Use of Fentanyl Titration for Severe Headache in a Patient with a Rare Type of Ruptured Cervicomedullary Dural Arteriovenous Fistula a Case Report
Abstract:
We report a case of a 40-year-old male with a 1 day history of neck stiffness and severe neck pain with numerical rating scale of 10/10 after undergoing soft neck massage with no neck thrusting on spinal manipulation. There was no noted dizziness, blurring of vision, nausea or vomiting, focal weakness or numbness. Neurologic examination was normal. Initial management included intravenous infusion of Paracetamol with adjunctive muscle relaxants but afforded no relief. Patient refused cranial imaging hence, he was admitted for observation and treatment. Pain was controlled using the combination of Tramadol given via a patient-controlled analgesia (PCA) machine, Paracetamol infusion, Baclofen and Eperisone. Initial impression was a simple musculoskeletal strain, however on the third day of admission, there was progression of headache with associated nuchal rigidity. On cranial computed tomography (CT) scan, subarachnoid hemorrhage was noted. Cerebral CT angiography was done and the patient was found to have right cervicomedullary dural arteriovenous fistula (DAVF). He subsequently underwent embolization of the DAVF. Post-operative pain was controlled using escalation dose of PCA fentanyl and other adjunctive analgesics. Pain was eventually controlled and opioid requirement was eventually down titrated and eventually removed 1 week post discharge.
