743 - Doming of the Diaphragm for the Treatment of Persistent Hiccups in a Post Operative Patient: A Case Report

Case Diagnosis: Persistent Hiccups in Post-Operative Patient

Case Description: Patient is a 79-year-old male with hypertension and lumbar surgery who presented with worsening right leg pain and right foot-drop. Patient underwent removal of instrumentation, exploration of spinal-fusion and revision of L5-S1laminectomy, right facetectomy, and L5-S1posterolateral fusion. Post-op, patient reported headaches. CT brain depicted a small amount of pneumocephalus with minimal mass effect on the left frontal lobe. MRI revealed a subacute subarachnoid-hemorrhage in the posterior fossa and along left temporal-convexity. Patient was admitted to acute inpatient-rehab and complained of persistent hiccups lasting more than 48hours ranging12-48 per-minute which were interfering with therapy. Patient was initially treated unsuccessfully with baclofen which was discontinued due to hallucinations. Patient was then started on chlorpromazine which showed mild improvement in the frequency of hiccups. Osteopathic-treatment was performed by doming-the-diaphragm to normalize restriction for 3-5respiratory cycles several times a day for 3days with immediate relief.

Discussions: Hiccups occur due to an involuntary-spasmodic contraction of the diaphragm and intercostal muscles due to a reflex-circuit involving the peripheral pathways of the phrenic-nerve, vagus-nerve, and sympathetic-nervous system, along with central modulation in the medulla. This causes sudden inspiration with abrupt closure of the glottis. Acute episodes last seconds-or-minutes, persistent last longer than 48hours, and intractable last more than one-month. Central causes, such as hemorrhagic and ischemic strokes, cerebellar aneurysms, neuromyelitis-optica, space-occupying lesions primarily involve the brain and its control over the hiccup-reflex. Peripheral causes include conditions like tumors, myocardial ischemia, and GERD. Other causes include certain drugs like dopamine-agonists, steroids, and chemotherapies. In the postoperative setting, propofol and irritation of the phrenic nerve by glottic-stimulation during intubation can also cause hiccups.

Conclusions: Hiccups are commonly a benign and usually transient condition but can be challenging to manage when they become persistent. Osteopathic-Manipulative-Treatment in addition to pharmacologic intervention showed significant improvement and cessation of hiccups.