Pacemaker Implantation for Bradyarrhythmias in High-Grade Cervical Spinal Cord Injury

Monday, March 23, 2026

9:00 AM - 10:00 AM Central Time

Location: Connections Central - RST 06

Fazila Aseem, MD, MPH (she/her/hers)

Virginia Commonwealth University, Virginia

Disclosure(s): No relevant financial relationship(s) to disclose.
RY

Richard Young, DO

Resident Physician
Virginia Commonwealth University

Disclosure information not submitted.
DM

Diana Marzouk, MD

Resident Physician
Virginia Commonwealth University

Disclosure information not submitted.
SD

Suraj Dahal, MD

Cardiology Fellow
Virginia Commonwealth University

Disclosure information not submitted.
GK

Gautham Kalahasty, MD

Associate Professor of Cardiology
Virginia Commonwealth University

Disclosure information not submitted.
TG

Theresa Gammel, MD

Resident Physician
Virginia Commonwealth University

Disclosure information not submitted.
AP

A. Chris Pais, MD

Resident Physician
Virginia Commonwealth University

Disclosure information not submitted.
AC

Andrew Caras, MD

Resident Physician
Virginia Commonwealth University

Disclosure information not submitted.
KA

Kelsey Atkinson, MD

Neurosurgery Resident
Virginia Commonwealth University

Disclosure information not submitted.
RM

Rami Maarouf, MD

Assistant Professor of Anesthesiology
Virginia Commonwealth University

Disclosure information not submitted.
BC

Brian Cameron, MD

Assistant Professor of Neurosurgery
Virginia Commonwealth University

Disclosure information not submitted.
JG

John Greer, MD, PhD

Assistant Professor of Neurosurgery
Virginia Commonwealth University

Disclosure information not submitted.

Introduction: Bradycardia and cardiac arrest are serious complications of cervical spinal cord injury (SCI). Asystole has been reported in 15% of cases. Bradycardia in SCI is produced by unopposed parasympathetic stimuli when sympathetic afferent impulses to the heart are disrupted. Despite significant impact on outcomes, autonomic dysfunction is not routinely incorporated into current SCI prognostic models. Bradycardia can last weeks to months and managed by avoiding provoking measures and pharmacotherapy. Pacemaker is typically reserved for refractory cases. Here we describe two cases of cervical SCI complicated by recurrent asystole and propose early consideration of pacemaker implantation as a lifesaving intervention.

Description: Case 1: A 65-year-old woman with history of arthritis presented with an ASIA grade A C1-2 SCI after a fall. She underwent C2 laminectomy, wound exploration and optimization of spinal cord perfusion yet remained quadriplegic and ventilator-dependent with significant autonomic dysfunction. On hospital day (HD) 15, she developed frequent episodes of sinus bradycardia progressing to asystole while lying flat, requiring atropine. After multidisciplinary discussion, the patient opted for comfort-focused care.

Case 2: A 34-year-old woman with history of anxiety presented with an ASIA grade A C4-6 SCI after a fall. She underwent anterior cervical discectomy and fusion and optimization of spinal cord perfusion. On HD 18, she experienced recurrent sinus bradycardia with asystole during suctioning and while lying flat. Episodes were refractory to pseudoephedrine and theophylline, and repeated doses of atropine. A leadless pacemaker was implanted after which there were no further bradyarrhythmic events, and she was discharged to rehabilitation.

Discussion: Bradyarrhythmias represent fatal yet underappreciated complication of SCI. Medical management alone is often insufficient, and reactive strategies, such as pharmacotherapy or transcutaneous pacing, often unreliable. These cases highlight the importance of considering pacemaker as a first-line intervention in select high-risk patients. We advocate for updated guidelines to include standardized evaluation and management of autonomic cardiovascular dysfunction in SCI care, with multidisciplinary collaboration to optimize outcomes.