Intractable hiccups and neck pain due to left C4 radiculopathy decreased with posterior foraminotomy.

BACKGROUND: Intractable hiccups can last for more than 1-2 months and can occur, as shown in this case study, due to cervical nerve root compression. CASE DESCRIPTION: A 76-year-old male presented with intractable hiccups and neck pain of 7 months' duration. The patient underwent magnetic resonance imaging studies of the entire neuraxis. The only abnormality found was on the cervical magnetic resonance images that demonstrated left C4 nerve root compression due to the C3- C4 lateral/foraminal osteophyte. Following a left-sided C3-C4 laminoforaminotomy, the hiccups and the neck pain improved.
CONCLUSION: A 76-year-old male presented with intractable hiccups and neck pain attributed to a left C3/C4 lateral/foraminal spondylotic ridge. Following a left C3-C4 laminoforaminotomy, the frequency of hiccup attacks remained the same, but their duration was markedly shortened to 30 s, while the neck pain improved. Copyright:

INTRODUCTION

Persistent hiccups and intractable hiccups are, respectively, defined based on their duration: more than 24–48 h and more than 1-2 months.[2,3,5,9] The etiology of intractable hiccups includes: psychogenetic disorders, infection, trauma, medications, congenital anomalies, stroke, vascular malformations, demyelinating diseases, familial background, and iatrogenic conditions.[1-5,8] Additional causative lesions for intractable hiccups involve the thoracic spine, mediastinum, abdomen, or neural tracts extending from the cerebral cortex to the lumbar spine.[2-4,8] Here, a 76-year-old male with intractable hiccups and neck pain underwent a left-sided C3–C4 laminoforaminotomy to remove an osteophyte resulting in focal C4 root compression.

CASE PRESENTATION

A 76-year-old male presented neurologically intact, but with neck pain of 9 months duration, and 7 months of intractable hiccups. Notably, the hiccup attacks occurred 20–80 times/day, each lasting approximately 15 min. Upper endoscopy and abdominal computed tomography studies were negative. The patient underwent magnetic resonance imaging (MRI) studies of the entire neuraxis. When the cervical MRI revealed left C4 foraminal nerve root-osteophytic compression, left C3–C4 laminoforaminotomy was performed [Figure 1a-e]. Postoperatively, the frequency of the hiccups remained the same, but the attacks were shortened to 30 s at most, and the neck pain improved.

Figure 1:

(a) Preoperative sagittal magnetic resonance image (MRI). Apparent cervical spinal cord stenosis is not observed. (b) An axial MRI at the level of the bilateral C4 nerve roots. Left foramen stenosis of the C4 nerve root is visible (white arrow heads). (c) A computed tomography image showing osteophytes causing left foramen stenosis of the C4 nerve root. The ventral and dorsal roots of C4 are compressed (black arrow heads). (d) The left C4 nerve root is posteriorly decompressed (triple arrows). (e) A postoperative computed tomography image showing release of the left C4 nerve root (black arrow heads).

DISCUSSION

Lesions that continuously irritate the afferent, central, and efferent pathways of the hiccup reflex may result in intractable hiccups [Table 1].[1-5,8,9] The afferent root receives ascending visceral and somatic sensory stimuli through the vagus nerve, phrenic nerve, and sympathetic neural branches of the T6-T12 nerve roots. Central modulation involves the cervical C3-C5 nerve roots, and the dorsolateral medulla. Descending hiccup modulation is regulated by the hypothalamus, reticular activating system, subthalamic nuclei, and the temporal lobe. Further, the phrenic nerve, the major efferent pathway of the hiccup reflex, is primarily composed of the ventral root of the C4 nerve.[6,7] Here, a 76-year-old male’s intractable hiccups and posterior neck pain were attributed to a left C3–C4 osteophyte/C4 radiculopathy, and markedly improved following a C3–C4 laminoforaminotomy.

Table 1:

Summary of literature on past cases of intractable hiccups.

CONCLUSION

A 76-year-old male with intractable hiccups/neck pain attributed to a left C4 root compression/C3–C4 osteophyte formation, experienced marked improvement in his hiccups (i.e., attacks markedly shortened to 30 s), and radiculopathy following a left C3–C4 laminoforaminotomy.