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Palm Beach Spine Pain Institute neuralgia

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					MEDICATIONS                                                          CONCLUSION
Tricyclic antidepressants and phenothiazine tranquilizers are        Post-herpetic neuralgia is a severe syndrome that affects
widely used substances in the therapy of severe pain due to          primarily the elderly and some debilitated patients.
acute Herpes zoster as well as Post-herpetic neuralgia.              The best treatment for this problem is early and aggressive

Neurontin and Lyrica may provide substantial benefit in pain         treatment of the acute Herpes zoster infection with

reduction. Early initiation of treatment is recommended, as          antiviral medications and nerve blocks. If Post-herpetic

this class of drugs may block sensitization of cells in the spinal   neuralgia does occur, an integrated, interdisciplinary        Innovative Solutions to Pain Medicine
cord to the intense pain of Shingles and PHN.                        treatment regimen should be employed utilizing medical
                                                                                                                                   In This Issue:     Nerve Blocks  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 2       Treatment Of PHN  .  .  .  .  .  .  .  .  .  .  .  .  .  . 3
                                                                     therapy, nerve blocks, psychological and rehabilitative                          Post-Herpetic Neuralgia  .  .  .  .  .  .  .  .  .  .  .  . 3        Medications  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4
Other adjunctive medications may provide significant
                                                                     modalities concurrently, to provide decreased pain and
benefit to the patient and careful controlled trials
should be attempted.
                                                                     maximal patient support during the illness.                   Introduction                                                                    SHINGLES AND
                                                                                                                                   Evidence-based medical approaches to pain treatments offer the                  POST-HERPETIC NEURALGIA
PSYCHOLOGICAL                                                                                                                      best opportunity and hope for finally relieving society’s most                  Shingles or Herpes zoster infection and Post-herpetic neuralgia are
                                                                                                                                   debilitating pain problems. Interventional injections by Board
As with any chronic pain syndrome, psychological and                                                                                                                                                               common syndromes seen by physicians everyday in the United
                                                                                                                                   Certified Medical Doctors offer new hope in specifically
emotional support is an important aspect in the treatment                                                                                                                                                          States. It is estimated that over 300,000 Americans are affected by
                                                                                                                                   identifying the source of pain and in eliminating that pain
of Post-herpetic neuralgia. Suicidal thoughts may occur,                                                                                                                                                           these syndromes each year. Nerve Blocks and antiviral medications
                                                                                                                                   utilizing new minimally invasive procedures. The interventional
especially if the patient does not have a solid support system                                                                                                                                                     have significantly enhanced the treatment and management of these
                                                                                                                                   pain procedures are performed in several steps, none of which
in place. Counseling, stress management and relaxation                                                                                                                                                             incapacitating and painful afflictions. Combined, these new
                                                                                                                                   require hospitalization. Each source of pain is identified and
can reduce anxiety and help the patient cope with the pain                                                                                                                                                         treatments have radically reduced the time and severity of Shingles.
                                                                                                                                   treated. These treatments utilize new technologies which allow
and lifestyle alteration. Behavior modification can further                                                                        the physician specialist to visualize the offending structures                  Nerve blocks, in fact, have dramatically reduced the incidence

prevent the establishment of chronic pain behavior states                                                                          with fluoroscopy or fiber optic imaging. These highly specific                  of Post-herpetic neuralgia.

and allow the patient to adapt and cope with the PHN pain.                                                                         procedures, coupled with evidence-based outcome studies,
                                                                                                                                   have allowed physicians to treat and relieve pain with a                        ACUTE HERPES ZOSTER
                                                                                                                                   greater degree of success.                                                      The virus responsible for Shingles is the herpes virus varicellae,
                                                                                                                                                                                                                   or commonly called varicella-zoster virus. The primary infection
                                                                                                                                                                                                                   in non-immune individuals is chickenpox. Herpes zoster is a
                                                                                                                                                                                                                   viral infection resulting from reactivation of the dormant varicella-
                                                                                                                                                                                                                   zoster virus. These dormant viruses reside in the dorsal root
                                                                                                                                                                                                                   ganglia next to the spinal cord. Reactivation of the virus is due
                                                                                                                                                                                                                   to a fall in host cell-mediated immunity, which may be due to
                                                                                                                                                                                                                   trauma, infection, chronic illness, acquired immunodeficiency
                                                                                                                                       Lawrence Gorfine, M .D .                Douglas MacLear, D .O .             syndrome (AIDS), malignancy, radiation therapy, chemotherapy,
                                                                                                                                                                                                                   or immunosuppressant therapy. Frequently, however, there is
                                                                                                            www.helpain.com                                                                                        no identifiable explanation for the reactivation.
                                                                                                            (561) 649-8770                                                                                         Herpes zoster is uncommon in the young, but much more common
                                                                                                                                                                                                                   in the elderly. Over the age of 65 years, the incidence is said to be
                                                                                              Lake Worth, Florida 33461                                                                                            in the range of .05-1%. There is a natural and gradual decrease in
                                                                                              4801 South Congress Avenue                                                                                           cellular mediated immunity as a person ages. This decrease in
                                                                                                                                     Innovative Solutions to Pain Medicine
                                                                              Innovative Solutions to Pain Medicine                  4801 South Congress Avenue, Suite 201                                         immunity explains the increased incidence of Shingles with age,
                                                                                                                                     Lake Worth, Florida 33461                                                     allowing greater potential for virus reactivation. Although rare,
                                                                                                                                     (561) 649-8770                                                                persons who have never had chickenpox may develop Herpes
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  West Palm Beach, FL                                                                                                                www.helpain.com | help@helpain.com                                            zoster solely from exposure to a patient with chickenpox.
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       Presorted
    TREATMENT                                                           Significant reduction in its incidence and pain level was                                                                                however, can be further characterized into two discrete elements.
                                                                        noted in several other studies all involving epidural steroid                                                                            The first is a continual aching and burning pain. This is
    Nerve blocks along with antiviral medication have been
                                                                        and local anesthetic injection.                                                                                                          hyperpathia and dysethesia. It is characterized by pain initiated
    shown to be superior in the treatment of Shingles and for
                                                                                                                                                                                                                 by light touch. The second quality of the pain is a feeling of
    the prevention of Post-Herpetic Neuralgia. Analgesics may           Much attention has been directed toward sympathetic blocks as
                                                                                                                                                                                                                 constricting tightness along the affected area. The baseline
    range from aspirin, to acetominaphen, to mild narcotic              an effective method in the treatment of acute Herpes zoster.
                                                                                                                                                                                                                 pain is frequently accompanied by episodic lancinating
    medications. Severe pain may require stronger pain medication       Although the exact pathophysiology of pain in Herpes zoster and
                                                                                                                                                                                                                 electrical pains, also shooting out in a radicular pattern
    and should serve as a warning to the clinician that there is a      Post-herpetic neuralgia remains unknown, the role of the
                                                                                                                                                                                                                 along the affected dermatome. Commonly, the pains are
    significant potential for the development of Post-Herpetic          sympathetic nervous system is receiving more attention. The
                                                                                                                                                                                                                 worse in the evenings and at night.
    Neuralgia. Aggressive treatment with nerve blocks to                earliest evidence of sympathetic blockade efficacy was noted in
    decrease the incidence of Post-herpetic neuralgia should be         the 1930’s when patients suffering from Herpes zoster and                                                                                Alterations in mood, sleep, appetite, personality, activity levels

    considered in addition to analgesics and antiviral agents.          Complex Regional Pain Syndrome (Reflex Sympathetic                                                                                       and social interactions are common. Patients are frequently
                                                                        Dystrophy) were administered sympathetic blocks for the relief                                                                           visibly depressed and desperate for even brief relief of their
                                                                        of their pain. It was noted that the Herpes zoster eruptions in                                                                          pain. They may exhibit significant weight loss, fatigue,
                                                                        those patients dried and crusted within 2-3 days and their pain                                                                          depression and poor personal hygiene.
                                                                        was immediately relieved. When these blocks were performed
                                                                        within the first 3 weeks after the eruptions were noted, there       shedding, accelerates the time to crusting, reduces new lesion      TREATMENT OF PHN
                                                                        was a rapid resolution of the acute illness and a decreased          formation and decreases the intensity and duration of pain.         Treatment of Post-herpetic neuralgia is best accomplished by
                                                                        incidence of post-herpetic neuralgia. Many more recent               Side effects are relatively uncommon.                               early and aggressive treatment of acute Herpes zoster or Shingles
                                                                        studies have confirmed these findings.                                                                                                   infection. Early shortening of the acute viral phase, combined
                                                                        Trigeminal and Ophthalmic herpes zoster appear to be
                                                                                                                                             POST-HERPETIC NEURALGIA (PHN)                                       with adequate pain relief, may act to minimize the potential for
                                                                        especially amenable to treatment with sympathetic blocks.            FOLLOWING THE ACUTE PHASE                                           Post-herpetic neuralgia. This is best accomplished with antiviral
                                                                        Ipsilateral bupivicaine 0.25% stellate ganglion blocks within        OF HERPES ZOSTER                                                    agents and nerve blocks.
                                                                        the first 3 weeks have been extremely successful in immediately      Severe pain during the acute Shingles eruptions and the
                                                                        stopping the pain and causing vesicular lesions to crust within      continuation of pain following resolution of the crusting stage     NERVE BLOCKS IN PHN
                                                                        48 hours. Early use of stellate ganglion blocks should be            of Zoster usually mark the onset of post-herpetic neuralgia.        Because of the pathological changes in the dorsal columns,
                                                                        considered in all patients with nasocilliary ganglion involvement    There is evidence that the greater the severity of acute pain,      peripheral nerves and dorsal root ganglia, much attention
                                                                        in an attempt to prevent ocular involvement and subsequent
    NERVE BLOCKS                                                                                                                             the greater the likelihood of developing Post-herpetic neuralgia.   has been given to the role of epidural blocks in the pain
                                                                        visual loss.                                                         The most common definition of this syndrome requires pain           management of PHN. In a well controlled study, Forrest
    Nerve blocks have been used extensively in the treatment of
                                                                        In the thoracic and lumbar areas, Shingles has been most             persistence for 4-8 weeks following resolution of the acute         obtained progressive relief of pain using a series of weekly
    pain in Herpes zoster. Numerous attempts have been made to
                                                                        effectively treated with epidural steroid injections. The            stage of Herpes zoster.                                             epidural injections over 3 weeks using Bupivicaine 0.5% with
    treat Herpes zoster and prevent Post-herpetic neuralgia using all
                                                                        epidural injections provide a sympathetic as well as a somatic       The incidence of Post-herpetic neuralgia (PHN) is 18-35%            methyl-prednisone 80-120mg. Eighty-six percent of the patients
    forms of somatic and sympathetic blocks. Because the acute
                                                                        block and the injections deposit the medication at the level of      of all Herpes zoster patients. Age, however, is a major factor in   in his study were still pain free at 6 and 12 month intervals.
    inflammation is primarily located in the nerve roots, much
                                                                        the dorsal root ganglia. The steroid at this level may in addition   the development and duration of PHN. Herpes zoster is more          Epidural steroid injections should be performed as
    work has been directed toward blocks in the nerve root area.
                                                                        have an anti-inflammatory affect upon the spinal cord and            common in the elderly and their pain is usually more intense        early as possible and in a series to maximize the
    The epidural route has been utilized with much success in
                                                                        dorsal root ganglia.                                                 with longer duration. The elderly are also more likely to develop   potential benefits.
    relieving the acute pain and shortening the duration of the
    infection. Perkins and Hanlin achieved excellent relief in                                                                               Post-herpetic neuralgia. In patients age 60 and above, as many as   Additionally, recent evidence indicating a sympathetic
    patients with Herpes zoster of less than 7 weeks’ duration          ANTIVIRAL DRUGS                                                      50% may develop PHN. Post-herpetic neuralgia is also more           component to Post-herpetic neuralgia, has created an interest
    using epidural blocks. Pain was relieved, lesions dried up          The antiviral agents in Herpes zoster appear to be effective in      common following Herpes zoster ophthalmicus and following           in sympathetic blocks for these patients. However, sympathetic
    rapidly, and no development of Post-herpetic neuralgia              reducing the severity and length of the Shingles manifestation.      Herpes zoster in patients with diabetes mellitus.                   blocks seem to be most effective in patients with the duration of
    was noted. Fothergill et al. reported 113 patients, aged 14-93,     ACYCLOVIR (Zovirax) is given at a dose of 800mg five times a         The baseline pain of Post-herpetic neuralgia is usually             PHN of less than 2 months. Sympathetic blocks performed
    who underwent epidural injections: immediate permanent              day for 7 to 10 days, FAMCICLOVIR (Famvir) 500mg three               described as a continuous, aching or burning pain, often            within the first 3-6 months of the syndrome’s onset greatly
    pain relief was achieved in 110. Post-herpetic neuralgia            times a day for 7 days or VALACYCLOVIR (Valtrex) 1000mg              with paroxysms of sharp, shooting pains in a radicular pattern      improved chances for pain relief or at least dimunition
    developed in only two of the 113 patients.                          three times a day for 7 days all shorten the period of viral         corresponding to the affected dermatome. The pain quality,          of pain to controllable levels.
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