A 41-year-old Chinese Han male presented at the our department in December of 2020, with an 11-year history of intractable hiccups. The symptoms started from 2009 without any specific inducement. The onset of hiccups was intermittent with irregular episodes, ranging from several minutes to more than 10 days. Initial hospitalization and medical therapy achieved complete but temporary recover, which only lasted for a few days. Patient suffered none underlying co-morbidity. Neither alcohol, smoking nor drug consuming was reported in this case. The patient can still participate in daily life.
However, the symptom was continuous in the next three years. In 2011 the patient tried invasive therapy like phrenic nerve blocking, however, control of hiccups was obtained temporally. The symptom restarted within two days after the procedures. Following the successful but short-term nerve block, the continuous epidural anesthesia was then performed, and none recurrent hiccups were reported any more before discharge.
Unfortunately, the patient suffered recurrent hiccups in 2018 and gradually worsened in the frequency and duration, which became non-stop for days and continued during sleep. The daily life of the patient was completely interrupted, and the temporal relief of symptom was only achieved temporally by the repeated induction of vomiting reflex (more than 10 times per day). Countless medical examinations were performed, including repeated brain and cervical magnetic resonance imaging, abdominal and pulmonary computed tomography, and invasive gastrointestinal endoscopy, yielding none abnormal findings. Multiple medications were administrated including metoclopramide, omeprazole, lansoprazole, hydrotalcites, baclofen, gabapentin, pregabalin and duloxetine, in the absence of specific etiology.
Therefore, this patient was referred to our pain clinic for the treatment of the intractable hiccups in December 2020. The patient presented normal with physical and neurological examination, as well as laboratory results. The neck magnetic resonance imaging revealed slight cervical disc herniation at C4-7 level. Nevertheless, the patient did not complain any pain, weakness, numbness or tingling in the neck or upper extremity. Given the unsatisfactory control by non-invasive therapy, ultrasound-guided phrenic nerve blocking was initially applied. However, none significant improvement of hiccups was reported after nerve blocking treatment. Consequently, we performed selective cervical nerve pulsed radiofrequency and blocking at C3-5 level. Total relief of hiccups was achieved after the mini-invasive procedure, and the therapeutic effect lasted for 4 days. Following the successful but short-term neuromodulation therapy, the patient underwent the second procedure one week later. However, the patient continued to hiccup after the treatment. After careful consideration and review of the MRI, we suggested the patient to perform ultrasound-guided percutaneous laser cervical discectomy, due to the underlying discogenic cause.
The hiccups were totally relieved after the mini-invasive surgery. We did not observe any obvious complications in this case. The patient reported only occasional and short-lasting episodes, which can be terminated without any intervention, up to the 14-month follow-up.
The detail of surgery was described as previously , the patient was placed in a supine position under general anesthesia. The surgery was performed by two senior consultants (Dr. Rong Hu and Dr. Rui Han). After routine antiseptic operation, we performed the mini-invasive surgery under the guidance of one high-frequency liner probe (Fujifilm, SONOSITE, United States). One 19-G cannula with an internal mandrel was inserted into the targeted disc space with in-plane sonographic technique.
The first step of cervical structural identification was to search the of C7 transverse apophysis. We can easily distinguish the transverse apophysis of C7 due to its straight shape compared with other cervical level as shown in Figure 2.a. We then gradually moved the ultrasonic probe head towards, and identified the characteristic U-type shape of C6 transverse apophysis (Figure 2.b). The cannulation was introduced under the real-time imaging guidance, which can help us avoid potential vessel injury. At this plane, the tip of needle can be guided to reach the anterior surface of C6 vertebral body, following which the cannulation was inserted into the C5/6 intervertebral disc space. We next scanned the fifth cervical nerve root (Figure2.c), and the intertubercle sulcus became superficial and vertical at this level. This transition of intertubercle sulcus shape can be used to identify the corresponding cervical level.
When the cannula was inserted into the disc space and stable, one C-arm unit (TOSHIBA) was applied to guide the cannulation. The ending tip was placed at the distal third segment of disc according to the lateral fluoroscopic view, and slightly beyond the middle line in the anterior-posterior view respectively (Figure.3). An optic fiber was then inserted through the cannula to conduct the laser discectomy. The total amount of laser power was set 150 joules for each disc during the first cycle, after which the tip of needle was pulled out at the middle of the intervertebral space (Figure.3.c) for the second cycle of ablation.