Skip to main content
Download PDF

Relief of pain in acute herpes zoster by nerve blocks and possible prevention of post-herpetic neuralgia

Le soulagement de la douleur de l’herpès zoster aigu et la prévention possible de la névralgie post-herpétique par des blocages nerveux

Canadian Journal of Anesthesia volume 52, pages 186–190 (2005)Cite this article

Abstract

Purpose

This report describes two cases of acute herpes zoster (AHZ) treated by nerve block resulting in immediate pain relief and possible prevention of post-herpetic neuralgia (PHN).

Clinical features

Two elderly females with AHZ of cervical dermatomes and severe pain received deep cervical and greater occipital nerve blocks with a local anesthetic, epinephrine and steroid. In both patients, pain resolved immediately and permanently (one year follow-up) after a single treatment.

Case # 1

A 79-yr-old female with a mechanical mitral valve and anticoagulated with warfarin presented with AHZ of 17 days duration of the right C2, 3, 4 dermatomes and severe pain. A stellate ganglion block was not performed because of anticoagulation. Rather, a deep cervical root block at C3 and a greater occipital nerve block were performed with bupivacaine, epinephrine and methylprednisolone. No adverse events were evident. Case #2: A 73-yr-old female with a history of osteoarthritis and Meniere’s disease presented with AHZ of seven days duration of the left C2, 3, 4 dermatomes and severe pain. Deep cervical root blocks at C3 and C4 and a greater occipital nerve block were performed with bupivacaine, epinephrine and methylprednisolone. Side effects of dizziness, hoarseness, hypertension and Horner’s syndrome resolved in a few hours. A mild sensation of itching persisted for two weeks.

Conclusion

This report illustrates the potential of nerve blocks in severe AHZ to treat acute pain and possibly prevent PHN.

Résumé

Objectif

Décrire deux cas d’herpès zoster aigu (HZA) traités par blocage nerveux résultant en un soulagement immédiat de la douleur et une prévention possible de la névralgie post-herpétique (NPH).

Éléments cliniques

Deux femmes âgées souffrant d’HZA des dermatomes cervicaux et de douleurs sévères ont reçu un bloc des nerfs cervical profond et grand occipital avec un anesthésique local, de l’épinéphrine et des stéroïdes. Dans les deux cas, la douleur a été soulagée de façon immédiate et permanente comme l’a montré le suivi d’un an.

Cas no 1

Une femme de 79 ans, porteuse d’une valvule mitrale mécanique, anticoagulée avec de la warfarine, souffrait depuis 17 jours d’un HZA au niveau des dermatomes droits C2, 3, 4 et de sévères douleurs. L’anticoagulation ne permettant pas de bloc du ganglion stellaire, on a plutôt opté pour un bloc de la racine cervicale profonde à C3 et un bloc du grand nerf occipital avec de la bupivacaïne, de l’épinéphrine et de la méthylprednisolone. Aucune évidence d’événement indésirable n’a été notée. Cas no 2: Une femme de 73 ans aux antécédents d’ostéoarthrite et de maladie de Ménière, a consulté pour un HZA installé depuis sept jours aux dermatomes gauches C2, 3, 4 et pour de sévères douleurs. Des blocs de la racine cervicale profonde à C3 et C4 et un bloc du grand nerf occipital ont été réalisés avec de la bupivacaïne, de l’épinéphrine et de la méthylprednisolone. Les effets secondaires, étourdissement, enrouement de la voix, hypertension et syndrome de Claude Bernard-Horner, se sont résorbés en quelques heures. Une légère sensation de prurit a persisté pendant deux semaines.

Conclusion

Cet article illustre le potentiel des blocages nerveux dans des cas d’HZA sévère pour traiter la douleur aiguë et possiblement prévenir la NPH.

References

  1. Rowbotham MC, Petersen KL. Zoster-associated pain and neural dysfunction. Pain 2001; 93: 1–5.

    PubMed  Article  CAS  Google Scholar 

  2. Bhala BB, Ramamoorthy C, Bowsher D, Yelnoorker KN. Shingles and postherpetic neuralgia. Clin J Pain 1988; 4: 169–74.

    Article  Google Scholar 

  3. Johnson RW. Consequences and management of pain in herpes zoster. J Infect Dis 2002; 186(Suppl 1): S83–90.

    PubMed  Article  Google Scholar 

  4. Winnie AP, Hartwell PW. Relationship between time of treatment of acute herpes zoster with sympathetic blockade and prevention of post-herpetic neuralgia: clinical support for a new theory of the mechanism by which sympathetic blockade provides therapeutic benefit. Reg Anesth 1993; 18: 277–82.

    PubMed  CAS  Google Scholar 

  5. Murphy TM. Somatic blockade of the head and neck.in:Cousins MJ, Bridenbaugh PO (Eds). Neural Blockade in Clinical Anesthesia and Management of Pain, 3rd ed. Philadelphia: Lippincott-Raven; 1998: 508–9.

    Google Scholar 

  6. Rosenak S. Procaine injection treatment of herpes zoster. Lancet 1938; 1056–8.

  7. Colding A. The effect of regional sympathetic blocks in the treatment of herpes zoster. A survey of 300 cases. Acta Anaesthesiol Scand 1969; 13: 133–41.

    Article  Google Scholar 

  8. Tenicela R, Lovaski D, Eaglstein W. Treatment of herpes zoster with sympathetic nerve blocks. Clin J Pain1985; 1: 63–7.

    Google Scholar 

  9. Pasqualucci A, Pasqualucci V, Galla F, et al. Prevention of post-herpetic neuralgia: acyclovir and prednisolone versus epidural local anesthetic and methylprednisolone. Acta Anaesthesiol Scand 2000; 44: 910–8.

    PubMed  Article  CAS  Google Scholar 

  10. Wu CL, Marsh A, Dworkin RH. The role of sympathetic nerve blocks in herpes zoster and postherpetic neuralgia. Pain 2000; 87: 121–9.

    PubMed  Article  CAS  Google Scholar 

  11. Kotani N, Kushikata T, Hashimoto H, et al. Intrathecal methylprednisolone for intractable postherpetic neuralgia.N Engl J Med 2000; 343: 1514–9.

    PubMed  Article  CAS  Google Scholar 

  12. Forrest JB. The response to epidural steroid injections in chronic dorsal root pain. Can Anaesth Soc J 1980; 27: 40–6.

    PubMed  Article  CAS  Google Scholar 

  13. de Moragas JM, Kierland RR. The outcome of patients with herpes zoster. Arch Dermatol 1957; 75: 193–6.

    Google Scholar 

  14. Dworkin RH, Nagasako EM, Johnson RW, Griffin DR. Acute pain in herpes zoster: the famciclovir database project. Pain 2001; 94:113–9.

    PubMed  Article  CAS  Google Scholar 

  15. Tyring S, Barbarash RA, Nahlik JE, et al. Famciclovir for the treatment of acute herpes zoster: effects on acute disease and postherpetic neuralgia. A randomized, double-blind, placebo-controlled trial. Collaborative Famciclovir Herpes Zoster Study Group.Ann Intern Med 1995; 123: 89–96.

    PubMed  CAS  Google Scholar 

  16. Dworkin RH, Schmader KE. Treatment and prevention of postherpetic neuralgia. Clin Infect Dis 2003; 36: 877–82.

    PubMed  Article  Google Scholar 

  17. Rowbotham M, Harden N, Stacey B, Bernstein P, Magnus-Miller L; Gabapentin Postherpetic Neuralgia Study Group. Gabapentin for the treatment of postherpetic neuralgia: a randomized controlled trial. JAMA1998; 280: 1837–42.

    CAS  Google Scholar 

  18. Filadora VA, Sist TC, Lema MJ. Acute herpetic neuralgia and postherpetic neuralgia in the head and neck: response to gabapentin in five cases. Reg Anesth Pain Med 1999; 24: 170–4.

    PubMed  Article  CAS  Google Scholar 

  19. Bowsher D. The effects of pre-emptive treatment of postherpetic neuralgia with amitriptyline: a randomized, double-blind, placebo-controlled trial. J Pain Symptom Manage 1997; 13: 327–31.

    PubMed  Article  CAS  Google Scholar 

  20. Campbell BJ, Rowbotham M, Davies PS, Jacob P III, Benowitz NL. Systemic absorption of topical lidocaine in normal volunteers, patients with post-herpetic neuralgia, and patients with acute herpes zoster. J Pharm Sci 2002; 91: 1343–50.

    PubMed  Article  CAS  Google Scholar 

  21. Stow PJ, Glynn CJ, Minor B. EMLA cream in the treatment of post-herpetic neuralgia. Efficacy and pharmacokinetic profile. Pain 1989; 39: 301–5.

    PubMed  Article  CAS  Google Scholar 

  22. Watson CP, Babul N. Efficacy of oxycodone in neuropathic pain. A randomized trial in postherpetic neuralgia. Neurology 1998; 50: 1837–41.

    PubMed  CAS  Google Scholar 

  23. Woolf CJ. Recent advances in the pathophysiology of acute pain. Br J Anaesth 1989; 63: 139–46.

    Article  Google Scholar 

  24. Johansson A, Bennett GJ. Effect of local methylprednisolone on pain in a nerve injury model. A pilot study. Reg Anesth 1997; 22: 59–65.

    Article  Google Scholar 

  25. Stoneham MD, Knighton JD. Regional anaesthesia for carotid endarterectomy. Br J Anaesth 1999; 82: 910–9.

    PubMed  CAS  Google Scholar 

  26. Johnson RW.Prevention of post-herpetic neuralgia: can it be achieved? Acta Anaesthesiol Scand 2000; 44: 903–5.

    PubMed  Article  CAS  Google Scholar 

Download references

Author information

Affiliations

  1. Department of Anesthesiology, The Ottawa Hospital-Civic Campus, 1053 Carling Avenue, K1Y4E9, Ottawa, Ontario, Canada

    Douglas Hardy

Authors
  1. Douglas Hardy
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Douglas Hardy.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Hardy, D. Relief of pain in acute herpes zoster by nerve blocks and possible prevention of post-herpetic neuralgia. Can J Anaesth 52, 186–190 (2005). https://doi.org/10.1007/BF03027727

Download citation

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF03027727

Keywords

  • Bupivacaine
  • Herpes Zoster
  • Nerve Block
  • Postherpetic Neuralgia
  • Famciclovir