Hyperhidrosis and Dysautonomia in a Patient With a History of Tetraplegia Following Cervical Facet Radiofrequency Ablation

Abstract

IntroductionChronic pain in persons with spinal cord injury (SCI) can significantly impact quality of life, with prevalence ranging from 26% to 96%. 1 Treatment of chronic pain is notoriously challenging and unsatisfactory for providers and patients. 1,2 Patients with traumatic SCI and fusion can develop adjacent-level degeneration. 3 Facet-mediated pain can be treated with radiofrequency ablation (RFA) of the medial branch nerves that innervate the zygapophyseal joints. 4 Autonomic dysreflexia (AD) is seen most often in patients with SCI at T6 or superior, described as unregulated sympathetic activity from noxious stimuli below-the-level of injury causing hypertension, flushing, sweating, bradycardia, and, if untreated, even death. 5 A paucity of literature describes the use of RFA in patients with SCI. Herein we present an unusual case of dysautonomia and hyperhidrosis following RFA in a patient with a cervical SCI. Case PresentationA 40-year-old man with a previously documented C7 American Spinal Injury Association [ASIA] Impairment Scale A complete SCI status post C6-7 fusion was evaluated in an academic pain clinic. He reported chronic axial neck pain. Physical examination was positive for cervical facet loading and tenderness of the bilateral facets. Notably, motor strength testing showed shoulder abduction 4/5, elbow flexion 2/5, and wrist extension 1/5 bilaterally. Magnetic resonance imaging (MRI) from 2014 demonstrated severe myelomalacia versus complete cord transection from C4-C7 (Figure 1), and radiographs revealed degenerative changes from C3-C6. He underwent medial branch blocks of the right C3-5 with 75% relief. He then received RFA of the right C3-C5 medial branch nerves ( Figure 2) using a 100-mm curved sharp 22-gauge RF cannula with a 10-mm active tip at 80 o C in continuous mode for 180 s. Motor and sensory testing was done at each level. There were no intraprocedure complications. Within several days he developed severe right neck, arm, and shoulder pain accompanied by allodynia, flushing, and labile blood pressures from his usual systolic of 100 to 160 mm Hg. The following week he developed severe contralateral left-sided face, neck, shoulder, and chest hyperhidrosis. He was diagnosed with postprocedure neuritis in the emergency department and given the ongoing dysautonomia, he was admitted for in-patient care. Common causes of AD, such as bowel or bladder dysfunction were ruled out, and further systemic workup was also negative. He was treated with fluids, oral opioids, and brief intravenous lidocaine infusion for pain. Following a short stay, he was discharged with resolution of his dysautonomia and improvement in pain and hyperhidrosis. At 1.5-month follow-up, he reported complete resolution of the right-sided neck and arm pain and improvement in his underlying right axial neck pain. DiscussionWe present a patient with a history of SCI status post cervical fusion with facet-mediated neck pain who underwent cervical RFA. He subsequently developed neuropathic-type pain with allodynia on the ...