correspondence: LIJMC, Lakeville Road, New Hyde Park, NY 11040. E:
asingh1@nshs.edu Summer 2010 Cardiac Bradyarrhythmias 63
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