|LETTER TO THE EDITOR
|Year : 2021 | Volume
| Issue : 2 | Page : 181-182
Flank pain from postherpetic neuralgia and role of erector spinae plane block
Rajendra Kumar Sahoo1, Ashok Jadon2, Ganesh C Satapathy3, Lingaraj Sahu3
1 Department of Anesthesiology and Pain Management, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha, India
2 Department of Anaesthesia and Pain Relief Services, Tata Motors Hospital, Jamshedpur, Jharkhand, India
3 Department of Anaesthesia and Pain Management, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha, India
|Date of Web Publication||31-Aug-2021|
Dr. Rajendra Kumar Sahoo
Department of Anesthesiology and Pain management, Kalinga Institute of Medical Sciences, Bhubaneswar - 751 024, Odisha
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sahoo RK, Jadon A, Satapathy GC, Sahu L. Flank pain from postherpetic neuralgia and role of erector spinae plane block. Indian J Pain 2021;35:181-2
An 84-year-old man got admitted under urologist with severe left-sided flank pain. A thorough evaluation and computed tomogram (CT) scan of the abdomen ruled out any calculus of renal system or visceral pathology for his flank pain. CT scan revealed degenerative changes of the spine with lumbar facet joint arthropathy. Intravenous paracetamol and tramadol did not provide much pain relief. Then, our spine surgeon evaluated the patient and did a trial of lumbar facet joint injection (left L2/3 to L4/5) but that failed to provide any significant pain relief. Then, they referred the patient pain management department. A magnetic resonance imaging of the spine could not be done as the patient had hip prosthesis.
On evaluation, we found that the patient had severe paraspinal pain in the left side upper lumbar area with radiation to the lateral flank. He was describing the pain as throbbing, tingling, sharp, stabbing, and occasionally burning. There was no radiation of pain to lower limb or bowel and bladder dysfunction. Physical examination revealed left upper lumbar paraspinal tenderness in the upper-to-mid lumbar area and additionally hyperalgesia in the surrounding area including the flank [Figure 1]a. On further history, he revealed that he had herpes zoster (HZ) around 8 months ago and the healed patch was clearly evident. Unfortunately, physical examination of the painful area or obtaining clinical history of past herpes zoster had not been done before our (Pain Management) help was sought. Now, it was clear that the severe pain was from postherpetic neuralgia (PHN) and not from facet joints.
|Figure 1: (a) Encircled area shows the healed skin lesion of herpes zoster. (b) Ultrasound-guided Erector spinae plane block with catheter insertion at T 12 area on the left side with needle entry from cephalad|
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Considering the severity of pain, we decided to offer the patient erector spinae plane block (ESPB). Under ultrasound guidance, the ESPB was done at T12 level on the left side where a 21 gauge block needle with catheter system was inserted from cephalad to caudad (Contiplex, B Braun Melsungen, Germany) [Figure 1]b. After touching the transverse process, first, hydrodissection was done with normal saline to appreciate the spread just below the erector spinae and then we deposited the local anesthetic (LA). A catheter was left in place after injecting 20 ml of 0.25% bupivacaine with 40 mg Depo-Medrol under ultrasound guidance [Figure 2]. Patient reported complete pain relief following the ESPB. The catheter was kept for 48-h to top up if the need arises. Fortunately, we did not have to top up as the patient did not report any further pain. He was discharged with pregabalin 25 mg tablet and slowly increased to 75 mg over 1-month period. He reported excellent pain relief even at 8 months follow-up period.
|Figure 2: (a) Sonoanatomy image of the Erector spinae plane block with needle (highlighted with bold arrows) tip at transverse process. (b) Sonoanatomy image showing the spread of local anesthetic after hydrodissection (marked with bold arrow) lifting the ESM. ESM: Erector spinae muscle, TP Transverse process|
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This patient taught us few important points: Thorough history taking, physical examination of the most painful area and asking for a history of HZ when the pain is around the flank and the characteristics suggest a neuropathic pain. It is not unusual to have more than 1 pain generator in chronic pain patients, like facet joints and dorsal root ganglion/nerve root from PHN in our patient. However, it is essential to apply clinical judgment to find out the dominant pain generator and choose the appropriate intervention.
ESPB was first described by Forero et al. as an interfascial plane block for thoracic neuropathic pain. Since then, the indications of this novel regional anesthesia technique are increasing rapidly. Now, ESPB is mainly used in providing postoperative analgesia for breast, thoracic, abdominal, laparoscopic, hip, and urogenital surgery. Furthermore, ESPB has been used in many chronic neuropathic pain over the thoracoabdominal region, frozen shoulder, myofascial pain and even for neuropathic pain after hip surgery., Still, a lot of controversies exists toward its mechanism, volume of LA, concentration of LA, and optimal technique. It is postulated that LA penetrates through anatomical openings in the spine and can spread into the paravertebral space and even block sympathetic ganglia.,
Interventional pain management for PHN involves peripheral nerves, neuraxial and sympathetic blocks. In the chest wall, paravertebral and intercostal blocks are another option. However, pneumothorax is a possible complication, whereas ESPB is usually safe and effective when done under ultrasound though complications from ESPB has been reported.
To conclude, PHN is a possible cause of flank pain, especially in the elderly population. Thorough history, detailed physical examination and high index of suspicion are key to accurate diagnosis. As elderly patients are very sensitive to most neuropathic pain medicines, ESPB can be considered as an alternative and safe interventional treatment and ultrasound guidance is encouraged to avoid complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41:621-7.
Tulgar S, Selvi O, Senturk O, Serifsoy TE, Thomas DT. Ultrasound-guided erector spinae plane block: Indications, complications, and effects on acute and chronic pain based on a single-center experience. Cureus 2019;11:e3815.
Tsui BC, Fonseca A, Munshey F, McFadyen G, Caruso TJ. The erector spinae plane (ESP) block: A pooled review of 242 cases. J Clin Anesth 2019;53:29-34.
Chin KJ, Barrington MJ. Erector spinae block: A magic bullet for postoperative analgesia? Anesth Analg 2019;129:8-9.
Jeon YH. Herpes zoster and postherpetic neuralgia: Practical consideration for prevention and treatment. Korean J Pain 2015;28:177-84.
[Figure 1], [Figure 2]