Novel therapy for intractable hiccups

Main Category: Stroke
Article Date: 25 Jun 2004 - 24:00 PDT

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Dr. Bryan R Payne, and Dr Robert Tiel, neurosurgeons at LSU Health Sciences Center in New Orleans have discovered a new approach to treating medically intractable hiccups. They implanted a Vagus Nerve Stimulator in a Texas man to stop the hiccups which have severely disrupted Shane Shafer's life following a stroke he had two years ago. This is the first reported case of its kind. When Dr. Payne activated the implant following the surgery, Shafer's hiccups stopped, and they have not as yet returned.

Although hiccups are a normal occurrence, they serve no useful purpose. Hiccups are normally self-limiting. In some cases, however, hiccups don't go away, and these prolonged attacks can cause significant illness and even death.

When the attack lasts longer than a month, the hiccups are termed intractable. Although more than a hundred causes have been described-everything from hysteria to trauma and malignancies--sometimes hiccups are caused by irritation of the vagus nerve.

The vagus nerve, measuring about 22 inches, is the longest cranial nerve, wandering throughout the upper body. It is one of the body's primary communication pathways from the brain to other organs, and it contains few if any pain fibers. Mr. Shafer's hiccups were likely due to an aberrant connection or cycle between the groups of brain cells associated with the vagus nerve and those of the phrenic nerve which supplies the diaphragm caused by his stroke.

A vagus nerve stimulator uses electrical impulses delivered by a programmable generator implanted in the chest to two tiny leads wrapping around the vagus nerve in the neck to disrupt faulty nerve communication.

The "dose" of stimulation, programmed by the physician, is automatically delivered. VNS therapy has been effective in controlling medically refractory seizures, and an FDA Advisory panel recently recommended approval of VNS therapy as an adjunct treatment for non-responsive depression as well. The minimally invasive procedure, which is reversible, requires two small incisions, and the generator can be turned off with a handheld magnet.

"Mr. Shafer had a stroke that caused severe hiccups of both halves of his diaphragm. We wanted to break the cycle of connection associated with hiccups in the same way that VNS therapy disrupts the circuit in seizures," said Dr. Bryan Payne, an LSU Health Sciences Center neurosurgeon who specializes in functional neurosurgery. "We thought that VNS therapy held promise."

Reduced to gagging himself to vomit which bought him about a 30-minute respite, Shafer's doctor in Texas tried a variety of treatments, finally resorting to injectable Stadol, an opiod analgesic, which brought some relief. But Shafer needed about ten injections a day, plus a nasal spray at night, costing about $100 a day for incomplete relief. The drug was not covered by his insurance because it was prescribed for an off-label use, and Shafer could not afford the medication, plus there were side effects.

According to emedicine.com's clinical knowledge database, the overall incidence of hiccups is equal between males and females; however, protracted and intractable hiccups occur more frequently in men (82% of cases.). Although hiccups occur less frequently with advancing age, intractable hiccups are more common in adult life.

The LSU Health Sciences Center neurosurgical team performed the procedures at Touro Infirmary in New Orleans. The 50-year-old IT professional says, "Dr. Payne said he was up for a challenge, and so here I am."

"We're excited about our short-term success, and are hopeful that we will offer Mr. Shafer long-term relief," says Dr. Payne.

Contact: Leslie Capo
lcapo@lsuhsc.edu
504-568-4806
Louisiana State University Health Science Center