Post Herpetic Neuralgia

Post herpetic neuralgia (PHN) is a sequelae of herpes zoster infection. Herpes zoster infection typically begins with flu like prodromal symptoms and progresses to a rash of grouped vesicles on an erythematous base as the reactivated virus replicates and spreads to dermoepidermal junction. Herpes zoster most often affects thoracic dermatomes in 50% of cases followed by the face in 10-20% of cases. Diagnosis of herpes zoster is made clinically with history and symptomatic dermatomal rash not crossing the midline. Risks factors for herpes zoster include older age and immunosuppression, greater severity of acute pain, presence of painful prodrome, greater rash severity. Treatment of herpes zoster rash with antiviral therapy has been shown to decrease acute and chronic pain and should be initiated within 72 hours of rash onset if possible. Herpes zoster treatment should also include effective multimodal pain therapy which may decrease the risk of PHN. Herpes zoster vaccination in adults is recommended in healthy adults 50 years and older with live attenuated vaccine or the new recombinant zoster, which is preferable.

Herpes zoster pain can precede or accompany the rash and mostly resolves as the rash resolves. When persistent pain results, it can be defined as post herpetic neuralgia if the pain that persists for more than 90 to 120 days after rash onset. Risk of PHN after herpes zoster varies from 5% to more than 30% worldwide depending on the study.

Treatment of postherpetic neuralgia is mostly pharmacological with a limited role of interventional and alternative modalities. Anticonvulsants, tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, opioids, and topical modalities are often used. Anticonvulsants are first line therapies and include gabapentin and pregabalin. Tricyclic antidepressants are also effective in PHN and act by inhibiting reuptake of norepinephrine and serotonin and sodium channel blockade. Opioids are effective, however, adverse effect profile must be considered including nausea, sedation, urinary retention, pruritis, constipation, immune suppression, hypogonadism, as well as tolerance, dependence and opioid induced hyperalgesia. Topical therapies including lidocaine and capsaicin are also attractive therapy in the older patients who are sensitive to side effects. Interventional therapies including nerve blocks, neuraxial blockade, dorsal root ganglion pulsed radiofrequency ablation, botulism injection, and sympathetic nerve blocks have been performed for PHN.

Add to CRPS

The treatment of complex regional pain syndrome (CRPS) is centered around a multidisciplinary team-based approach to control pain and restore function.  Early diagnosis and appropriate referral are crucial to improved outcomes. 

Similar to other pain syndromes, multimodal pharmacotherapy can prove useful as well for treatment of symptoms.  NSAIDs, Antidepressants, and Anticonvulsants have shown to have some benefit in CRPS.  While opioids as well have shown some benefit in the short term, long term benefit has yet to be established. The use of bisphosphonates is an area of promise with significant benefit shown in several RCTs.

While physical therapy remains the frontline modality, interventional pain techniques (sympathetic blocks) can prove useful to improve compliance with physical therapy where significant pain is present. Stellate Ganglion blocks are used for the arms and Lumbar Sympathetic Blocks are performed for the legs prior to physical therapy which allows for more intense physical therapy and desensitization. For patients that fail physical therapy, pharmacotherapy, and interventional pain techniques, the use of spinal cord stimulation has shown to provide benefit in several RCTs.

Stellate Ganglion Block: Effects

The most common indication for stellate ganglion block is complex regional pain syndrome of the upper extremity. Additional indications for stellate ganglion blockade include: neuropathic pain of the hand or arm, symptoms of menopause, refractory ventricular tachycardia, cardiac electrical storm, vascular insufficiency, hyperhidrosis, among others. 

The stellate ganglion is formed by the fusion of the inferior cervical ganglion and first thoracic ganglion, normally located at the level of cervical vertebral body, C7.  The target stellate ganglion blockade is most commonly the transverse process of C6 (Chassaignac's tubercle). Needle placement occurs at the level of C6 to avoid side effects of pneumothorax, nerve root injury and vascular injection. 

Common side effects of stellate ganglion block are: Horner’s Syndrome (ptosis, miosis, anhidrosis, enophthalmos), Hoarseness (Recurrent Laryngeal Nerve), as well as Hemidiaphragm (Phrenic Nerve). Horner’s syndrome is by far the most commonly encountered side effect and is considered by some practitioners to be an indicator of successful blockade.  

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