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.

INTRODUCTION

Caudal epidural steroid injection (CESI) is a minimally invasive procedure that can help to relieve back and leg pain, caused by inflamed spinal nerves due to stenosis, spondylolysis, or disc herniation. Steroid injection includes both corticosteroid and a local anesthetic agent. Corticosteroid injections can reduce inflammation and can be effective when delivered directly into the painful area. However, these injections are not free of complications.[1] Reported side effects seen after CESI are headache, back pain, for diabetic patients, and the increase in blood sugar levels. Rare side effects that may occur include; weakness, dizziness, and fatigue, skin changes, and osteoporosis. Extremely rare risks include infection, bleeding, dural puncture, a nerve damage, and hiccups.

Hiccup more than 24 h is defined as persisting. The causes of hiccup are many and include electrolyte derangement, nutritional deficiencies, gastrointestinal disorders and instrumentation, cardiovascular disorders, renal impairment, central nervous system (CNS) disorders and drugs.[23] They are synchronous and involuntary contractions of diaphragm can be caused by the central nervous system lesions, or of the phrenic and vagus nerves irritability. The etiology of it is still not clear and should be investigated.[4]

CASE REPORT

A 43-year-old well male presented to the Department of Neurosurgery with left-sided leg symptoms. Despite several months of physical therapy and nonsteroid anti-inflammatory drugs and gabapentin usage, his symptoms persisted. The clinical examination and magnetic resonance scan confirmed L3–L4, L5–S1 disc prolapse. Neurosurgeon advised caudal epidural injection and referred the patient to Algology Department. His physical examination revealed normal reflexes and sensation. Informed consent was obtained after explaining the risks to the patient. The patient was taken to the operating room, standard monitorization was carried out. His vital signs were stable and continuously monitored. Intravenous (IV) access with 20-gauge cannula was obtained and 500 ml isotonic saline solution was given before the procedure. The patient was treated with prone position with a cushion under the abdomen. Under sterile conditions, following the local anesthesia the procedure involved 18-gauge epidural needle through the sacral hiatus. After negative aspiration for blood and cerebrospinal fluid, totally 20 ml of drug mixture of celestone 6 mgr (1cc) and bupivacaine 15 mgr (3cc) and 16 ml saline solution carefully administered. In the recovery room, hemodynamic was stable, his visual pain scale decreased from 8 to 0. He was discharged from the hospital. At 20th h, after the injection hiccups were started and persisted for 3 days. Computed tomography scans were normal. Laboratory results were within normal limits. After neurology consultation, 2 * 1 chlorpromazine IV was started and continued for 3 days. Hiccups subsided with the medical therapy.

DISCUSSION

Caudal steroid injections are generally well tolerated. Adverse reactions are uncommon and transient. Till date, the occurrence of hiccups after epidural injection has been described in a few cases. Kanniah reported acute transient hiccups after epidural injection of levobupivacaine. Epidural injection of 5 ml loading dose of 0.125% levobupivacaine was administered and infusion of 0.1% levobupivacaine was initiated. Within a few minutes, hiccups started. Hiccups lasted for about an hour after which they resolved spontaneously.[5]

Beyaz reported a 61-year-old male with a history of low back pain over 10 years complaining of hiccups subsided 48 h later, after single shot CESI.[6] Slipman reported persistent hiccups after thoracic epidural steroid injection.[7]

Steroids are known as a beneficial treatment, but side effects of steroids are common ranging from a minör case to life-threatening cases. Mechanism and incidence of hiccups due to steroids are not known, but steroids effect the neurotransmitters of the brainstem. Steroids have neuroexcitatory properties.[8] Bupivacaine alone or in combination with steroids can cause hiccups. Local anesthetics given into epidural space may lead to hiccup also.

The incidence of hiccup after epidural injection is not known. Hiccups are reported extremely rarely. The reasons of hiccup and mechanism are not clear yet. Several reasons are blamed, but not exact. The volume and the value of CESI are controversial. The possible mechanism of hiccups can be explained by the volume effect because this may change the balance of the cerebrospinal fluid volume, pressure, and flow so that hiccups can start as a response.[9] We assume that dural sac is compressed as a result of caudal injections. Dural compression lasts at least 30 min after injection, and the changes of the cerebrospinal fluid lead to these complications.

CONCLUSION

Anesthesiologists should be aware of complications for caudal epidural injections as epidural steroid injections are increasing currently. This procedure includes many side effects as mentioned above. Hiccups are largely ignored but should always be on consider.

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Conflicts of interest

There are no conflicts of interest.