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Lesions of the C4 or C5 segments of the spinal cord, if complete, will interrupt suprasegmental control of both the sympathetic and sacral parasympathetic nervous systems Much the same effect is observed with lesions of the upper thoracic cord (above T6) Lower thoracic lesions leave much of the descending sympathetic out ow intact, only the descending sacral parasympathetic control being interrupted Traumatic necrosis of the spinal cord is the usual cause of these states, but they may be due as well to infarction, certain forms of myelitis, and tumors As discussed in greater detail in Chap 44, the initial effect of an acute cervical cord transection is abolition of all sensorimotor, re ex, and autonomic functions of the isolated spinal cord The autonomic changes include hypotension, loss of sweating and piloerection, paralytic ileus and gastric atony, and paralysis of the bladder Plasma epinephrine and NE are reduced This state, known as spinal shock, lasts for several weeks The basic mechanisms are not known, but changes in neurotransmitters (catecholamines, endorphins, substance P, and 5-hydroxytryptamine) are under investigation After spinal shock dissipates, sympathetic and parasympathetic functions return, since the afferent and efferent autonomic connections within the isolated segments of the spinal cord are intact, although no longer under the control of higher centers With cervical cord lesions, there is a loss of the sympathetically mediated cardiovascular changes in response to stimuli reaching the medulla However, cutaneous stimuli (pinprick or cold) in segments of the body below the transection will raise the blood pressure However, a fall in blood pressure is not compensated by sympathetic vasoconstriction Hence tetraplegics are almost obligatorily prone to orthostatic hypotension Pinching the skin below the lesion causes goose esh in adjacent segments Heating the body results in ushing and sweating over the face and neck but not the trunk and legs Bladder and bowel, including their sphincters, which are at rst accid, become automatic as spinal re ex control returns There may be re ex penile erection or priapism and even ejaculation With lesions in the upper thoracic cord, similar but lesser degrees of labile blood pressure are seen; in several of our patients with destructive myelitis, a viral infection of fever brought out episodes of a drop in blood pressure to approximately 80/60 mm Hg and a subsequent rapid rise to 190/110 mmHg After a time the tetraplegic may develop a mass re ex (page 1052), in which exor spasms of the legs and involuntary emptying of the bladder are associated with a marked rise in blood pressure, bradycardia, and sweating and pilomotor reactions in parts below the cervical segments (autonomic dysre exia) These reactions may also be evoked by pinprick, passive movement, con-.

Acute Autonomic Crises (Sympathetic Storm)

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Figure 511 Intraoperative photograph demonstrating orbital fat resection with a carbon dioxide laser during upper eyelid blepharoplasty The solid line indicates the light colored medial orbital fat while the dashed line demonstrates the yellow central or preaponeurotic fat over-resection of fat produces a hollow look in the eyelid The nasal fat pocket is explored and may be very conservatively contoured Gentle pressure may be applied to the eyelid to help prolapse orbital fat into the surgical eld The nasal fat is white in color, while the central fat is yellow (Figure 511) The inferior edge of the orbital septum may be re ected inferiorly and transected just above its fusion with the levator aponeurosis Attention is then turned to the lateral brow where fullness and contour irregularity must be addressed A pronounced appearance to the lateral brow may be caused by prominence of the underlying frontal bone or by relative enlargement or descent of the brow fat pad This fat pad, usually referred to as ROOF, tends to migrate inferiorly due to loss of support and natural attenuation While many patients are reluctant to undergo reduction of the bony orbital rim, contouring of the ROOF complex may be readily performed with the laser to achieve an optimal aesthetic result The details of this procedure are beyond the scope of this chapter Hemostasis must be maintained in a meticulous fashion throughout the entire procedure to avoid orbital hemorrhage and the possibility of blindness Hemostasis may be achieved with defocused laser, bipolar cautery, or even monopolar cautery Wound closure may be performed in many ways In cases where the lid crease is not to be formed, interrupted or running 6-0 or 7-0 permanent mono lament suture such as nylon or polypropylene may be used A small cutting needle (P-1 or PC-1 Ethicon, Somerville, NJ) works very well although some surgeons prefer a taper-cut needle, which may cause less trauma to the tissue but which also becomes dull more quickly than the cutting needles Sutures should be passed from skin edge to skin edge without engaging the underlying orbicularis muscle; it may bleed and cause a hematoma if cut by the needle Care should be taken to ensure that the wound is properly aligned across its entire extent Because of the curvilinear shape of the incision, the vectors of force vary across the entire width of the wound If interrupted sutures are used, the wound should be aligned by placing cardinal sutures centrally, nasally, and temporally prior to lling in the areas in between Care should be taken to ensure wound edge eversion Running sutures may also be used If a lid crease is to be created, an interrupted 6-0 undyed polygalactin suture is placed through skin and orbicularis muscle on the inferior border of the wound, which engages the levator aponeurosis at the superior tarsal border, and then is passed through orbicularis muscle and skin on the superior border of the wound Three such sutures are placed one in the nasal portion of the lid, one in the central portion, and one in the temporal portion The wound in between these sutures is.

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