Indian Journal of Pain

REVIEW ARTICLE
Year
: 2019  |  Volume : 33  |  Issue : 1  |  Page : 7--10

Role of interventional treatment in acute pain of herpes zoster and prevention of postherpetic neuralgia


Shubhangi Mishra, Adil Rasul, Hammad Usmani 
 Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Correspondence Address:
Prof. Hammad Usmani
Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh
India

Abstract

Acute pain associated with herpes zoster (HZ) is the most debilitating symptom, which if not treated in early phase may lead to postherpetic neuralgia (PHN), a potentially crippling disorder with prolonged intractable chronic pain. The socioeconomic consequences secondary to prolonged severe pain include decreased socialization, depression, fatigue, restricted daily activities, and poor quality of life. HZ and PHN impose a significant economic burden in the form of direct inpatient care and loss of productivity. Early interventional treatments attenuate central sensitization by interrupting the transmission of nociceptive afferent impulses to the central nervous system and minimize nerve damage by improving blood flow to the nervous tissue in addition to the local anti-inflammatory action of corticosteroids. Interventions treatment options have been increasingly used as a part of multimodal approach in the management of acute pain of HZ in addition to pharmacological agent. This article reviews the various interventional treatment options which have used in the recent years for the management of acute pain of HZ and subsequent prevention of PHN.



How to cite this article:
Mishra S, Rasul A, Usmani H. Role of interventional treatment in acute pain of herpes zoster and prevention of postherpetic neuralgia.Indian J Pain 2019;33:7-10


How to cite this URL:
Mishra S, Rasul A, Usmani H. Role of interventional treatment in acute pain of herpes zoster and prevention of postherpetic neuralgia. Indian J Pain [serial online] 2019 [cited 2019 Oct 18 ];33:7-10
Available from: http://www.indianjpain.org/text.asp?2019/33/1/7/255706


Full Text

 Introduction



Acute herpes zoster (AHZ) or “shingles” is one of the most common viral neurological conditions worldwide with an average incidence of 2.2–3.4/1000 persons/year.[1],[2],[3],[4] Approximately 20%–30% of people have HZ during their lifetime.[5] It occurs as a result of the reactivation of latent varicella-zoster virus in spinal or cranial sensory ganglia. Individuals affected by the reactivated HZ develop characteristic painful vesicular skin lesions in the affected dermatome. The pain is described as throbbing, paresthesia, dysesthesia, and itching. Older age, compromised immunity, female sex, the presence of prodrome, greater acute pain sensitivity, and greater rash severity are risk factors for prolonged zoster pain.[6],[7] Other factors which have been implicated are genetic susceptibility, psychological stress, and mechanical trauma. The most commonly affected sites are the thoracic region followed by the ophthalmic branch of the trigeminal nerve.[8],[9]

Interventions aimed to treat acute pain of HZ are imperative to prevent progression to postherpetic neuralgia (PHN), a potentially crippling persistent pain disorder. PHN is defined as pain that lasts for >3 months from the onset of rash.[10],[11],[12] The incidence of PHN varies from 5 to 50% depending on the study design, age distribution of the patients enrolled, and PHN definitions.[11],[12],[13] Although the intensity of postherpetic pain typically decreases over time, pain lasts for >1 year in >30% of patients.[10] Some patients of PHN may develop depression, fatigue, and sleep disturbance following prolonged intractable chronic pain. The socioeconomic consequences secondary to prolonged severe pain include decreased socialization, restricted daily activities, and poor quality of life.[14] HZ and PHN impose a significant economic burden in the form of direct inpatient care and loss of productivity.[15]

Various pharmacotherapeutic agents used to treat acute HZ and prevent/reduce the incidence of PHN include antiviral agents, analgesics, corticosteroids, antidepressants, and anticonvulsants. Antiviral agents such as acyclovir, famciclovir, and valacyclovir if initiated within 3 days of skin eruption have been shown to reduce acute HZ pain and speed lesion healing; however, the evidence supporting the role of these agents in the prevention of PHN is limited.[16],[17],[18] Oral corticosteroid when combined with antiviral therapy significantly alleviates pain from HZ but has no effect on the severity and duration of PHN.[19] Among analgesics, nonsteroidal anti-inflammatory drugs can be prescribed to treat acute pain, but their use can aggravate the lesion of HZ. Opioids have been shown to be effective in decreasing acute HZ pain but are associated with various adverse effects such as nausea, dizziness, somnolence, and constipation.[20],[21] Adjuvant analgesics such as antidepressants and anticonvulsant medication are effective in reducing the acute pain of HZ.[22],[23] However, the effectiveness of these agents in preventing PHN is insufficient except a strong evidence for the administration of vaccines to adult patients of >60 years of age.[12],[24]

 Interventional Treatment Options for Zoster-Associated Pain



Interventions treatment options have been increasingly used as a part of multimodal approach in the management of acute pain of HZ in addition to pharmacological agent. Early interventional treatments attenuate central sensitization by interrupting the transmission of nociceptive afferent impulses to the central nervous system and minimize nerve damage by improving blood flow to the nervous tissue in addition to the local anti-inflammatory action of corticosteroids.[25] Recent clinical trials have shown that early interventions in the acute HZ could prevent the development PHN;[26],[27] however, there was a significant heterogeneity among the trials in terms of incidence of PHN.

Subcutaneous infiltration of local anesthetics

The subcutaneous infiltration of local anesthetics with or without steroids in the areas of eruption of AHZ has been tried by many authors. Some authors have reported short pain-free period [28] while others found no significant benefit in acute pain of HZ.[29] The role of this technique in the prevention of PHN has not been documented by any of the studies.

Epidural blocks

Hwang et al. demonstrated a significant relief of acute pain of HZ and a rapid resolution of late residual pain in patients who received single epidural injection of methylprednisolone (40 mg) with 0.25% bupivacaine followed by continuous infusion of 0.125% bupivacaine for 7 days in addition to standard antiviral therapy. However, the authors did not study the effectiveness of these interventions in the prevention of PHN.[30]

A single-center study on 75 patients of acute HZ showed that single epidural injections of methylprednisolone with bupivacaine (0.25%) followed by repetitive epidural injection of 0.25% bupivacaine for 4–6 days in addition to standard antiviral therapy provided no significant relief in acute pain as compared to patients receiving only standard antiviral therapy. No significant difference in the incidence of PHN was seen in either group.[31]

Pasqualucci et al. conducted a randomized controlled study on 600 patients with acute HZ (within 7 days of onset of rash). The control group received intravenous steroids and acyclovir therapy for 9 days while the study group received only local anesthetic and steroid through an epidural catheter placed at the affected dermatomes repeatedly every 3–4 days for a period ranging from 7 to 21 days. They concluded that repetitive epidural administration of local anesthetic in combination with steroids is significantly more effective in preventing PHN than treatment with intravenous acyclovir and steroids.[32]

Studies conducted by Opstelten et al. and van Wijck et al. showed a modest pain reduction for 1 month after single epidural injection of methylprednisolone and local anesthetics in addition to standard antiviral and analgesic medication in the acute phase of HZ, as compared to those who received only standard therapy. However, the treatment was not effective in the prevention of PHN at 3 and 6 months.[33],[34]

A retrospective analysis on the efficiency of continuous epidural block in acute HZ pain showed that patients requiring prolonged epidural injections to control pain are at higher risk of developing PHN.[35]

A systemic review of different clinical trials conducted by Kim et al. showed that applying interventional techniques (epidural, paravertebral, and sympathetic blocks) in addition to standard antiviral therapy during the acute phase of HZ shortens the duration and severity of zoster-related pain.[36] Although the use of single epidural or stellate ganglion blocks (SGBs) fail to decrease the incidence of PHN, studies involving repeated or continuous blocks showed a significant reduction in the incidence of PHN (2017).

A recent retrospective trial on transforaminal epidural injection technique with steroid and local anesthetic injections in patients of HZ showed that the patients who received the block during the acute phase (within 30 days of HZ) had significantly better pain relief and lower incidence of PHN than the patients who received the block during subacute phase, i.e. between 30 and 90 days. The authors were of the view that this technique ensures sufficient delivery of drugs to the dorsal root ganglion which is an essential pain generator leading to a superior degree of pain relief and prevents subsequent development of central sensitization in patients of HZ.[37] However, there is a major risk of vascular injury during the transforaminal technique, especially at the thoracic and upper lumbar levels.[38],[39]

Paravertebral block

Paravertebral block with local anesthetics and steroids has been found to provide more complete and unilateral segmental block of the spinal nerve dorsal ramus, communicants, and the sympathetic chain. Recent clinical trials have shown that paravertebral blocks with local anesthetics and steroids are effective treatment modality for the relief of acute herpetic pain and prevention of PHN.

Ji et al. evaluated the effectiveness of repetitive paravertebral injections with local anesthetics and steroids in addition to antiviral therapy in acute HZ pain. They reported a significant reduction in zoster-associated pain in the paravertebral group as compared to the standard treatment group.[40] Moreover, the incidence of PHN was also found to be significantly lower in the paravertebral group than in the standard treatment group.

Makharita et al. evaluated the efficacy of single paravertebral injection of local anesthetic and steroids in acute thoracic HZ pain. They reported a significantly shorter duration of pain and lower requirement of analgesics in the active group as compared to the placebo group.[41] However, the incidence of PHN was comparable in both the groups.

Sympathetic blockade

Although sympathetic nerve blocks have been used for years in the treatment of acute pain of HZ, their efficacy in providing long-term pain relief and subsequent development of PHN is not fully established.

A review of different observational studies conducted by Wu et al. on the effect of sympathetic blocks on the acute pain of HZ and on the occurrence of PHN showed conflicting results. Majority of the studies included in this review were retrospectively analyzed and showed short-term pain relief with early blockade of the sympathetic nervous system in the acute phase of HZ.[42] However, the role of sympathetic nerve blocks in the prevention of PHN remains unclear. Moreover, it is doubtful whether the reported short-term benefits could be attributed to selective sympathetic blockade or there is a simultaneous blockade of the somatic fibers along with the sympathetic fibers with local anesthetic and steroid injection.

A study conducted by Lipton et al. in 30 patients of HZ ophthalmicus showed that single SGB provided pain relief in acute phase with no significant difference in the incidence of PHN.[43]

Lee et al. evaluated the efficacy of SGB in 20 patients of acute HZ of >50 years of age involving cranial nerves and cervical and upper thoracic dermatome. They demonstrated a significantly lower incidence of acute pain and no incidence of PHN in patients who received SGB within 2 weeks of the onset of skin lesions. However, there was no significant difference in the incidence of pain in patients who received SGB after 2 weeks of the onset of skin lesion.[44]

A recent study conducted by Makharita et al. showed that two injections of SGB with local anesthetic and steroids 1 week apart in acute facial HZ pain showed a significant reduction in the duration and severity of acute pain of HZ along with a significantly lower incidence of PHN at 3 and 6 months.[45]

Hence, the available medical literature supports the efficacy of sympathetic ganglion block in decreasing the intensity and duration of acute pain of HZ involving selective dermatomes. However, the role of multiple sympathetic ganglion blocks in subsequently decreasing the incidence of PHN needs further evaluation through large-scale randomized controlled trials.

Intrathecal blocks

The role of intrathecal steroids on acute pain of HZ has not been studied by any authors till date. The studies conducted by Kikuchi et al. and Kotani et al. showed promising results in patients of intractable herpetic neuralgia following the use of intrathecal steroid and local anesthetics.[46],[47] However, the risk of adhesive arachnoiditis could be a serious concern of intrathecal steroid administration.

Peripheral nerve blocks

Peripheral nerve/plexus blocks with or without local anesthetic and steroids have been utilized for the relief of acute pain of HZ in patients with absolute or relative contraindications to central neuraxial blockade.[48]

A recent case report has highlighted the potential use of ultrasound imaging for precise deposition of drugs around the involved nerve roots in patients of acute pain of HZ involving cervical dermatomes. They have shown significant relief of pain and itching around the involved dermatome and hypothesized that this could prevent the subsequent development of PHN.[49]

 Conclusion



The available medical literature supports the efficacy of interventional techniques in addition to standard antiviral therapy during the acute phase of HZ. The use of sympathetic and somatic nerve blocks during the acute phase of HZ shortens the duration and severity of zoster-related pain.

Few clinical trials have shown that repeated or continuous nerve blocks during the early phase of HZ could prevent the occurrence of PHN. However, large multicentric randomized controlled trials are still needed to further investigate the efficacy of various interventional techniques in the management of acute pain of HZ and prevention of PHN.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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