Low-dose epidural anesthesia for autonomic dysreflexia prevention in individuals with high-risk cervical spinal cord injury undergoing transurethral procedures: A retrospective case series

CONTEXT: Autonomic dysreflexia (AD) is a life-threatening condition frequently triggered during transurethral procedures in individuals with cervical spinal cord injury (SCI). General anesthesia (GA) does not consistently prevent AD in this population, and optimal anesthetic management remains uncertain. FINDINGS: We report five male individuals with C4-C6 SCI, American Spinal Injury Association Impairment Scale (AIS) grade A/B with documented AD during daily catheterization who underwent transurethral procedures under low-dose epidural anesthesia (EA). Lumbar EA was performed with ropivacaine 0.2%-0.5% (4-10 mL). Sensory level testing was not possible; blockade adequacy was inferred from spasticity control and hemodynamic stability. No individual developed intraoperative AD, defined as an acute increase in systolic blood pressure (BP) of >20 mmHg above baseline in response to surgical stimuli. All procedures (four bladder lithotripsies, one bladder neck incision) were completed uneventfully. Systolic BP remained within 20 mmHg of baseline in four individuals; one individual with preoperative anxiety showed BP reduction to stable levels. No clinically significant hypotension or tachycardia occurred. One individual received atropine for transient bradycardia, which resolved promptly. CONCLUSION/CLINICAL RELEVANCE: Low-dose EA was associated with an absence of intraoperative AD in five individuals with high-risk cervical spinal cord injury, with stable hemodynamics and effective spasticity control. No adverse hemodynamic instability was observed, in contrast to our previous experience with GA. While preliminary, these findings suggest EA warrants further investigation as a prophylactic strategy for AD in this population.