Treatment of Postherpetic neuralgia

[NOSfan]

80 year man with 3 year history of PHN. Past treatments include:
Gabapentin, Keppra, Topamax, Primidone, Cymbalta, TCA's, Namenda, Botox, SCS trial, SSNB/TESI, Iontophoresis, Lidoderm patch, opioids, topical gels (various preparations Ether, Ketamine, Lidocaine, Gabapentin, Baclofen, Ketoprofen).

Other ideas appreciated...🙂

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[exmike]

80 year man with 3 year history of PHN. Past treatments include:
Gabapentin, Keppra, Topamax, Primidone, Cymbalta, TCA's, Namenda, Botox, SCS trial, SSNB/TESI, Iontophoresis, Lidoderm patch, opioids, topical gels (various preparations Ether, Ketamine, Lidocaine, Gabapentin, Baclofen, Ketoprofen).

Other ideas appreciated...🙂

sounds like he'll need a nerve block x 2 followed by ablation if successful 🙂

 

[NOSfan]

Spinal Selective Nerve Block did not provide any significant relief. Of note, pulsed RF was attempted by another md prior to my eval, although the patient states that 'nerve block' prior to RF, also, did not afford any relief.

 

[spondy14]

APAP, reassurance

 

[Pain_doc]

intrathecal methylprednisolone. Kotani, NEJM Nov 23 2000

 

[teri78]

Why not just try carbamazepine instead of a bunch of invasive procedures that are doomed to fail? Isn't it still the gold standard for PHN? Maybe even Lyrica.

 

[Mister Mxyzptlk]

I haven't heard of Tegretol being a gold standard for PHN. I'd use Trileptal instead of Tegretol. Lyrica is always worth a try. Maybe mexilitene or phenytoin?

How about an IT baclofen trial?

Psych eval? Are there secondary gain issues?

 

[NOSfan]

Sorry, failed to mention, he had been placed on Lyrica by the Mayo clinic two years ago and prior to seeing me, again, without any efficacy. Of note, they also recommended SCS trial if that failed.


No secondary gain issues. Additionally, the patient had undergone psych evaluation in his workup for SCS trial without any evidence of psychogenic overlay.

Apprehensive for IT steroids (I would be worried about toxicity issues and subsequent potential for myelopathy)

Trileptal is a thought. And if that fails, then likely PHT. I like Mexitil also for it’s Sodium Channel Blockade, although the patient has had some cardiac issues in the past.


Thanks for all of the suggestions. 🙂

 

[ampaphb]

Might want to add Effexor or Cymbalta to your cocktail

 

[teri78]

My mistake, tca's are usually considered the gold standard for PHN. Tegretol is usually the gold standard for trigeminal neuralgia.

I personally do like tegretol over trileptal, as I find it tends to have better eficacy. However, it is usually a good idea to get an initial lft, cbc, and level after starting it, which is not really necessary with trileptal. Cymbalta also sounds like it would be worth trying.

If the oral meds don't work, then IT baclofen is probably worth trying. What i have seen, is IT baclofen either has no effect or it is a miracle drug. There really doesn't seem to be a middle ground. Has anybody else noticed this, or is it my imagination? I have seen some patients who have said it almost completely gets rid of their pain, which is incredible for neuropathic pain.

As a reminder, I am just a lowly resident, so you are welcome to take what I say with a grain of salt. However, I do appreciate the fact that you haven't treated me that way.

 

[lobelsteve]

So many off-label treatments already done, so many proposed.

Prialt anyone?

Except for the hallucinations and exorbitant cost, also it depends what level dermatome is affected.

PAZ- good thinking, but how do you inject Cymbalta?

Steve

 

[Ligament]

Trial of Prialt as Lobel suggested. Or adenolysis of the pituitary.

 

[NOSfan]

Prialt --> Insurance won't approve.

Yes, many off label indications, but, when there are only 3 FDA approved treatments (GBP, 5% lidocaine, and PGB) one is sure to try other medication classes. 😉

Already tried Cymbalta.

Dermatome --> T5/T6. Botulinum Toxin was used as this case is similar to:
Botulinum Toxin A Relieved Neuropathic Pain in a Case of Post-Herpetic Neuralgia. Hsu-Tang Liu MD et. al.
Pain Medicine 7 (1) 2006, 89–91. Note: my patient states the Botulinum Toxin worsened his pain. Although, I have used in a patient with PHN in the Trigeminal V1 distribution with good results.

Adenolysis of the pituitary --> from what I understand it most of the time there is only has a transient effect (6-8 weeks) and morbidity is fairly high.

Perhaps an intercostal nerve block and if responsive, then thoracoscopic neurectomy? Although, one must wonder if the central neurotropic changes would prove this ineffective. Thoracic rhizotomy?

 

[Mister Mxyzptlk]

Since it is so tightly focused in one or two dermatomes what about placing an epidural catheter with the tip at that level on the affected side, and use highly concentrated bupivacaine?

I don't know the max concentration for bup, but suppose you gave a 5 mg bolus every 8 hours. If you could compound to 3% you would only be giving 1/2 cc/day.

You could do a feasibility trial easily enough with a percutaneous catheter.

 

[ampaphb]

Prialt --> Insurance won't approve.

Elan will often provide you with a free vial to do the intrathecal trial. If your trial is successful, the insurance company will have a much harder time denying, and even if they do initially, I have had good success appealing to the medical directors with sufficient clinical data.

 

[Tenesma]

sometimes we just have to tell the patient that they will have to live some of the pain...

i would not favor intercostal/nerve root/drg ablation as it has become more evident that prolonged nerve injury has a significant central sensitization process and you may only make the pain worse.

- maybe pulsed RF of the DRG (you may have to drill a hole to get to it though)

- or consider cordotomy with all the risks ensuing

- or refer the patient to one of those high-end CRNA pain programs (http://www.cottagehospital.org/physician/physician_detail.cfm?SpecialtyID=6&PhysicianID=6)

 

[NOSfan]

i would not favor intercostal/nerve root/drg ablation as it has become more evident that prolonged nerve injury has a significant central sensitization process and you may only make the pain worse.

Agreed. Have seen it quite often s/p resection of Occipital or Lateral Femoral Cutaneous Nerves.

- or refer the patient to one of those high-end CRNA pain programs (http://www.cottagehospital.org/physician/physician_detail.cfm?SpecialtyID=6&PhysicianID=6)

LMAO 😀

Thanks again for everyones input.

 

[lovebailey2001]

Prialt --> Insurance won't approve.

Yes, many off label indications, but, when there are only 3 FDA approved treatments (GBP, 5% lidocaine, and PGB) one is sure to try other medication classes. 😉

Already tried Cymbalta.

Dermatome --> T5/T6. Botulinum Toxin was used as this case is similar to:
Botulinum Toxin A Relieved Neuropathic Pain in a Case of Post-Herpetic Neuralgia. Hsu-Tang Liu MD et. al.
Pain Medicine 7 (1) 2006, 89–91. Note: my patient states the Botulinum Toxin worsened his pain. Although, I have used in a patient with PHN in the Trigeminal V1 distribution with good results.

Adenolysis of the pituitary --> from what I understand it most of the time there is only has a transient effect (6-8 weeks) and morbidity is fairly high.

Perhaps an intercostal nerve block and if responsive, then thoracoscopic neurectomy? Although, one must wonder if the central neurotropic changes would prove this ineffective. Thoracic rhizotomy?

Hi Nosfan! how did u use botox for V1 PHN? local infiltration or sm other method! just today I got a 85 yr old with PHN in V1 ditribution, hv put him on Lyrica and tryptomer, lets c what is the response...

 

[clubdeac]

Wanted to resurrect this thread. I got a referral today for a guy who developed presumable shingles in his RUE, C6/7 dermatomes? It was supposedly c/b cellulitis. He was treated for both, now out 6 mos and still has a swollen, erythematous, scaly, allodynic right hand with a fine tremor in his thumb and inability to move his fingers. It actually looks pretty bad. ID said all infection had resolved; dermatology presented it at their grand rounds and diagnosed it as definitive RSD; and neurology has diagnosed it as PHN with possible continued active herpes infx. They tried every TCA and AED known to man and are now referring to me for IT steroids. Would anyone consider this?? First off I wouldn't even know how to do it. Act like I'm doing a C7/T1 ESI and go a mm further into the sac? I'd be a little worried about hitting cord or as you've all said, neurotoxicity/arachnoiditis from the steroid. Although, preservative free steroid should be fine. I was thinking stellates and if no relief SCS trial. What would you guys do???? I almost want to see if the IT steroid works....

 

[lobelsteve]

Wanted to resurrect this thread. I got a referral today for a guy who developed presumable shingles in his RUE, C6/7 dermatomes? It was supposedly c/b cellulitis. He was treated for both, now out 6 mos and still has a swollen, erythematous, scaly, allodynic right hand with a fine tremor in his thumb and inability to move his fingers. It actually looks pretty bad. ID said all infection had resolved; dermatology presented it at their grand rounds and diagnosed it as definitive RSD; and neurology has diagnosed it as PHN with possible continued active herpes infx. They tried every TCA and AED known to man and are now referring to me for IT steroids. Would anyone consider this?? First off I wouldn't even know how to do it. Act like I'm doing a C7/T1 ESI and go a mm further into the sac? I'd be a little worried about hitting cord or as you've all said, neurotoxicity/arachnoiditis from the steroid. Although, preservative free steroid should be fine. I was thinking stellates and if no relief SCS trial. What would you guys do???? I almost want to see if the IT steroid works....

Skip IT, Skip CESI.

Stellate then SCS, smells like CRPS in the hand 337.21

 

[PMR 4 MSK]

Wanted to resurrect this thread. I got a referral today for a guy who developed presumable shingles in his RUE, C6/7 dermatomes? It was supposedly c/b cellulitis. He was treated for both, now out 6 mos and still has a swollen, erythematous, scaly, allodynic right hand with a fine tremor in his thumb and inability to move his fingers. It actually looks pretty bad. ID said all infection had resolved; dermatology presented it at their grand rounds and diagnosed it as definitive RSD; and neurology has diagnosed it as PHN with possible continued active herpes infx. They tried every TCA and AED known to man and are now referring to me for IT steroids. Would anyone consider this?? First off I wouldn't even know how to do it. Act like I'm doing a C7/T1 ESI and go a mm further into the sac? I'd be a little worried about hitting cord or as you've all said, neurotoxicity/arachnoiditis from the steroid. Although, preservative free steroid should be fine. I was thinking stellates and if no relief SCS trial. What would you guys do???? I almost want to see if the IT steroid works....

Neuro does spinal taps all the time, why can't they put the steroid in if that's what they want? The intrathecal space is continuous, so why put it in up there?

Why not just use oral steroids for a while (besides the obvious side effects). What I'm getting at is you are asking if you should do a procedure you've never deliberately done (wet tap in C-spine), that would be controversial at best in the acute phase, for a now chronic problem. I would decline.

Zoster does not last that long unless they are significantly immuno-compromised. If that were the case, I would not inject.

I agree with going after it as CRPS. If he fails SGB, consider referral to tertiary/academic center. If you are that center, good luck!

 

[NOSfan]

Hi Nosfan! how did u use botox for V1 PHN? local infiltration or sm other method! just today I got a 85 yr old with PHN in V1 ditribution, hv put him on Lyrica and tryptomer, lets c what is the response...

Yes local infiltration about 1 cm apart to cover the areas.
May also consider addressing the contralateral side with any remaing BTX so the will be symmetrical 🙂

 

[hyperalgesia]

Wanted to resurrect this thread. I got a referral today for a guy who developed presumable shingles in his RUE, C6/7 dermatomes? It was supposedly c/b cellulitis. He was treated for both, now out 6 mos and still has a swollen, erythematous, scaly, allodynic right hand with a fine tremor in his thumb and inability to move his fingers. It actually looks pretty bad. ID said all infection had resolved; dermatology presented it at their grand rounds and diagnosed it as definitive RSD; and neurology has diagnosed it as PHN with possible continued active herpes infx. They tried every TCA and AED known to man and are now referring to me for IT steroids. Would anyone consider this?? First off I wouldn't even know how to do it. Act like I'm doing a C7/T1 ESI and go a mm further into the sac? I'd be a little worried about hitting cord or as you've all said, neurotoxicity/arachnoiditis from the steroid. Although, preservative free steroid should be fine. I was thinking stellates and if no relief SCS trial. What would you guys do???? I almost want to see if the IT steroid works....

I would stick to our established, supported algorithms. Any deviation will have to be explained in the event of a complication. And there is no explanation for IT steroids.

 

[Ligament]

Don't do IT steroids in the c-spine for sure. If you really want IT, then just put it lumbar.

But, I agree with steve first; stellate then SCS.

 

[clubdeac]

Thanks everyone. Now I feel better about telling neurology nah on the IT steroid. Appreciate it

 

[Jcm800]

i am always amazed at what people will recommend you do, when they dont have to do it...

sometimes i get referrals for a specific procedure and i tell the patient I do not think they need THAT procedure. They invariably say "my doctor wanted you to do this" I usually tell them that I am not an injection service, and I have to be comforable doing the procedure to do it. ANd as someone who makes a living DOING THINGS, if I am telling you NOT TO DO something, maybe you should think about that..."

Wanted to resurrect this thread. I got a referral today for a guy who developed presumable shingles in his RUE, C6/7 dermatomes? It was supposedly c/b cellulitis. He was treated for both, now out 6 mos and still has a swollen, erythematous, scaly, allodynic right hand with a fine tremor in his thumb and inability to move his fingers. It actually looks pretty bad. ID said all infection had resolved; dermatology presented it at their grand rounds and diagnosed it as definitive RSD; and neurology has diagnosed it as PHN with possible continued active herpes infx. They tried every TCA and AED known to man and are now referring to me for IT steroids. Would anyone consider this?? First off I wouldn't even know how to do it. Act like I'm doing a C7/T1 ESI and go a mm further into the sac? I'd be a little worried about hitting cord or as you've all said, neurotoxicity/arachnoiditis from the steroid. Although, preservative free steroid should be fine. I was thinking stellates and if no relief SCS trial. What would you guys do???? I almost want to see if the IT steroid works....

 

[Jeff05]

Why not just try carbamazepine instead of a bunch of invasive procedures that are doomed to fail? Isn't it still the gold standard for PHN? Maybe even Lyrica.

carbamazepine is the starting drug for trigeminal neuralgia, not PHN. based on his failure of listed meds, lyrica has a low probability of success.

peripheral nerve stimulation has been reported, as well.
http://www.pain.com/go/default/prac...poster-sessions/peripheral-nerve-stimulation/
and click on "download related file"

also, trial of ITP. place thoracic epidural and make sure to trial with local.

after 3 years of pain however, there may also be a central component.

as far as procedures being doomed to fail - that all depends on appropriate patient selection (diagnosis), experience of practitioner, and patient-specific physiology/psychology. When all are optimized, our procedures are no more doomed to fail than any other intervention in medicine.

allowing this patient to live out his last several years without excruciating pain (it's well documented that people have committed suicide secondary to pain from PHN) is what makes this profession worth it (heavily balanced on the other side by 35 year females/males on disability on chronic opioids with spreading CRPS without any objective signs)

 

[Doctodd]

anybody try Qutenza yet?.....i think i remember a thread about it. And i agree with a definitie no to IT steroids.

 

[jpb26]

I just tried Qutenza for the first time on Friday. Seemed to go well, the Pt didnt have any pain at all with the patch on and I didnt get any calls over the weekend from him. Hes coming back next week to let me know if it helped. Ill post something then.

 

[clubdeac]

Hey sorry for the dumb question but if you don't get a horner's during a stellate block does that mean you didn't get a good block?

 

[lobelsteve]

Hey sorry for the dumb question but if you don't get a horner's during a stellate block does that mean you didn't get a good block?

Depends who you read.

Horner's does not mean you successfully blocked the sympathetic fibers to the arm, only to the head. SO if the problem is CRPS, you lose. Stellate is fused lower and middle, and a lot of times the injectate can block the superior cervical ganglion producing Horner's but having no arm findings: engorged veins, possibly warmth, probably pain relief.

For your board's- yes, for real life- doesn't matter.

 

[Mister Mxyzptlk]

Hey sorry for the dumb question but if you don't get a horner's during a stellate block does that mean you didn't get a good block?

There are no "dumb questions". There are only dumb people who ask questions. 😀

The superior cervical ganglion is formed from postganglionic fibers that synapse with T1-T4 preganglionic sympathetic fibers. So if you hit the T1 region you should get a Horner's. If you don't get a Horner's you should seriously consider a technically failed block.

As mentioned, you can definitely get a good Horner's w/o getting a good stellate block. That's because you can block too cephalad, catch the superior ganglion to the head but not the lower two ganglia to the arm.

 

[clubdeac]

Sooooo..... I'm getting two different answers. No horners = technically failed block and no horners = depends on whether you want face or arm.

 

[sweetalkr]

I completely misused the terms specificity and sensitivity.. just ignore this post 🙂

 

[clubdeac]

I completely misused the terms specificity and sensitivity.. just ignore this post 🙂

what are you talking about? Get off my thread sweets! hehe 😀