Professional Documents
Culture Documents
&
Post herpetic
Neuralgia
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
Herpes zoster
Herpes zoster is an infectious disease
that is caused by the varicella-zoster
virus
It is postulated that during the course
of primary infection with VZV, the
virus migrates to the dorsal root or
cranial ganglia
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
Herpes zoster
In some individuals the virus may
reactivate and travel along peripheral
or cranial sensory pathways to the
nerve endings, producing the pain and
skin lesions characteristic of shingles
The reason for reactivation ?
decrease in cell-mediated immunity
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
Risk factors
Suffering from malignancies (particularly
lymphoma)
52%
20%
17%
II %
Differential Diagnosis
Appendicitis
Contact dermatitis
Intervertebral disc
Erysipelas
disease
Folliculitis
Myocardial infarction
Incontinentia pigmenti
Pleurisy
Jellyfish sting
Renal stone
Lichen striatus
Trigeminal neuralgia
Pemphigus
Cholecystitis
Photoallergic reaction
Glaucoma
Phytophotodermatitis
Bells palsy
Rhus dermatitis
Brachioradial pruritus
Urticaria
Bullous impetigo
Zosteriform herpes
Bullous pemphigoid
Zosteriform metastasis
Candidiasis
Cellulitis
Dr Mehran Rezvani pain fellowship
Caterpillar dermatitis
anesthesiologist & acupuncturist
COMPLICATIONS
TREATMENT
Relief of acute pain and symptoms
Prevention of complications, including
postherpetic neuralgia
Earlier treatment
less likely postherpetic
neuralgia
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
TREATMENT
Careful initial evaluation, including a
thorough history and physical
examination, is indicated to rule out
occult malignancy or systemic
disease
TREATMENT
Sympathetic neural blockade appears
to be the treatment of choice to
relieve the symptoms of acute
herpes zoster as well as to prevent
the occurrence of postherpetic
neuralgia
Noordenbos "fiber dissociation"
TREATMENT
Herpes zoster in trigeminal nerve & geniculate,
cervical, and high thoracic regions:
stellate ganglionblockade with
LA daily basis
Herpes zoster thoracic, lumbar, and sacral
regions:
epidural neural blockade with
LA
daily basis
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
TREATMENT
If the pain is not as severe, NSAIDs or
acetaminophen may be all that is
needed
In acute eruption oral narcotics may
be
administered in the short term,
especially with (NSAIDs)
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
TREATMENT
Narcotic analgesics may be useful in
relieving the aching pain
Antidepressants will help :
Alleviate the significant sleep disturbance
Ameliorate the neurotic component of the pain
May exert a mood-elevating
May cause urinary retention and constipation
TREATMENT
Anticonvulsants
May be of value as an adjunct to sympathetic
neural blockade
They may be particularly useful in persistent
paresthetic or dysesthetic pain
TREATMENT
Anxiety may be treated
Hydroxyzine
Behavioral interventions
(e.g., monitored relaxation training and hypnosis)
TREATMENT
Antiviral agents:
Acyclovir , valacyclovir, famcyclovir
and perhaps interferon have been
shown to shorten the course of acute
herpes zoster
TREATMENT
Corticosteroids
In systemic ? (the risk of dissemination?)
Local infiltration of affected skin areas with
corticosteroid with or without local
anesthetic
may be of value as an adjunct to
sympathetic neural blockade
TREATMENT
Local application of ice packs
Application of heat
Transcutaneous electrical nerve
stimulation
Vibration
Spinal cord stimulation
TREATMENT
Topical application
Aluminum sulfat
Zinc oxide ointment
Topical lidocaine patches for PHN
Topical capsaicin for PHN
Postherpetic
Neuralgia
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
PHN
Differential Diagnosis
Thoracic nerve roots include
Thoracic radiculopathy
Peripheral neuropathy
Intrathoracic and intra-abdominal
pathology
TREATMENT
The anticonvulsant gabapentin
represents a first-line
Carbamazepine
Phenytoin
Antidepressants may also be useful
TREATMENT
Sympathetic neural blockade with local
anesthetics and steroids via either
epidural nerve block or blockade of
the sympathetic nerves may be next
step ?
Some texts: peripheral nerve,
epidural, or sympathetic anesthetic
blocks do not appear to be useful
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
TREATMENT
Neurodestructive procedures have a
very low success rate
Opioid analgesics have a limited role
Application of ice packs
Application of heat
Transcutaneous electrical nerve
stimulation
Vibration
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
FDA APPROVED
gabapentin
Pregabalin
Topical lidocaine patch5%
Capsaicin cream
TREATMENT
Topical local anesthetics, such as
EMLA cream
Subcutaneous lidocaine infiltration
Intrathecal methylprednisolone
Implanted spinal catheters and
pumps
Dorsal root entry zone lesion
Behavioral therapy
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
TREATMENT
In one controlled trial (Kotani et al.
2000),
repeated intrathecal administration
of methylprednisolone acetate
resulted in sustained pain relief in
90% of PHN
The treatment was well tolerated
TREATMENT
If the pain is severe, and all other
methods fail, immediate pain relief
may be obtained in hospitalized
patients with a short course of highdose chlorprothixene (50mg every 6
hours for 5 days)