Persistent hiccup associated with thoracic epidural injection

Persistent Hiccups After Cervical Epidural Steroid Injection

Patient: Male, 60

Final Diagnosis: Persistent hiccups

Symptoms: Hiccups

Medication: —

Clinical Procedure: Cervical epidural steroid injection

Specialty: Anesthesiology

Unexpected Complication after Caudal Epidural Steroid Injection: Hiccup

Persistent hiccup is uncommon, and the mechanism is poorly understood. We present the case of a 43-year-old male patient referred to the Algology department due to chronic back pain who developed what we believe a rare case of persistent hiccup secondary to caudal epidural steroid injection (CESI). The causes of hiccup are many and include electrolyte derangement, nutritional deficiencies, gastrointestinal disorders and instrumentation, cardiovascular disorders, renal impairment, central nervous system disorders, and drugs; however, the cause may be unknown. CESI is one of the treatments of back pain, in addition to various other modalities including surgical interventions. CESI has gained rapid and widespread acceptance for the treatment of lumbar and lower extremity pain. However, there are only a few well-designed, randomized, controlled studies on the effectiveness of steroid injections. Consequently, side effects should be considered. We aimed to present a persistent hiccup after CESI for chronic low back pain.

Persistent Singultus Associated with Lumbar Epidural Steroid Injections in a Septuagenarian: A Case Report and Review

Singultus are rare but notable adverse effect of epidural steroid injections (ESIs). To date, reports of persistent hiccups associated with ESIs have been reported mostly in adults aged 65 years or older. We present the first case of persistent hiccups in a septuagenarian who underwent repeated transforaminal ESIs for chronic lumbar radiculopathy. Under fluoroscopic guidance, 1.5 mL of 1% lidocaine (preservative free) and 0.8 mL of dexamethasone solution (10 mg/mL) was injected into the bilateral L4-L5 neural foramen and epidural space.After the first epidural injection, episodes of singultus occurred at a frequency of 5 to 7 episodes per minute and lasted for 36 hours. One month later, he was treated with the second epidural injection after which he immediately developed singultus, occurring at 2- to 3-hour intervals. Interventions for the singultus included drinking small sips of water, vagal maneuvers, and oropharyngeal stimulation with ice chips. The singultus eventually resolved without medical intervention within 5 days of onset. A major take-home point is that preprocedure informed consent should include singultus as one of the potential adverse effects of ESIs. Increased awareness and appropriate planning may help curb the incidence of adverse outcomes in older adults undergoing ESI.

Persistent Hiccups After an Epidural Steroid Injection Successfully Treated With Baclofen: A Case Report

Persistent hiccups are an established adverse reaction to epidural steroid injections. Although oral baclofen has been used to treat hiccups in various clinical settings, none of the previously reported studies that used baclofen were related to hiccups occurring after spinal injections/procedures. We report a case of a man who developed persistent hiccups after a transforaminal epidural steroid injection that was treated successfully with oral baclofen.

LEVEL OF EVIDENCE

V.

Persistent hiccups after interventional pain procedures: a case series and review

Interventional spine procedures are nonsurgical interventions that are commonly used to treat acute and chronic pain. These procedures generally are considered to be safe, but patients may experience transient and minor complications. Hiccups previously have been reported in the pain management setting as a complication after lumbar and thoracic epidural steroid injections and an intrathecal morphine pump infusion. In this case series of 8 patients, we describe hiccups after various interventional procedures, including cervical and lumbar epidural steroid injections, facet joint injections, and sacroiliac joint injections. A comprehensive literature review of hiccups associated with interventional pain procedures is provided, along with the known pathophysiology, etiologies, and treatment options for hiccups. The objective of this case series presentation and literature review is to highlight the importance of recognizing hiccups as a potentially under-reported adverse reaction in the setting of various interventional spine procedures.

Persistent hiccups with continuous intrathecal morphine infusion

OBJECTIVE

To report a case of hiccups secondary to intrathecal (IT) morphine infusion.

METHODS

Case report and discussion.

RESULTS

The hiccups in our patient resolved on substitution of IT morphine infusion with hydromorphone.

DISCUSSION

We report a case of a 44-year-old man who developed persistent hiccups with IT morphine infusion pump therapy. The hiccups persisted despite various nonpharmacological and pharmacological measures. The untoward symptom resolved after substitution of IT hydromorphone for IT morphine.

Persistent hiccups associated with epidural ropivacaine in a newborn

OBJECTIVE

To report a case of persistent hiccups associated with epidural ropivacaine in a newborn infant.

CASE SUMMARY

A term female infant (3.05 kg) received epidural ropivacaine for pain control during and after an operative procedure to correct a tracheoesophageal fistula. Three intermittent doses of ropivacaine were administered during the operative period (total dose 2.29 mg/kg) followed by a continuous epidural (caudal) infusion (0.1% ropivacaine; initial dose 0.23 mg/kg/h plus fentanyl 0.46 μg/kg/h). The infant was extubated in the recovery area and transferred to the intensive care unit. Within hours of transfer, she developed persistent hiccups. The epidural infusion was titrated for pain control, up to 0.32 mg/kg/h (ropivacaine). The hiccup frequency increased to every 10-30 seconds, with the patient appearing hypotonic with lip trembling and intermittent tongue fasciculation. An electroencephalogram did not show any epileptiform activity or focal features consistent with seizure activity. The epidural infusion was reduced to 0.26 mg/kg/h (ropivacaine), with dramatic improvement in hiccups and tone. The infusion was discontinued and complete resolution of hiccups was observed.

DISCUSSION

Ropivacaine is commonly used for infiltration anesthesia and peripheral and epidural block anesthesia. Use of the Naranjo probability scale determined that our patient's hiccups were probably caused by ropivacaine. To our knowledge, this is the first report of persistent hiccups associated with epidural ropivacaine.

CONCLUSIONS

Clinicians should consider the potential of neurotoxicity, manifested as persistent hiccups, when epidural ropivacaine is administered to young infants.

Spinal injection procedures: a review of concepts, controversies, and complications

The field of spinal injection procedures is growing at a tremendous rate. Many disciplines are involved, including radiology, anesthesiology, orthopedics, physiatry and rehabilitation medicine, as well as other specialties. However, there remains tremendous variability in the assessment of patients receiving these therapies, methods for evaluation of outcome, and in the understanding of where these procedures belong in the triaging of those who require surgery. In this article, we attempt to highlight the biologic concepts on which these therapies are based, controversies that have arisen with their increasing use, and a description of complications that have been reported.

Hiccup and neurosurgeons: a report of 4 rare dorsal medullary compressive pathologies and review of the literature

OBJECTIVE

The aim of this study was to present 4 rare cases of medullary compressive lesions presenting with IH, to discuss the indications for neurosurgical decompression in such cases, and to review the possible etiologies of IH briefly.

METHODS

The reported cases include (1) a 19-year-old adolescent boy and a 21-year-old man with Chiari I malformation and cervical syrinx compressing or tightening the cervico-medullary junction; (2) a 35-year-old man with ependymoma extending from the lower half of the fourth ventricle to C1/C2 junction and compressing this part of the medulla; and (3) a 16-year-old adolescent boy who was referred to the emergency department in severe distress because of IH, occurring as a result of a distal PICA aneurysm located on the floor of the lower triangle of the fourth ventricle.

RESULTS

Surgical decompression in all the cases was successful in withholding the hiccups.

CONCLUSION

The dorsal medullary area is not an unusual location for genesis of hiccup. When encountering a case of IH, appropriate CNS imaging studies should be included in the evaluation protocol.

Adverse Effects of Fluoroscopically Guided Interlaminar Thoracic Epidural Steroid Injections

OBJECTIVES

To assess the prevalence of adverse effects or complications from fluoroscopically guided thoracic interlaminar epidural steroid injections.

DESIGN

A retrospective study with independent observer review. Patients presenting with thoracic radicular pain, caused by either herniated nucleus pulposus or thoracic spondylosis as confirmed by magnetic resonance imaging, received an interlaminar thoracic epidural steroid injection as part of a conservative-care treatment plan. The study was performed in a multidisciplinary spine care center. All injections were performed over a 5-yr period. An independent observer reviewed medical charts, which included a 24-hr postprocedure standardized questionnaire completed by telephone by an ambulatory surgical center nurse. Ambulatory surgical center operative reports and physician follow up office notes up to 3 mos after the procedures, along with epidurograms, were also reviewed.

RESULTS

A total of 21 patients who received 39 injections were reviewed. Adverse effects or complications per injection observed included three with increased pain at injection site (7.7%), two with facial flushing (5.1%), one transient nonpositional headache (2.6%), one episode of insomnia the night of the injection (2.6%), and one episode of fever the night of the procedure (2.6%). Statistical analysis revealed no significant difference based on diagnosis (herniated nucleus pulposus vs. spondylosis, P = 0.9156), and age was not linked to higher prevalence of adverse/effects complications (P = 0.3137).

CONCLUSIONS

No major complication arose. Adverse effects did occur with a rate of 20.5%. All adverse effects resolved without morbidity. No statistical difference was observed in the rate of adverse effects in patients with herniated nucleus pulposus or spondylosis.

Sectional Neuroanatomy of the Middle Thoracic Spine (T5-T8) and Chest

This is the third in a series of articles on the spine. The first reviewed the anatomy of the neck. The second reviewed the upper thoracic spine and chest (T1-T4). A fourth article is planned for the lower thoracic spine. Procedures in the midthoracic spine include chest tube placement, trigger point injections, chemodenervation with botulinum toxin, video-assisted thoroscopic surgery, and spinal injections. Complications include pneumothorax, hemothorax, diaphragmatic irritation, sympathetic trunk irritation, postthoracotomy pain, and intradural abscesses. This article provides anatomically accurate schematics of innervations of the middle thoracic chest and spine (T5-T8) that can be used to interpret magnetic resonance images of the muscles and nerves. Cross-sectional schematics of the middle thoracic chest and spine were drawn as they appear on imaging projections. The relevant nerves were color coded. The muscles and skin surfaces were labeled and assigned the color of the appropriate nerves. An organized comprehensive map of the motor innervation of the middle thoracic chest and spine allows the physician to increase the accuracy and efficacy of interventional procedures. This could also assist the electromyographer in correlating the clinical and electrophysiologic findings with magnetic resonance images.

Recurrent persistent hiccups after epidural steroid injection and analgesia with bupivacaine

This case report presents a patient who developed persistent hiccups after epidural administration of dilute bupivacaine on several different occasions. Substitution of saline for the dilute bupivacaine during epidural steroid injection did not result in hiccups; however, subsequent postoperative epidural analgesia with bupivacaine caused a recurrence of the hiccups.

Management of hiccups in the palliative care population

There are close to a hundred causes for hiccups, or singultus, the most common of which are gastrointestinal. Causes may be natural or drug induced, and the same agents that are used to treat hiccups may also induce them. Hiccups can be classified by their duration, as follows: up to 48 hours, acute; longer than 48 hours, persistent; and more than two months, intractable. Treatment options for hiccups can include both pharmacologic and nonpharmacologic agents. If the cause of hiccups can be identified, it is, of course, preferable to direct the treatment at that cause. However many times a cause cannot be identified; in this case, general measures or treatments should be instituted. Intractable hiccups can occur in the palliative care population. When they do, it can be extremely distressing and have a significant impact on quality of life. Pharmacologic approaches are often the most rational therapies for these patients. Baclofen seems to be a promising drug for use with both palliative care and perioperative patients, and using garabentin as an add-on to baclofen may also be a reasonable option to consider