V1 PHN

[TIVAndy]

80 something yr old lady with left V1 phn. she failed all neuropathic agents you can think of. also failed capsaicin.
i recently did supratrochlear and supraorbital block and got 100% relief for few days and still doing better but obviously block not lasting long.

what do u guys do next? RF? pulsed RF? peripheral stim?
any thoughts/experience appreciated

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[willabeast]

lidoderm patch? SQ infiltration with botox or lidocaine or steroid? tens unit? Probably the best intervention IMHO would be to tell the patient the problem will go away or be much less in a year with no intervention. Hope can be very powerful and ignorance even more powerful in these situations.

 

[Ducttape]

I struggle with the 2 sides.


in this case, what is the likelihood that PHN pain will resolve in an 80 year old? imo, not good...


is it better to give patients hope that things will get better with a procedure or even just by itself, or is it better to be brutally honest and tell them that there is a reason that their pain is chronic, while some things may help, its time to understand chronic pain and learn to manage it and the consequences?

 

[willabeast]

I struggle with the 2 sides.


in this case, what is the likelihood that PHN pain will resolve in an 80 year old? imo, not good...


is it better to give patients hope that things will get better with a procedure or even just by itself, or is it better to be brutally honest and tell them that there is a reason that their pain is chronic, while some things may help, its time to understand chronic pain and learn to manage it and the consequences?

//
Natural history of herpes zoster: late follow-up of 3.9 years (n=43) and 7.7 years (n=10).
Reda H1, Greene K, Rice FL, Rowbotham MC, Petersen KL.
Author information
1Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA.
Abstract
Postherpetic neuralgia (PHN) is a common complication after herpes zoster (HZ). Subjects who completed a longitudinal observational 6-month study (4 visits) of the natural history of HZ were recontacted for 2 additional follow-up visits that included pain and sensory symptom assessment, quantitative sensory testing, capsaicin response test, and 3-mm punch skin biopsies in HZ-affected, mirror-image, and control skin sites. Forty-three subjects (14 with PHN at 6 months) of the original 94 subjects in the cohort were comprehensively assessed at a median 3.9 years after HZ onset (visit 5), and 10 subjects underwent a final assessment at a median 7.7 years after HZ onset (visit 6). At 3.9 years, none of the 29 subjects who had been pain free at 6 months had a recurrence of pain. Only 2 of the 14 subjects with PHN at 6 months still had pain at 3.9 years. One subject with PHN at 6 months was free of symptoms at 3.9 years but had very mild pain at 7.7 years. Sensory function continued on a path toward normalization, but was still abnormal in many subjects, especially those who met criteria for PHN at 6 months. Even at 7.7 years, reinnervation of HZ-affected skin was not apparent.
Copyright © 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
KEYWORDS:
Capsaicin response test; Chronic pain; Postherpetic neuralgia; Quantitative sensory testing; Thermal
Comment in

• Natural course of herpes zoster: resolution of pain in spite of poor recovery of nerve fibers. [Pain. 2013]//

 

[soccrwz]

Could try stellate ganglion nerve block, I've heard of success with this for V1 PHN. Baclofen has neuropathic components could try a topical or oral. Data for PHN gabapentin and TCA combination working synergistically, so worth a retrial

 

[Timeoutofmind]

I have had good results with gasserian block

 

[clubdeac]

Just finished studying for boards. 50% of PHN gone by 1 year and this increases the farther out you get. I've tried supra-orbital RFA, frontalis botox injections, SGB and SPB for this all with varying degrees of success. All are pretty low risk with the exception of RF which is still low risk. It's fairly superficial though so you could get tissue necrosis

 

[Orin]

If you're looking at a V1 issue, I would agree with a trial of a supraorbital/supratrochlear stimulator if she is savvy enough to use that.

The other thing I remind patients/providers of is that the virus may still be activating at a low level intermittently without the rash showing up. Oral antivirals are generally well tolerated and a 2 - 3 month course of them to assess efficacy is not unreasonable.

I realize the data for sympathetic blocks for PHN are weak, but does anyone do a cervical plexus block here?

 

[TIVAndy]

sorry for the late reply. she had PHN for more than 3 years. as i have mentioned failed most neuropathic agents you can think of - lidoderm, capsaicin, gaba, lyrica, cymbalta, triptylines, tegretol.. you name it. i gave up finding one she hasn't tried. complaining of severe (VAS >7) pain all the time.
the only thing that worked so far is the supraorbital and supratrochlear nerve block - albert short lived. don't know the data regarding doing stellate for this pain. if someone can enlighten me that would be great. anyways.. i wish pulsed RF would work.. a bit nervous about RFing the nerve due to superficial course of the nerve.. don't want to burn her skin/face...

 

[Ducttape]

you could pulse the nerve for 2 min, then do a 5 second thermal RFA of at least 60 degrees...

as far as SGB for atypical facial pain or trigeminal neuralgia - case reports out there.

Utility of stellate ganglion block in atypical facial pain: a case report and consideration of its possible mechanisms - PubMed

We present this report of a young patient with chronic severe atypical facial pain who was successfully controlled with stellate ganglion block under ultrasound guidance. The patient had a history of severe disabling, unilateral, facial neuropathic pain with minimal response to analgesic...

www.ncbi.nlm.nih.gov

Pain relief by stellate ganglion block in a case with trigeminal neuralgia caused by a cerebellopontine angle tumor - PubMed

A 29-year-old woman with symptoms suggestive of trigeminal neuralgia is presented. Because of her age, an intracranial tumor was suspected, but images of a brain computerized tomography scan revealed nothing in particular. A magnetic resonance imaging was scheduled 2 weeks later. However, as the...

www.ncbi.nlm.nih.gov

thoracic epidurals = SGB. the assumption is that SGB work for facial PHN.

High thoracic epidural block relieves acute herpetic pain involving the trigeminal and cervical regions: comparison with effects of stellate ganglion block - PubMed

High thoracic epidural block was as effective as stellate ganglion block in relieving moderate-to-severe AHP involving the trigeminal and cervical regions.

www.ncbi.nlm.nih.gov

interesting study on early use of SGB for facial acute PHN:

Effect of early stellate ganglion blockade for facial pain from acute herpes zoster and incidence of postherpetic neuralgia - PubMed

Early stellate ganglion blockade, in combination with an antiviral agent, is a very effective treatment modality; it dramatically decreases the intensity of acute pain and shortens its duration and reduces the incidence of postherpetic neuralgia.

www.ncbi.nlm.nih.gov

Pulsing of SGB....

CT-Guided Stellate Ganglion Pulsed Radiofrequency Stimulation for Facial and Upper Limb Postherpetic Neuralgia - PubMed

<span><b>Objective:</b> Postherpetic neuralgia (PHN) is the most common complication of herpes zoster, manifesting as a persistent, spontaneous, knife-like pain or paroxysmal burning that seriously affects a patient's quality of life. An effective treatment of PHN is lacking. This retrospective...

www.ncbi.nlm.nih.gov

 

[lobelsteve]

Go deep.

Frontiers | Efficacy of CT Guided Pulsed Radiofrequency Treatment for Trigeminal Postherpetic Neuralgia

ObjectivesTrigeminal postherpetic neuralgia (TPHN) often presents with moderate to severe pain, hyperalgesia, and allodynia. Conventional analgesic treatment...

www.frontiersin.org

POSTHERPETIC TRIGEMINAL NEURALGIA (fun article from Max Peet 1929)

Neurosurgeons’ Armamentarium for the Management of Refractory Postherpetic Neuralgia: A Systematic Literature Review

Background/Aims: Postherpetic neuralgia (PHN) can be refractory to both medical and minimally invasive treatments. Its complex pathophysiology explains the numerous neurosurgical procedures that have been implemented through the years. Our objective was to summarize all available neurosurgical...

www.karger.com

 

[TIVAndy]

Go deep.

Frontiers | Efficacy of CT Guided Pulsed Radiofrequency Treatment for Trigeminal Postherpetic Neuralgia

ObjectivesTrigeminal postherpetic neuralgia (TPHN) often presents with moderate to severe pain, hyperalgesia, and allodynia. Conventional analgesic treatment...

www.frontiersin.org

POSTHERPETIC TRIGEMINAL NEURALGIA (fun article from Max Peet 1929)

Neurosurgeons’ Armamentarium for the Management of Refractory Postherpetic Neuralgia: A Systematic Literature Review

Background/Aims: Postherpetic neuralgia (PHN) can be refractory to both medical and minimally invasive treatments. Its complex pathophysiology explains the numerous neurosurgical procedures that have been implemented through the years. Our objective was to summarize all available neurosurgical...

www.karger.com

thanks for the info. unfortunately i've never done a gasserian block/access. i'm usually not afraid of trying something new but gasserian is one injection i would like someone to teach me properly

 

[TIVAndy]

you could pulse the nerve for 2 min, then do a 5 second thermal RFA of at least 60 degrees...

as far as SGB for atypical facial pain or trigeminal neuralgia - case reports out there.

Utility of stellate ganglion block in atypical facial pain: a case report and consideration of its possible mechanisms - PubMed

We present this report of a young patient with chronic severe atypical facial pain who was successfully controlled with stellate ganglion block under ultrasound guidance. The patient had a history of severe disabling, unilateral, facial neuropathic pain with minimal response to analgesic...

www.ncbi.nlm.nih.gov

Pain relief by stellate ganglion block in a case with trigeminal neuralgia caused by a cerebellopontine angle tumor - PubMed

A 29-year-old woman with symptoms suggestive of trigeminal neuralgia is presented. Because of her age, an intracranial tumor was suspected, but images of a brain computerized tomography scan revealed nothing in particular. A magnetic resonance imaging was scheduled 2 weeks later. However, as the...

www.ncbi.nlm.nih.gov

thoracic epidurals = SGB. the assumption is that SGB work for facial PHN.

High thoracic epidural block relieves acute herpetic pain involving the trigeminal and cervical regions: comparison with effects of stellate ganglion block - PubMed

High thoracic epidural block was as effective as stellate ganglion block in relieving moderate-to-severe AHP involving the trigeminal and cervical regions.

www.ncbi.nlm.nih.gov

interesting study on early use of SGB for facial acute PHN:

Effect of early stellate ganglion blockade for facial pain from acute herpes zoster and incidence of postherpetic neuralgia - PubMed

Early stellate ganglion blockade, in combination with an antiviral agent, is a very effective treatment modality; it dramatically decreases the intensity of acute pain and shortens its duration and reduces the incidence of postherpetic neuralgia.

www.ncbi.nlm.nih.gov

Pulsing of SGB....

CT-Guided Stellate Ganglion Pulsed Radiofrequency Stimulation for Facial and Upper Limb Postherpetic Neuralgia - PubMed

<span><b>Objective:</b> Postherpetic neuralgia (PHN) is the most common complication of herpes zoster, manifesting as a persistent, spontaneous, knife-like pain or paroxysmal burning that seriously affects a patient's quality of life. An effective treatment of PHN is lacking. This retrospective...

www.ncbi.nlm.nih.gov

i think perhaps i'll try this trick to bill for RF.. pt not interested in cash pay for pRF

 

[PainMD23]

Trigeminal block-- send her to someone who does it. If helpful, follow up with pulsed RF.

 

[Bsb2015]

Could try stellate ganglion nerve block, I've heard of success with this for V1 PHN. Baclofen has neuropathic components could try a topical or oral. Data for PHN gabapentin and TCA combination working synergistically, so worth a retrial

Have you found your elderly patients are tolerating TCA?


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[soccrwz]

Yes, I'm stopping at 50mg usually, and notriptyline less sedating than elavil, less SE profile. Not doing in afib, arrythymia patients. These PHN patients are suffering so its a trade off

 

[deleted993114]

80 something yr old lady with left V1 phn. she failed all neuropathic agents you can think of. also failed capsaicin.
i recently did supratrochlear and supraorbital block and got 100% relief for few days and still doing better but obviously block not lasting long.

what do u guys do next? RF? pulsed RF? peripheral stim?
any thoughts/experience appreciated

Cryo of the supra-orbital- fast and easy. Just watch for blanching of the skin, as there is not as much soft tissue available as other areas.

 

[painfree23]

Cryo of the supra-orbital- fast and easy. Just watch for blanching of the skin, as there is not as much soft tissue available as other areas.

Do you mind sharing fluoro pics or your procedure note ?

 

[deleted993114]

Do you mind sharing fluoro pics or your procedure note ?

I just started at a new practice (getting back to the Midwest for my last few years) and don't have pics. It's pretty darn simple- just identify the supra-orbital notch and go. If you are not sure, you can used the stimulating feature with an rf machine and needle to mark the nerve. The potential for thermal injury is present, as there is generally not much soft tissue there. The hand held "iovera" cryo gizmo has a small heating element at the skin surface to reduce (not prevent) thermal injury. With a conventional probe, put your finger on the adjacent tissue to warm it and stop if things start to blanche. Never had skin ulceration with it, but it could happen if you got careless.

I had several V1 TIC patients I would do this on about every 9-12 months and it worked pretty well for them.

With a V1 TIC, keep in mind that 10% have MS.