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Have a case with a 55 yo female with previous L4-5 decompression (1990) and iodine allergy with subacute right L2,3 sensory/motor radiculopathy. Pain is intense 10/10 burning like in the right groin, anterior thigh, and anterior knee. Pain has been present for 2months but has become progressively worse, especially within the last two weeks.
Saw her last week.She had no treatment yet. Exam revealed normal strength but absent righ patella reflex. Positive femoral nerve stretch test. Otherwise exam was unremarkable. Started neurontin 300 tid. Order MRI L-spine. Had MRI, which reveals L2-3 right eccentric disk extrusion in the foramen and in central canal causing stenosis. The rest of MRI is unremarkable. I saw her yesterday and she claims, since lying down in the MRI pain is worse. Exam now reveals 4/5 anterior hip flexion strength, 4/5 knee extension strength and great nerve sensitivity with neural tension testing.
Since, her last visit with me, she has developed herpes zoster on the left anterior abdomen (t10 like distribution). PCP just started acyclovir.
I am concerned about the weakness and will monitor her closely, of course if this progresses, he will see a surgeon. However, the guys I work with don't get too concerned unless you are 3/5.
My question is would you guys even consider epidural steroid injection via right TFESI 2-3 in someone with acute herpes zoster or make them ride out the storm for a while and uptitrate analgesic medication with activity modification until completing acyclovir course. We discussed PT but she is in so much pain now she would not be able to tolerate much except some passive modalities of limited use.
Another concern about the injection and acute zoster, is she would need oral steroid (50 mg times 3) allgery prep for iodine allergy, as we don't carry gad contrast at our facility.
Did find this cochrane review, which failed to isolate any different adverse events between people treated with or without oral, intramuscular, or IV steroids for acute herpes zoster.
Corticosteroids for preventing postherpetic neuralgia.
Chen N, Yang M, He L, Zhang D, Zhou M, Zhu C.
SourceDepartment of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, China, 610041.
Abstract
BACKGROUND: Postherpetic neuralgia is a common serious complication of herpes zoster. Corticosteroids are anti-inflammatory and might be beneficial.
OBJECTIVES: To examine the efficacy of corticosteroids in preventing postherpetic neuralgia.
SEARCH STRATEGY: We updated the searches for randomised controlled trials of corticosteroids for preventing postherpetic neuralgia in MEDLINE (January 1950 to February 2010), EMBASE (January 1980 to February 2010), LILACS (January 1982 to February 2010), the Chinese Biomedical Retrieval System (1978 to 2010 ) and the Cochrane Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2010). We also reviewed the bibliographies of identified trials, contacted authors and approached pharmaceutical companies to identify additional published or unpublished data.
SELECTION CRITERIA: We included all randomised controlled trials involving corticosteroids given by oral, intramuscular or intravenous routes for people of all ages with herpes zoster of all degrees of severity within seven days after onset, compared with no treatment or placebo, but not with other treatments.
DATA COLLECTION AND ANALYSIS: Two authors identified potential articles, extracted data and assessed quality of each trial independently. Disagreement was resolved by discussion with other co-authors.
MAIN RESULTS: Five trials were included with 787 participants in total. All were randomised, double-blind, placebo-controlled parallel group studies. No new trials were identified in the 2010 update. In the updated version we conducted a meta-analysis of two trials, and the results showed that oral corticosteroids did not prevent postherpetic neuralgia six months after the herpes onset (RR, 0.95; 95% CI 0.45 to 1.99). The three other included trials also had similar results although their data could not be included in the meta-analysis. Adverse events during or within two weeks after stopping treatment were reported in all five included trials. There were no significant differences in serious or non-serious adverse events between the corticosteroids and placebo groups.
AUTHORS' CONCLUSIONS: Corticosteroids given acutely during zoster infection are ineffective in preventing postherpetic neuralgia. In people with acute herpes zoster the risks of administration do not appear to be great. Corticosteroids have been recommended to relieve the zoster-associated pain in the acute phase of disease; if further research is designed to evaluate the efficacy of corticosteroids for herpes zoster, long-term follow-up should be included to observe their effect on the transition from acute pain to postherpetic neuralgia. Future trials should include measurements of function and quality of life.
Saw her last week.She had no treatment yet. Exam revealed normal strength but absent righ patella reflex. Positive femoral nerve stretch test. Otherwise exam was unremarkable. Started neurontin 300 tid. Order MRI L-spine. Had MRI, which reveals L2-3 right eccentric disk extrusion in the foramen and in central canal causing stenosis. The rest of MRI is unremarkable. I saw her yesterday and she claims, since lying down in the MRI pain is worse. Exam now reveals 4/5 anterior hip flexion strength, 4/5 knee extension strength and great nerve sensitivity with neural tension testing.
Since, her last visit with me, she has developed herpes zoster on the left anterior abdomen (t10 like distribution). PCP just started acyclovir.
I am concerned about the weakness and will monitor her closely, of course if this progresses, he will see a surgeon. However, the guys I work with don't get too concerned unless you are 3/5.
My question is would you guys even consider epidural steroid injection via right TFESI 2-3 in someone with acute herpes zoster or make them ride out the storm for a while and uptitrate analgesic medication with activity modification until completing acyclovir course. We discussed PT but she is in so much pain now she would not be able to tolerate much except some passive modalities of limited use.
Another concern about the injection and acute zoster, is she would need oral steroid (50 mg times 3) allgery prep for iodine allergy, as we don't carry gad contrast at our facility.
Did find this cochrane review, which failed to isolate any different adverse events between people treated with or without oral, intramuscular, or IV steroids for acute herpes zoster.
Corticosteroids for preventing postherpetic neuralgia.
Chen N, Yang M, He L, Zhang D, Zhou M, Zhu C.
SourceDepartment of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, China, 610041.
Abstract
BACKGROUND: Postherpetic neuralgia is a common serious complication of herpes zoster. Corticosteroids are anti-inflammatory and might be beneficial.
OBJECTIVES: To examine the efficacy of corticosteroids in preventing postherpetic neuralgia.
SEARCH STRATEGY: We updated the searches for randomised controlled trials of corticosteroids for preventing postherpetic neuralgia in MEDLINE (January 1950 to February 2010), EMBASE (January 1980 to February 2010), LILACS (January 1982 to February 2010), the Chinese Biomedical Retrieval System (1978 to 2010 ) and the Cochrane Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2010). We also reviewed the bibliographies of identified trials, contacted authors and approached pharmaceutical companies to identify additional published or unpublished data.
SELECTION CRITERIA: We included all randomised controlled trials involving corticosteroids given by oral, intramuscular or intravenous routes for people of all ages with herpes zoster of all degrees of severity within seven days after onset, compared with no treatment or placebo, but not with other treatments.
DATA COLLECTION AND ANALYSIS: Two authors identified potential articles, extracted data and assessed quality of each trial independently. Disagreement was resolved by discussion with other co-authors.
MAIN RESULTS: Five trials were included with 787 participants in total. All were randomised, double-blind, placebo-controlled parallel group studies. No new trials were identified in the 2010 update. In the updated version we conducted a meta-analysis of two trials, and the results showed that oral corticosteroids did not prevent postherpetic neuralgia six months after the herpes onset (RR, 0.95; 95% CI 0.45 to 1.99). The three other included trials also had similar results although their data could not be included in the meta-analysis. Adverse events during or within two weeks after stopping treatment were reported in all five included trials. There were no significant differences in serious or non-serious adverse events between the corticosteroids and placebo groups.
AUTHORS' CONCLUSIONS: Corticosteroids given acutely during zoster infection are ineffective in preventing postherpetic neuralgia. In people with acute herpes zoster the risks of administration do not appear to be great. Corticosteroids have been recommended to relieve the zoster-associated pain in the acute phase of disease; if further research is designed to evaluate the efficacy of corticosteroids for herpes zoster, long-term follow-up should be included to observe their effect on the transition from acute pain to postherpetic neuralgia. Future trials should include measurements of function and quality of life.
