Delayed Reflex Bradycardia and Hypotension 24 Hours After Fluoroscopy-Guided Upper Cervical and Occipital Pulsed Radiofrequency: A Case Report

Abstract

Background. Pulsed radiofrequency (PRF) is a tissue-sparing treatment for refractory cervical radicular pain and occipital neuralgia and is generally regarded as safe. Delayed autonomic complications after upper cervical PRF are rarely reported.

Objective. To describe severe bradycardia, hypotension and reduced consciousness 24 hours after upper cervical and occipital PRF and to discuss possible mechanisms.

Methods. A 41-year-old woman with cervical root syndrome (C3–C6), occipital neuralgia and treated hypertension had fluoroscopy-guided PRF (120 s, 2 Hz, 45 V, maximum 42 °C) of the bilateral C3 and C4 dorsal root ganglia and the occipital nerves. Blood pressure, heart rate and Glasgow Coma Scale (GCS) were recorded at ten time points over 14 days.

Results. The procedure was uneventful, and hemodynamics were stable for 12 hours. At 24 hours the patient collapsed: blood pressure 75/40 mmHg (mean arterial pressure 51.67 mmHg, −52.01% from baseline), heart rate 42 bpm (−47.50%) and GCS 12. Electrocardiogram, troponin I and glucose excluded cardiac and metabolic causes. Trendelenburg positioning, 1,000 mL of crystalloid and atropine 0.5 mg restored heart rate (78 bpm) and mean arterial pressure (83.33 mmHg) within 60 minutes; GCS was 15 at 36 hours. At 14 days there was no recurrence, and neck-movement pain had fallen from 5–6 to 4–5 on the numeric rating scale.

Conclusion. Severe but reversible bradycardia and hypotension can occur 24 hours after upper cervical PRF. A reflex mechanism is plausible but was not measured, and one case cannot establish causation. Longer observation may be considered in patients on vasodilators.