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Intercostal Postherpetic Intercostal Postherpetic Neuralgia –Neuralgia –
Which Target to Choose?Which Target to Choose?
Andrea Trescot, MD, FIPPAndrea Trescot, MD, FIPP
DISCLOSUREDISCLOSUREAndrea Trescot, MDAndrea Trescot, MD
Board of directors, WIPBoard of directors, ASIPP
Medical director: Pinnacle Lab Services (not relevant to this program)
Post Herpetic NeuralgiaPost Herpetic Neuralgia
IntroductionIntroductionDifferential diagnosisDifferential diagnosisSigns and SymptomsSigns and SymptomsPathophysiologyPathophysiologyTreatmentTreatmentComplicationsComplicationsPrognosisPrognosis
Herpes Zoster (Shingles)Herpes Zoster (Shingles)
Herpes = from Greek Herpes = from Greek ““herpeinherpein”” meaning meaning ““to creepto creep””Zoster = from Greek meaning Zoster = from Greek meaning ““girdlegirdle””Shingles = from Latin Shingles = from Latin ““cingerecingere”” meaning meaning ““beltbelt””
Herpes Zoster (Shingles)Herpes Zoster (Shingles)
Thoracic 56%Thoracic 56%Cervical 17%Cervical 17%Trigeminal Trigeminal 12%12%Lumbar 10%Lumbar 10%Sacral 5%Sacral 5%
Herpes Zoster (Shingles) DistributionHerpes Zoster (Shingles) Distribution
Herpes Zoster (Shingles) IncidenceHerpes Zoster (Shingles) Incidence
Age (years)0–14
15–29 30–39
40–49 50–59
60–69 70–79 80
Cases (N=9,152) 397 527 600 1,213 1,989 1,778 1,692 956
*Age-specific incidence rates (across both sexes) from a healthcare claims database of more than 2.8 million individuals for the years 2000–2001 were sex adjusted to the 2000 US population. Insinga RP, Itzler RF, Pellessier JM, Saddier P, Nikas AA.J Gen Intern Med. 2005;20:748–753.
Pain from shingles is from Pain from shingles is from ischemia, ischemia,
not from the rashnot from the rash
Post-Herpetic Neuralgia (PHN)Post-Herpetic Neuralgia (PHN)
PHN is a chronic neuropathic pain PHN is a chronic neuropathic pain syndrome that persists or reoccurs in the syndrome that persists or reoccurs in the dermatome affected by zosterdermatome affected by zosterLoss of large myelinated sensory nerves Loss of large myelinated sensory nerves with residual C fiberswith residual C fibers
22ndnd leading cause of suicide in patients >70 leading cause of suicide in patients >70 years oldyears old
Effect of AntiviralsEffect of Antivirals
Acyclovir was developed in the 1980’s, but there has been no change in the incidence of PHN
Pain From PHNPain From PHN
IntractableIntractableConstantConstantFeeling of heatFeeling of heatBurning, shooting, twisting, lancinating, Burning, shooting, twisting, lancinating, pressure, and grippingpressure, and grippingNo relief during sleepNo relief during sleep
1515
Map of Sensory DisturbancesMap of Sensory Disturbances
Allodynia
PHN scarring
Reduced sensation to touch
Differential diagnosisDifferential diagnosis
Coronary artery diseaseCoronary artery diseasePleurisy/pleurodyniaPleurisy/pleurodyniaCholecystitisCholecystitisNeural diseaseNeural diseaseAppendicitisAppendicitisPeritonitisPeritonitisCollapsed intervertebral diskCollapsed intervertebral disk
Targets of InterventionTargets of Intervention
TreatmentTreatment
DrugsDrugsNerve BlocksNerve BlocksNeurolytic BlockNeurolytic BlockPsychosocial TherapyPsychosocial TherapyTENS, Ice, Accupuncture, HypnosisTENS, Ice, Accupuncture, HypnosisSurgery and NeurosurgerySurgery and Neurosurgery
DrugsDrugs
AnalgesicsAnalgesicsAntidepressants and TranquilizersAntidepressants and TranquilizersAnticonvulsantsAnticonvulsantsTopical capsaicinTopical capsaicinAntiarrhythmicsAntiarrhythmics
Nerve BlocksNerve Blocks
Local infiltrationLocal infiltrationSomatic Nerve BlockSomatic Nerve BlockSympathetic Nerve BlockSympathetic Nerve BlockEpidural BlockEpidural Block
Local infiltrationLocal infiltration
Subcutaneous infiltration of corticosteroidsSubcutaneous infiltration of corticosteroids– Triamcinolone 0.2% in normal saline or local Triamcinolone 0.2% in normal saline or local
anestheticanesthetic– May address localized scarringMay address localized scarring
SarapinSarapin– ““Reversable neurolytic”Reversable neurolytic”
Botulinum toxinBotulinum toxin
Thoracic EpiduralThoracic Epidural
Commonly performed but questionable Commonly performed but questionable efficacyefficacy““Shot gun approach”Shot gun approach”Needs to be done close to the level of Needs to be done close to the level of lesionslesionsFelt to be more effective earlier than laterFelt to be more effective earlier than later
Intercostal Nerve BlockIntercostal Nerve Block
Perpendicular vs parallelPerpendicular vs parallel
Used for treatment, diagnosis and Used for treatment, diagnosis and prognosis (Neurolytic)prognosis (Neurolytic)
Intercostal Nerve BlocksIntercostal Nerve Blocks
Skin Lung
Standard Approach
Intercostal Nerve BlocksIntercostal Nerve Blocks
Skin Lung
Standard Approach
Traditional ApproachTraditional Approach
Trescot ApproachTrescot Approach
Paravertebral ApproachParavertebral Approach
Cryo IntercostalCryo Intercostal
Thoracic DRGThoracic DRG
Diagnostic of the level of the Diagnostic of the level of the pathologypathology
Pulsed RF to treat the pathologyPulsed RF to treat the pathology
Sympathetic Nerve BlockSympathetic Nerve Block
Sometimes helpfulSometimes helpfulOnly benefits PHN with < 2 Only benefits PHN with < 2 monthsmonths’’ duration durationThoracic sympatheticThoracic sympathetic
Thoracic Sympathetic Nerve Thoracic Sympathetic Nerve Blocks TechniqueBlocks Technique
Patient Patient positioned prone, positioned prone, T2 and T3 IDT2 and T3 ID’’d by d by fluorofluoroOblique about Oblique about 20º20ºInsert needle to Insert needle to hug the lateral hug the lateral border to reach border to reach the posterior the posterior 1/3rd of T21/3rd of T2
Spinal and Peripheral Spinal and Peripheral StimulationStimulation
SCS lead usually needs to be SCS lead usually needs to be placed laterally, which may result placed laterally, which may result in unacceptable abdominal in unacceptable abdominal stimulationstimulationPeripheral nerve stimulation, or a Peripheral nerve stimulation, or a combination of the 2, may be combination of the 2, may be usefuluseful
Other Targets to ConsiderOther Targets to Consider
Thoracic Facet Joint NervesThoracic Facet Joint Nerves
Thoracic Facet PatternThoracic Facet Pattern
Thoracic FacetsThoracic Facets
Why would a Why would a shingles patient shingles patient have facet have facet problems?problems?
Neurolytic BlockNeurolytic Block
Ethyl alcohol 50% in aqueous solutionEthyl alcohol 50% in aqueous solution– Increased neuritis compared with phenolIncreased neuritis compared with phenol
Absolute alcohol 95% in aqueous solutionAbsolute alcohol 95% in aqueous solutionPhenol 6%Phenol 6%Duration- variable 2 to 6 monthsDuration- variable 2 to 6 months
AmmoniumAmmonium
Ammonium sulfate 10% in Lidocaine 1%Ammonium sulfate 10% in Lidocaine 1%Ammonium chloride 15%Ammonium chloride 15%Duration 4-24 weeksDuration 4-24 weeksNeuritis does not occur with ammoniumNeuritis does not occur with ammoniumSide effect NUMBNESSSide effect NUMBNESS
Do Not Forget Myofascial PainDo Not Forget Myofascial Pain
SurgerySurgery
Last resortLast resortRhizotomyRhizotomyCordotomyCordotomy
NeurosurgeryNeurosurgeryStereotactic ablation of conducting Stereotactic ablation of conducting pathwayspathways– ThalamusThalamus– MesencephalonMesencephalon
Frontal lobotomyFrontal lobotomySpinal cord stimulatorSpinal cord stimulatorDeep brain stimulatorDeep brain stimulator– Mesencephalic medial lemniscusMesencephalic medial lemniscus– Stimulate endorphin secretionStimulate endorphin secretion
ComplicationsComplications
EmotionalEmotionalDepressionDepressionSuicidial tendenciesSuicidial tendenciesPatientPatient’’s lifestyles lifestylePhysical functionPhysical function
ConclusionConclusion
Prompt treatment of active shingles can Prompt treatment of active shingles can prevent prevent PHN by restoring blood flow to PHN by restoring blood flow to the nervethe nerveTreatment of PHN needs to be Treatment of PHN needs to be multimodalitymultimodalityDo not assume that pain after shingles is Do not assume that pain after shingles is purely nerve painpurely nerve pain
