- Email: [email protected]
Persistent Hiccups After an Epidural Steroid Injection Successfully Treated With Baclofen: A Case Report
Accepted Manuscript Persistent Hiccups after an Epidural Steroid Injection Successfully Treated with Baclofen: A Case Report Berdale Colorado, DO, MPH, Gregory Decker, MD PII:
S1934-1482(16)31266-7
DOI:
10.1016/j.pmrj.2017.04.013
Reference:
PMRJ 1897
To appear in:
PM&R
Received Date: 12 December 2016 Accepted Date: 19 April 2017
Please cite this article as: Colorado B, Decker G, Persistent Hiccups after an Epidural Steroid Injection Successfully Treated with Baclofen: A Case Report, PM&R (2017), doi: 10.1016/j.pmrj.2017.04.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Running Head: Persistent Hiccups
Title:
RI PT
Persistent Hiccups after an Epidural Steroid Injection Successfully Treated with Baclofen: A
Authors: Berdale Colorado, DO, MPH 1, 2; Gregory Decker, MD 2
SC
Case Report
M AN U
Department of Orthopedic Surgery 1, Department of Neurology 2, Washington University School of Medicine
Corresponding Author:
TE D
Berdale Colorado, DO, MPH Department of Orthopedic Surgery
Washington University School of Medicine
425 S. Euclid Ave.
EP
Campus Box 8233
AC C
St. Louis, MO 63110
Fax #: (314) 514 – 3555
Phone #: (314) 747 – 2823
E-mail: [email protected]
Conflicts of Interest and Acknowledgements of Financial Support: None declared
ACCEPTED MANUSCRIPT
1
Title:
2
Persistent Hiccups after an Epidural Steroid Injection Successfully Treated with Baclofen: A
3
Case Report
RI PT
4 5 6
SC
7 8
M AN U
9 10 11 12
16 17 18 19 20 21 22 23
EP
15
AC C
14
TE D
13
ACCEPTED MANUSCRIPT Persistent Hiccups 1
Abstract
25
Persistent hiccups are an established adverse reaction to epidural steroid injections. While oral
26
baclofen has been used to treat hiccups in various clinical settings, none of the prior reported
27
studies utilizing baclofen were related to hiccups occurring after spinal injections/procedures.
28
We report a case of a male who developed persistent hiccups following a transforaminal epidural
29
steroid injection that was successfully treated with oral baclofen.
32
Introduction
Hiccups are an established adverse reaction to epidural steroid injections [1-4]. While
M AN U
31
SC
30
RI PT
24
33
they are usually benign and self-limited, occasionally persistent or intractable hiccups do occur
34
and cause significant distress. Transient hiccups last less than 48 hours, while “persistent” last
35
more than 48 hours, and “intractable” hiccups greater than 1 month.
Non-pharmacological treatment options involve interrupting the vagal afferents of the
TE D
36
reflex arc, including drinking water and holding one’s breath. Alternatively, Valsalva maneuver
38
and carotid massage can abolish hiccups via vagal nerve stimulation [5]. Pharmacologic
39
treatments for hiccups include chlorpromazine, metoclopramide, haloperidol, nifedipine,
40
carbamazepine, and baclofen [5].
In a case series of eight patients, Abbasi et al. described hiccups following interventional
AC C
41
EP
37
42
pain procedures including cervical and lumbar epidural steroid injections, facet joint injections,
43
and sacroiliac joint injections [3]. It is unclear if hiccups are the result of the procedure itself, the
44
anesthetic/steroid, or the physiologic effect of the local anesthetic in the epidural space. A case
45
report by McAllister et al. described a patient who on several occasions developed persistent
46
hiccups following an epidural injection of dilute bupivicaine. However, in one instance when
ACCEPTED MANUSCRIPT Persistent Hiccups 2
saline was substituted for bupivicaine, the patient did not develop post-procedural hiccups [1].
48
The authors concluded that hiccups were due to the anesthetic in the epidural injection. However,
49
it is unclear if the hiccups were a direct result of the bupivicaine used or rather the physiologic
50
effects of the needle introduced into the epidural space.
51
RI PT
47
Baclofen is a GABA-B agonist with inhibitory effects on presynaptic motor neurons. Baclofen has been used to treat hiccups in various clinical settings. Zhang et al. studied patients
53
with cerebrovascular accident and persistent hiccups and randomized 30 patients to receive
54
baclofen 10 mg three times per day or placebo. Hiccups resolved in all but one of the patients in
55
the treatment group, and hiccups continued in all but two subjects of the placebo group [6].
56
Gueland et al. treated a series of 37 patients with intractable hiccups in an open label
57
observational study. The study reported a 76% response to baclofen as 18 patients had complete
58
response, while 10 patients had considerable improvement. The study started with baclofen 5 mg
59
three times per day and increased by 15 mg/day every 3 days until the hiccups were controlled
60
[7]. None of the prior reported studies utilizing baclofen were related to hiccups occurring after
61
spinal injections/procedures.
64 65 66
M AN U
TE D
EP
63
To our knowledge, there are no known reported cases of persistent hiccups following an epidural steroid injection successfully treated with oral baclofen.
AC C
62
SC
52
Case Presentation
A 69-year-old male presented with five-week history of low back pain and left leg pain,
67
which began after driving his car on a road trip. His pain was described as sharp and rated
68
“severe” on an intensity scale. Pain was aggravated by bending and transitioning from sit to
69
stand. The leg pain was located in the left posterior thigh and extended to the posterior calf. He
ACCEPTED MANUSCRIPT Persistent Hiccups 3 70
denied any lower extremity numbness, weakness, bowel or bladder changes, or gait ataxia. He
71
tried nonsteroidal anti-inflammatory drugs, oral steroids, muscle relaxants, and physical therapy
72
with minimal relief. He could not recall any prior spinal injections. Physical examination revealed a non-antalgic gait without loss of balance. Active range
74
of motion of the lumbar spine was decreased in both extension and flexion, with increased pain
75
with lumbar extension. There was tenderness to palpation primarily over the left lower lumbar
76
paraspinals. Strength was 5 out of 5 in the bilateral hip flexors, knee extensors, ankle
77
dorsiflexors, and great toe extensors. He was able to perform heel raises bilaterally. Sensation
78
was intact to light touch in the bilateral lower extremities. Muscle stretch reflexes were 2+ in the
79
bilateral patella and 1+ in the bilateral Achilles. No ankle clonus was noted bilaterally. Sit slump
80
test, log roll test, and FABER test were negative bilaterally.
SC
M AN U
81
RI PT
73
Radiographs of the lumbar spine were obtained, which revealed mild to moderate multilevel degenerative disc disease of the lumbar spine with mild, Grade 1 L3-4 retrolisthesis.
83
MRI of the lumbar spine was obtained, which revealed multilevel neural foraminal stenosis of
84
the lumbar spine, with severe spinal canal stenosis at L2-3. At L5-S1, there was moderate left
85
neural foraminal narrowing.
EP
86
TE D
82
The patient was referred for a left S1 transforaminal epidural steroid injection. Despite the primary pathology located at the L5-S1 foramen, the left S1 level was chosen because the
88
patient’s leg symptoms were primarily in an S1 distribution. After informed consent was
89
obtained, the patient lay in a prone position on the fluoroscopy table. The left S1 foramen was
90
identified under fluoroscopic guidance. The area was prepped and draped in a sterile fashion. A
91
25-gauge 2-inch needle was inserted into the region, and 2 mL of buffered 1% lidocaine without
92
epinephrine was infused for local anesthesia. Then a 25-gauge spinal needle was inserted into the
AC C
87
ACCEPTED MANUSCRIPT Persistent Hiccups 4
superior lateral region of the left S1 foramen and advanced into the epidural space under
94
fluoroscopic guidance. Confirmation of entry into the epidural space was obtained with infusion
95
of approximately 1 mL of Omnipaque contrast (Figures 1 and 2). There was no evidence of
96
vascular flow utilizing live fluoroscopic visualization. Further, there was no blood visualized in
97
the needle hub. Digital subtraction angiography was not utilized. Then a combination of 2 mL of
98
1% lidocaine and 1 mL of 10 mg/mL dexamethasone was infused. The patient tolerated the
99
procedure without complications. He was given a pain diary.
SC
RI PT
93
The patient contacted the clinic 5 days after the procedure reporting persistent hiccups
101
that began the day following the injection. He had tried non-pharmacologic treatments such as
102
drinking water, holding his breath, and breathing into a paper bag with no relief.
104 105
The patient was prescribed baclofen 10 mg orally every 8 hours as needed until hiccup resolution. He was instructed to contact the clinic the next day to provide an update. The patient reported resolution of his hiccups within 16 hours, after two doses of the
TE D
103
M AN U
100
baclofen. Two weeks after the left S1 transforaminal epidural steroid injection, the patient
107
reported 75% improvement in his pain symptoms. He had some return of his pain and obtained a
108
second left S1 transforaminal epidural steroid injection six weeks after his initial injection. The
109
procedure was performed by the same physician using the same technique and injectate as
110
before. The patient again reported hiccups starting the day after the procedure. He repeated the
111
oral baclofen and had resolution of his hiccups after two doses.
113 114 115
AC C
112
EP
106
Discussion
There are several potential mechanisms for the development of hiccups following epidural injections. Epidural anesthetics can cause sympathetic blockade along the sympathetic
ACCEPTED MANUSCRIPT Persistent Hiccups 5
chain allowing parasympathetic dominance resulting in small contracted gut [8]. Another
117
possible mechanism includes a volume effect of solution injected into the epidural space, which
118
compresses the dural sac [9]. The injection may acutely alter the CSF volume, flow, and pressure
119
resulting in hiccups. This latter mechanism would appear less likely in this case given the
120
relatively low volume of injectate.
RI PT
116
Systemic corticosteroids have been associated with development of hiccups [10]. It is
121
believed that steroids may trigger hiccups through steroid receptors on the reflex arc [11]. It is
123
possible that unrecognized vascular uptake may have occurred in this case, resulting in a
124
systemic corticosteroid effect that triggered the hiccups. It is important to note, however, that
125
prior treatments with oral steroids did not produce any hiccups or other adverse effects in the
126
patient.
M AN U
127
SC
122
Several studies have addressed pharmacological treatment of persistent hiccups after interventional pain procedures. Abbasi et al. noted that six of eight patients that developed
129
hiccups following interventional spine procedures resolved spontaneously or following the non-
130
pharmacological treatments described above. However, the two patients with persistent hiccups
131
were successfully treated with chlorpromazine. One patient’s hiccups ceased with one 10 mg
132
dose of chlorpromazine, and the other resolved within 16 hours of chlorpromazine,10 mg orally
133
q 6 hours [3]. In a case report by Slipman et al., hiccups following an epidural injection were not
134
relieved with non-pharmacological treatment or chlorpromazine, 10 mg orally q 6 hours. At 2.5
135
days following the start of chlorpromazine, the patient’s medication was changed to
136
metoclopramide, 10 mg orally every 6 hours, and within 24 hours of this change, his hiccups
137
resolved. Additionally, the patient developed hiccups following a second epidural injection,
AC C
EP
TE D
128
ACCEPTED MANUSCRIPT Persistent Hiccups 6 138
which was again successfully treated with four doses of metoclopramide, 10 mg orally every 6
139
hours [2].
140
Baclofen was chosen as an initial treatment for the persistent hiccups because the senior author (BC) had prior success with this medication for persistent hiccups unrelated to an epidural
142
steroid injection. Baclofen also provided the patient with potential relief for his muscle spasms.
143
The patient had been prescribed tizanidine for muscle spasms the day prior to the injection. He
144
had been instructed to discontinue the tizanidine when the hiccups initially started in the event
145
that this may have been an adverse effect to this medication. However, the hiccups persisted
146
despite medication discontinuation, and the patient had some increase in his muscle spasms.
147
This case report provides a novel approach to the management of hiccups following
M AN U
SC
RI PT
141
epidural steroid injections. While a lack of a placebo control limits the ability to determine if the
149
response was truly due to baclofen, the fact that the response was consistent on two separate
150
occasions suggests that the effect was related.
153 154 155 156 157 158 159 160
EP
152
AC C
151
TE D
148
ACCEPTED MANUSCRIPT Persistent Hiccups 7
161
References
162
1.
163
after epidural steroid injection and analgesia with bupivacaine. Anesthesia and analgesia
164
2005;100:1834-6.
165
2.
166
epidural injection. American journal of physical medicine & rehabilitation 2001;80:618-21.
167
3.
168
procedures: a case series and review. PM & R 2012;4:144-51.
169
4.
170
anaesthesiology, clinical pharmacology 2012;28:418-9.
171
5.
172
Annals of emergency medicine 1991;20:565-73.
173
6.
174
hiccups: a randomized, double-blind, placebo-controlled trial. Trials 2014;15:295.
175
7.
176
therapy for chronic hiccup. The European respiratory journal 1995;8:235-7.
177
8.
178
blockade in clinical anesthesia and management of pain. Philadelphia: Lippencott-Raven;
179
1998:243-321.
180
9.
181
fluid volume and velocity waveform: a magnetic resonance imaging study. Anesthesiology
182
2005;102:285-92.
RI PT
McAllister RK, McDavid AJ, Meyer TA, Bittenbinder TM. Recurrent persistent hiccups
Slipman CW, Shin CH, Patel RK, et al. Persistent hiccup associated with thoracic
SC
Abbasi A, Roque-Dang CM, Malhotra G. Persistent hiccups after interventional pain
M AN U
Beyaz SG. Persistent hiccup after lumbar epidural steroid injection. Journal of
Kolodzik PW, Eilers MA. Hiccups (singultus): review and approach to management.
TE D
Zhang C, Zhang R, Zhang S, Xu M, Zhang S. Baclofen for stroke patients with persistent
EP
Guelaud C, Similowski T, Bizec JL, Cabane J, Whitelaw WA, Derenne JP. Baclofen
AC C
Cousins MJ, Bridenbaugh PO, Carr DB, Horlocker TT. Epidural neural blockade. Neural
Higuchi H, Adachi Y, Kazama T. Effects of epidural saline injection on cerebrospinal
ACCEPTED MANUSCRIPT Persistent Hiccups 8 183
10.
Hung YM, Miller MA, Patel MM. Persistent hiccups associated with intravenous
184
corticosteroid therapy. Journal of Clinical Rheumatology 2003; 9 (5): 306-309.
185
11.
186
hiccup reflex arc: competitive binding to the corticosteroid-receptor? Neuroendocrinology
187
Letters 2003; 24 (3-4): 167-169.
RI PT
Dickerman RD, Overby C, Eisenberg M, Hollis P, Levine M. The steroid-responsive
188
SC
189 190
M AN U
191 192 193 194
198 199 200 201 202 203 204 205
EP
197
AC C
196
TE D
195
ACCEPTED MANUSCRIPT Persistent Hiccups 9
Figures
207
Figure 1: Fluoroscopy image (Lateral View)
208
Figure 2: Fluoroscopy image (AP View)
210 211 212 213 214
AC C
EP
TE D
209
M AN U
SC
RI PT
206
S1934-1482(16)31266-7
DOI:
10.1016/j.pmrj.2017.04.013
Reference:
PMRJ 1897
To appear in:
PM&R
Received Date: 12 December 2016 Accepted Date: 19 April 2017
Please cite this article as: Colorado B, Decker G, Persistent Hiccups after an Epidural Steroid Injection Successfully Treated with Baclofen: A Case Report, PM&R (2017), doi: 10.1016/j.pmrj.2017.04.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Running Head: Persistent Hiccups
Title:
RI PT
Persistent Hiccups after an Epidural Steroid Injection Successfully Treated with Baclofen: A
Authors: Berdale Colorado, DO, MPH 1, 2; Gregory Decker, MD 2
SC
Case Report
M AN U
Department of Orthopedic Surgery 1, Department of Neurology 2, Washington University School of Medicine
Corresponding Author:
TE D
Berdale Colorado, DO, MPH Department of Orthopedic Surgery
Washington University School of Medicine
425 S. Euclid Ave.
EP
Campus Box 8233
AC C
St. Louis, MO 63110
Fax #: (314) 514 – 3555
Phone #: (314) 747 – 2823
E-mail: [email protected]
Conflicts of Interest and Acknowledgements of Financial Support: None declared
ACCEPTED MANUSCRIPT
1
Title:
2
Persistent Hiccups after an Epidural Steroid Injection Successfully Treated with Baclofen: A
3
Case Report
RI PT
4 5 6
SC
7 8
M AN U
9 10 11 12
16 17 18 19 20 21 22 23
EP
15
AC C
14
TE D
13
ACCEPTED MANUSCRIPT Persistent Hiccups 1
Abstract
25
Persistent hiccups are an established adverse reaction to epidural steroid injections. While oral
26
baclofen has been used to treat hiccups in various clinical settings, none of the prior reported
27
studies utilizing baclofen were related to hiccups occurring after spinal injections/procedures.
28
We report a case of a male who developed persistent hiccups following a transforaminal epidural
29
steroid injection that was successfully treated with oral baclofen.
32
Introduction
Hiccups are an established adverse reaction to epidural steroid injections [1-4]. While
M AN U
31
SC
30
RI PT
24
33
they are usually benign and self-limited, occasionally persistent or intractable hiccups do occur
34
and cause significant distress. Transient hiccups last less than 48 hours, while “persistent” last
35
more than 48 hours, and “intractable” hiccups greater than 1 month.
Non-pharmacological treatment options involve interrupting the vagal afferents of the
TE D
36
reflex arc, including drinking water and holding one’s breath. Alternatively, Valsalva maneuver
38
and carotid massage can abolish hiccups via vagal nerve stimulation [5]. Pharmacologic
39
treatments for hiccups include chlorpromazine, metoclopramide, haloperidol, nifedipine,
40
carbamazepine, and baclofen [5].
In a case series of eight patients, Abbasi et al. described hiccups following interventional
AC C
41
EP
37
42
pain procedures including cervical and lumbar epidural steroid injections, facet joint injections,
43
and sacroiliac joint injections [3]. It is unclear if hiccups are the result of the procedure itself, the
44
anesthetic/steroid, or the physiologic effect of the local anesthetic in the epidural space. A case
45
report by McAllister et al. described a patient who on several occasions developed persistent
46
hiccups following an epidural injection of dilute bupivicaine. However, in one instance when
ACCEPTED MANUSCRIPT Persistent Hiccups 2
saline was substituted for bupivicaine, the patient did not develop post-procedural hiccups [1].
48
The authors concluded that hiccups were due to the anesthetic in the epidural injection. However,
49
it is unclear if the hiccups were a direct result of the bupivicaine used or rather the physiologic
50
effects of the needle introduced into the epidural space.
51
RI PT
47
Baclofen is a GABA-B agonist with inhibitory effects on presynaptic motor neurons. Baclofen has been used to treat hiccups in various clinical settings. Zhang et al. studied patients
53
with cerebrovascular accident and persistent hiccups and randomized 30 patients to receive
54
baclofen 10 mg three times per day or placebo. Hiccups resolved in all but one of the patients in
55
the treatment group, and hiccups continued in all but two subjects of the placebo group [6].
56
Gueland et al. treated a series of 37 patients with intractable hiccups in an open label
57
observational study. The study reported a 76% response to baclofen as 18 patients had complete
58
response, while 10 patients had considerable improvement. The study started with baclofen 5 mg
59
three times per day and increased by 15 mg/day every 3 days until the hiccups were controlled
60
[7]. None of the prior reported studies utilizing baclofen were related to hiccups occurring after
61
spinal injections/procedures.
64 65 66
M AN U
TE D
EP
63
To our knowledge, there are no known reported cases of persistent hiccups following an epidural steroid injection successfully treated with oral baclofen.
AC C
62
SC
52
Case Presentation
A 69-year-old male presented with five-week history of low back pain and left leg pain,
67
which began after driving his car on a road trip. His pain was described as sharp and rated
68
“severe” on an intensity scale. Pain was aggravated by bending and transitioning from sit to
69
stand. The leg pain was located in the left posterior thigh and extended to the posterior calf. He
ACCEPTED MANUSCRIPT Persistent Hiccups 3 70
denied any lower extremity numbness, weakness, bowel or bladder changes, or gait ataxia. He
71
tried nonsteroidal anti-inflammatory drugs, oral steroids, muscle relaxants, and physical therapy
72
with minimal relief. He could not recall any prior spinal injections. Physical examination revealed a non-antalgic gait without loss of balance. Active range
74
of motion of the lumbar spine was decreased in both extension and flexion, with increased pain
75
with lumbar extension. There was tenderness to palpation primarily over the left lower lumbar
76
paraspinals. Strength was 5 out of 5 in the bilateral hip flexors, knee extensors, ankle
77
dorsiflexors, and great toe extensors. He was able to perform heel raises bilaterally. Sensation
78
was intact to light touch in the bilateral lower extremities. Muscle stretch reflexes were 2+ in the
79
bilateral patella and 1+ in the bilateral Achilles. No ankle clonus was noted bilaterally. Sit slump
80
test, log roll test, and FABER test were negative bilaterally.
SC
M AN U
81
RI PT
73
Radiographs of the lumbar spine were obtained, which revealed mild to moderate multilevel degenerative disc disease of the lumbar spine with mild, Grade 1 L3-4 retrolisthesis.
83
MRI of the lumbar spine was obtained, which revealed multilevel neural foraminal stenosis of
84
the lumbar spine, with severe spinal canal stenosis at L2-3. At L5-S1, there was moderate left
85
neural foraminal narrowing.
EP
86
TE D
82
The patient was referred for a left S1 transforaminal epidural steroid injection. Despite the primary pathology located at the L5-S1 foramen, the left S1 level was chosen because the
88
patient’s leg symptoms were primarily in an S1 distribution. After informed consent was
89
obtained, the patient lay in a prone position on the fluoroscopy table. The left S1 foramen was
90
identified under fluoroscopic guidance. The area was prepped and draped in a sterile fashion. A
91
25-gauge 2-inch needle was inserted into the region, and 2 mL of buffered 1% lidocaine without
92
epinephrine was infused for local anesthesia. Then a 25-gauge spinal needle was inserted into the
AC C
87
ACCEPTED MANUSCRIPT Persistent Hiccups 4
superior lateral region of the left S1 foramen and advanced into the epidural space under
94
fluoroscopic guidance. Confirmation of entry into the epidural space was obtained with infusion
95
of approximately 1 mL of Omnipaque contrast (Figures 1 and 2). There was no evidence of
96
vascular flow utilizing live fluoroscopic visualization. Further, there was no blood visualized in
97
the needle hub. Digital subtraction angiography was not utilized. Then a combination of 2 mL of
98
1% lidocaine and 1 mL of 10 mg/mL dexamethasone was infused. The patient tolerated the
99
procedure without complications. He was given a pain diary.
SC
RI PT
93
The patient contacted the clinic 5 days after the procedure reporting persistent hiccups
101
that began the day following the injection. He had tried non-pharmacologic treatments such as
102
drinking water, holding his breath, and breathing into a paper bag with no relief.
104 105
The patient was prescribed baclofen 10 mg orally every 8 hours as needed until hiccup resolution. He was instructed to contact the clinic the next day to provide an update. The patient reported resolution of his hiccups within 16 hours, after two doses of the
TE D
103
M AN U
100
baclofen. Two weeks after the left S1 transforaminal epidural steroid injection, the patient
107
reported 75% improvement in his pain symptoms. He had some return of his pain and obtained a
108
second left S1 transforaminal epidural steroid injection six weeks after his initial injection. The
109
procedure was performed by the same physician using the same technique and injectate as
110
before. The patient again reported hiccups starting the day after the procedure. He repeated the
111
oral baclofen and had resolution of his hiccups after two doses.
113 114 115
AC C
112
EP
106
Discussion
There are several potential mechanisms for the development of hiccups following epidural injections. Epidural anesthetics can cause sympathetic blockade along the sympathetic
ACCEPTED MANUSCRIPT Persistent Hiccups 5
chain allowing parasympathetic dominance resulting in small contracted gut [8]. Another
117
possible mechanism includes a volume effect of solution injected into the epidural space, which
118
compresses the dural sac [9]. The injection may acutely alter the CSF volume, flow, and pressure
119
resulting in hiccups. This latter mechanism would appear less likely in this case given the
120
relatively low volume of injectate.
RI PT
116
Systemic corticosteroids have been associated with development of hiccups [10]. It is
121
believed that steroids may trigger hiccups through steroid receptors on the reflex arc [11]. It is
123
possible that unrecognized vascular uptake may have occurred in this case, resulting in a
124
systemic corticosteroid effect that triggered the hiccups. It is important to note, however, that
125
prior treatments with oral steroids did not produce any hiccups or other adverse effects in the
126
patient.
M AN U
127
SC
122
Several studies have addressed pharmacological treatment of persistent hiccups after interventional pain procedures. Abbasi et al. noted that six of eight patients that developed
129
hiccups following interventional spine procedures resolved spontaneously or following the non-
130
pharmacological treatments described above. However, the two patients with persistent hiccups
131
were successfully treated with chlorpromazine. One patient’s hiccups ceased with one 10 mg
132
dose of chlorpromazine, and the other resolved within 16 hours of chlorpromazine,10 mg orally
133
q 6 hours [3]. In a case report by Slipman et al., hiccups following an epidural injection were not
134
relieved with non-pharmacological treatment or chlorpromazine, 10 mg orally q 6 hours. At 2.5
135
days following the start of chlorpromazine, the patient’s medication was changed to
136
metoclopramide, 10 mg orally every 6 hours, and within 24 hours of this change, his hiccups
137
resolved. Additionally, the patient developed hiccups following a second epidural injection,
AC C
EP
TE D
128
ACCEPTED MANUSCRIPT Persistent Hiccups 6 138
which was again successfully treated with four doses of metoclopramide, 10 mg orally every 6
139
hours [2].
140
Baclofen was chosen as an initial treatment for the persistent hiccups because the senior author (BC) had prior success with this medication for persistent hiccups unrelated to an epidural
142
steroid injection. Baclofen also provided the patient with potential relief for his muscle spasms.
143
The patient had been prescribed tizanidine for muscle spasms the day prior to the injection. He
144
had been instructed to discontinue the tizanidine when the hiccups initially started in the event
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that this may have been an adverse effect to this medication. However, the hiccups persisted
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despite medication discontinuation, and the patient had some increase in his muscle spasms.
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This case report provides a novel approach to the management of hiccups following
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epidural steroid injections. While a lack of a placebo control limits the ability to determine if the
149
response was truly due to baclofen, the fact that the response was consistent on two separate
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occasions suggests that the effect was related.
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ACCEPTED MANUSCRIPT Persistent Hiccups 7
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References
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therapy for chronic hiccup. The European respiratory journal 1995;8:235-7.
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fluid volume and velocity waveform: a magnetic resonance imaging study. Anesthesiology
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McAllister RK, McDavid AJ, Meyer TA, Bittenbinder TM. Recurrent persistent hiccups
Slipman CW, Shin CH, Patel RK, et al. Persistent hiccup associated with thoracic
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Abbasi A, Roque-Dang CM, Malhotra G. Persistent hiccups after interventional pain
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Beyaz SG. Persistent hiccup after lumbar epidural steroid injection. Journal of
Kolodzik PW, Eilers MA. Hiccups (singultus): review and approach to management.
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Zhang C, Zhang R, Zhang S, Xu M, Zhang S. Baclofen for stroke patients with persistent
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Guelaud C, Similowski T, Bizec JL, Cabane J, Whitelaw WA, Derenne JP. Baclofen
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Cousins MJ, Bridenbaugh PO, Carr DB, Horlocker TT. Epidural neural blockade. Neural
Higuchi H, Adachi Y, Kazama T. Effects of epidural saline injection on cerebrospinal
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Hung YM, Miller MA, Patel MM. Persistent hiccups associated with intravenous
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corticosteroid therapy. Journal of Clinical Rheumatology 2003; 9 (5): 306-309.
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hiccup reflex arc: competitive binding to the corticosteroid-receptor? Neuroendocrinology
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Dickerman RD, Overby C, Eisenberg M, Hollis P, Levine M. The steroid-responsive
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Figures
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Figure 1: Fluoroscopy image (Lateral View)
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Figure 2: Fluoroscopy image (AP View)
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