Pain
Motasem Abul-Huda, DO
Resident Physician
JFK Johnson Rehabilitation Institute
Lodi, New Jersey, United States
Ekrem Cetinkaya, MS, DO
Resident Physician
Virginia Commonwealth University
Henrico, Virginia, United States
Joseph Tafalla, MS
Medical Student
Kansas City University: Osteopathic Medical School
Kansas City, Missouri, United States
Adam Atoot, MD
Attending Physician
Palisades Medical Center
Hackensack, New Jersey, United States
Ali Atoot, MD
Attending Physician
Hackensack University Medical Center
Hackensack, New Jersey, United States
Motasem Abul-Huda, DO
Resident Physician
JFK Johnson Rehabilitation Institute
Lodi, New Jersey, United States
We present a rare case regarding persistent and severe hiccups after a diagnostic bilateral L3-S1 lumbar medial branch block.
Case Description:
A 41-year-old male with a history of axial low back pain presented for his first diagnostic bilateral L3–S1 medial branch block (MBB). The procedure was well tolerated without immediate complications. However, later that evening, he developed persistent, severe hiccups lasting approximately 24 hours. The patient was then prescribed baclofen for the hiccups during follow-up visit. He later underwent additional diagnostic MBBs and radiofrequency ablation with intermittent recurrence of hiccups, which were alleviated by baclofen. The patient reported experiencing similar hiccups following a prior medial branch block, which had resolved without intervention.
Discussions:
This case highlights a rare, yet benign, complication associated with interventional pain management procedures. Although this complication is atypical, there have been a few reports of similar occurrences, including a comprehensive literature review of eight patients who experienced hiccups following interventional pain procedures. These include facet and sacroiliac joint injections, as well as epidural steroid injections in both the cervical and lumbar spine. Although the pathophysiology of hiccups remains not well elucidated, the hiccup reflex arc is thought to involve an afferent pathway mediated by the vagus nerve, phrenic nerve, and sympathetic chain, with an efferent pathway directed to the diaphragm and intercostal muscles. It has been suggested that irritation or disruption of any component within this arc may precipitate hiccups. Several medications have been used for symptom management, including muscle relaxants, anticonvulsants, and proton pump inhibitors. In this case, baclofen was used with moderate to complete resolution of hiccups.
Conclusions: Recognizing hiccups as a potential consequence of interventional pain procedures may aid in patient counseling and management. Further research is required to better elucidate the pathophysiology and measures to avoid this rare complication.
