What is Post Herpetic Neuralgia?

Post-herpetic Neuralgia or Pain after Shingles: A common procedure known as Selective Transforaminal Nerve Block works powerfully to reduce inflammation and control pain

  • Every year, nearly 1 million Americans get shingles
  • Nearly 1 and 3 people over the age of 60 will get shingles in her lifetime
  • Pain after 3 months of shingles is considered post herpetic neuralgia or pain after shingles.
  • More than 5% of elderly patients have post-herpetic neuralgia 1 year after acute herpes zoster
  • Selective Transforaminal Nerve Root Blocks under Fluoroscopy Guided-Image Technology is a quick, safe, effective alternative solution for treating pain associated with postherpetic neuralgia.

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Pain after shingles, or Postherpetic neuralgia (PHN), is a common complication of shingles. Shingles is a disease caused by the varicella zoster virus. The same virus that causes chickenpox. If you have shingles, the virus has probably been in your body since you were a child, but has remained dormant. It may seem strange that a virus could lay dormant in your body for decades. But that’s just what this virus does. And it is pretty common. Nearly 1 in 3 people over the age of 60 will get shingles in their lifetime. More than 5% of elderly patients have post-herpetic neuralgia 1 year after acute herpes zoster.  The overall incidence of HZ is approximately 3/1000 of the population per year rising to 10/1000 per year by 80 years of age. Approximately 50% of individuals reaching 90 years of age will have had HZ. In approximately 6%, a second attack may occur (usually several decades after the first). Patients with HZ can transmit the virus to a non-immune individual causing varicella. HZ is not contracted from individuals with varicella or HZ. Reduced cell-mediated immunity to HZ occurs with aging, explaining the increased incidence in the elderly and from other causes such as tumors, HIV and immunosuppressant drugs.

What many people don’t know is that shingles can actually cause long-lasting pain. Shingles symptoms start with a painful, blistering rash that usually forms on a person’s chest or back. However, the shingles rash will go away in time. But once it is gone, you may still experience burning, stabbing, shooting symptoms of nerve pain caused by shingles. When you have shingles, nerves can often be damaged because of your shingles rash.

This can cause a specific type of pain—nerve pain from shingles. The site of your shingles rash usually determines where you are most likely to feel nerve pain.



Pain symptoms  after shingles:

  • Shooting pain where shingles rash used to be
  • Sensory, painful to light touch clothing
  • Electric shock
  • Burning
  • Stabbing


Herpes ZosterShingles symptoms may start with a painful, blistering rash on the trunk, arms, and face. The rash normally goes away over time, but you may still experience burning, stabbing and shooting pain. This pain is caused by nerves damaged by the shingles virus. The site of your shingles rash usually determines where you are most likely to feel nerve pain.

Pain after shingles, or post herpetic neuralgia is a common complication of shingles. Shingles is a disease caused by the varicella zoster virus. The same virus that causes chickenpox. If you have shingles, the virus has probably been in your body since you were a child, but has remained dormant. It may seem strange that a virus could lay dormant in your body for decades. But that’s just what this virus does. And it is pretty common. Nearly 1 in 3 people over the age of 60 will get shingles in their lifetime.

What many people don’t know is that shingles can actually cause long-lasting pain. Shingles symptoms start with a painful, blistering rash that usually forms on a person’s chest or back. However, the shingles rash will go away in time. But once it is gone, you may still experience burning, stabbing, shooting symptoms of nerve pain caused by shingles. When you have shingles, nerves can often be damaged because of your shingles rash.This can cause a specific type of pain—nerve pain from shingles.


Treatment options for Postherpetic Neuralgia

Postherpetic neuralgia (PHN) is a chronic neuropathic pain syndrome that occurs after reactivation of varicella zoster virus infection with damage to sensory ganglia in nerve roots. Numerous treatment strategies for PHN, including topical lidocaine patches, antidepressants, anticonvulsants, corticosteroids, opioids and nerve blocks, have shown some degree of efficacy, but the effects are often limited and many patients are refractory to these treatments. Previous report has suggested that N-Methyl-d-Aspartate (NMDA) receptor antagonists, such as ketamine can decrease pain associated with PHN. Transcutaneous Electrical Nerve Stimulation (TENS) may be effective in some cases. However, adverse effects such as psychomimetic effects limit its therapeutic use, even at low doses. Interventional pain procedures such as epidural local anesthetic, LA + steroid in HZ, and intrathecal LA + steroid in PHN, Sympathetic blocks, and selective transforaminal nerve blocks may  reduce  Post- herpetic Neuralgia.

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Case Report: this patient is a 70-year-old male who presented with a 3 year period of debilitating right flank pain secondary to herpes zoster, which was diagnosed 3 years ago.  At that time the vesicular rash involve the areas along the  dermatomal distribution of L1, L2, and L3.  Patient's pain failed to improve with standart medications, including tricyclic antidepressants (TCAs), oral narcotics, pregabalin, topical lidocaine.  Due to the refractory response of these medication, the patient underwent a right L1-L2, L2-L3 and L3-L4 transforaminal nerve block under fluoroscopic guidance.  Prior to the injection the  pain intensity was rated as 9-10/10 and 3 minutes after the injection it was reduced to 1/10. At 1 week, his pain had maintained an intensity of 2/10 and over  2 weeks have resolved. So far after after a year, he  remained pain-free .  In this case, the use of selective transforaminal nerve blocks provided dramatic results in the treatment of debilitating postherpetic neuralgia.  Further investigation is needed to determine the efficacy of selective transforaminal nerve blocks in the early management of postherpetic neuralgia.



 Lumbar sympatheticOne of the procedures that we currently perform in our clinic and have seen very good result with our patients, are the transforaminal nerve blocks under fluoroscopic guidance with various injectables including local anesthetics and steroids, especially in treating patients with herpes zoster and postherpetic neuralgia for more than 6 months. During this procedure the doctors determines the nerves which are involve and causing the pain, and if you are a good candidate he will proceed with the nerve block. A selective nerve root block is an injection of a local anesthetic along a specific nerve root under fluoroscopy guided-image technology. Along the spine, there are several “holes” or “foramina” through which nerve roots emerge. This nerves are normally irritated   and  typically cause  shooting or radiating pains along that nerve roots associated with postherpetic neuralgia.  

In a selective transforaminal nerve root block, a small needle is placed in the foramen alongside the nerve root and the medication is injected under imaging technology. Overall, 80% of patients,  in most current literature, showed a positive outcome with these blocks. 


In summary:

Selective Transforaminal Nerve Root Block is a safe and effective treatment option for debilitating pain associated with postherpetic neuralgia.

Selective Transforaminal Nerve Root Blocks under Fluoroscopy Guided-Image Technology is a quick, safe, effective alternative solution for treating pain associated with postherpetic neuralgia.

A Selective Transforaminal Nerve Root Block involves directly injecting a mixture of anesthetic and anti-inflammatory medication into the epidural space of the irritated nerve.

By appropriately treating your pain, you can quickly recover to your optimal physical and functional abilities, thus improving your quality of life.


If you or someone you know suffers from potsherpetic neuralgia, visit us at our pain clinic for a consultation to offer you the most advanced medical treatments, such as fluoroscopic image-guided injection technology, for the pain relief of your potsherpetic neuralgia. With proper treatment, you can quickly recover to your optimal physical and functional abilities, thus improving the quality of your life.


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In this case, patient underwent a right L1-L2, L2-L3 and L3-L4 transforaminal nerve block under fluoroscopic guidance. This fluoroscopic image shows spreading of contrast media in L2, L3, and L4 nerve root and epidural space

 

 

 

 

Postherpetic Neuralgia as a cause of Neuropathy

Neuropathy is one of the most common problems derived from shingles. Not only can it cause loss of sensation in the trunk, face or extremities, but it can also produce chronic severe incapacitating pain.  It is important that physicians consistently monitor and re-evaluate a patient’s treatment plan in order to track progress and eventually taper therapies when possible.

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Dr. Felix Roque has a vast and extensive experience in treating potsherpetic neuralgia with Selective Transforaminal Nerve Root Blocks under Fluoroscopy Guided-Image Technology. Dr. Roque’s Pain Relief Center, located at 543 45th St. Union City, NJ 07087 - Telephone 201-766-6469 - is fully equipped with innovative, cutting-edge technology and equipment necessary to perform this type of procedure safely and effectively.

 

 

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