Erector Spinae Plane (ESP) Block as Abortive Treatment for Acute
Exacerbation of Post-Herpetic Neuralgia (PHN): A Case Report
John C. Alexander, MD, MBA
University of Texas Southwestern
Introduction
Post-herpetic neuralgia (PHN) is a neuropathic pain
syndrome of persistent pain following healing of the acute
painful lesions associated with herpes zoster (HZ) which is
caused by inflammation of the dorsal root ganglion
following reactivation of the varicella zoster virus (VZV).
Initial treatment consists of gabapentinoids, tricyclic
antidepressants, and topical local anesthetics (2, 3). In
addition, many interventional procedures have been
described as potential treatments (4), but a lack of
prospective trials coupled with the inherent cost, risk
profile, and technical difficulty of interventional
procedures make recommendations of best practices
difficult.
The ESP block is a relatively new regional anesthesia
technique that has been used for perioperative analgesia
in the trunk (1, 5). This case report outlines the efficacious
use of ESP block for abortive treatment of acute pain due
to exacerbation of PHN.
Figure 1: Erector Spinae Plane Block. Arrows denote spread of local anesthetic.
TM (Trapezius Muscle), RMM (Rhomboid Major Muscle), ESM (Erector Spinae
Muscle), TP (Transverse Process).
Case Report
A 57-year-old female presented to the pain management clinic with an
acute episode of 6-10/10 left-sided chest wall pain similar in character and
intensity to previous PHN exacerbations after a case of acute HZ two years
before. Examination revealed dysesthesia to light touch over the left T6-9
dermatomes from the medial border of the scapula to the mid-axillary line,
but no allodynia, hyperalgesia, or skin lesions. She reported partial relief
using an analgesic regimen consisting of Amitriptyline 20mg PO QHS,
Robaxin 750mg PO QHS prn, Vicodin 5/500 PO prn, and Lidoderm patch
Q12 hours prn. She did report a dose-limiting side effect of dry mouth with
Amitriptyline, and could not tolerate Gabapentin due to sedation.
After discussion of the risks, benefits, and alternatives we proceeded with a
trial of ESP block at the T8 level in the manner described by Forero, et al (1)
(Figure 1). A total of 20 mL of a solution containing 18ml ropivacaine
5mg/ml and 2ml betamethasone 6mg/ml was incrementally injected in 3-5
mL aliquots with constant visualization of the needle tip and regular
aspiration.
The patient noted partial relief immediately, and when contacted six hours
following the procedure she reported a 90% decrease in her pain.
Reassessment at 14 and 90 days revealed pain levels of 0-1/10 and the
patient stopped taking Vicodin.
Discussion
The advantages of the use of ESP block in the setting of acute
exacerbation of PHN pain result from the relative safety and
ease of placement given the lack of major blood vessels, pleura,
and neural structures in the area. Further studies are needed to
confirm the safety and efficacy of this novel regional anesthetic
technique for abortive therapy in acute exacerbation of PHN as
well as whether single injection or continuous infusion via
indwelling catheter are more efficacious. In this report, a single
injection effectively abated the PHN exacerbation.
In summary, this report demonstrates the use of ESP block is a
viable option for abortive treatment of acute exacerbation of
PHN, but further studies are needed to establish whether ESP
blocks provide equivalent analgesia when compared with other
interventional techniques.
References
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Novel Analgesic Technique in Thoracic Neuropathic Pain. Reg Anesth Pain Med.
2016;41(5):621-627. PMID: 27501016
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31:811-826 PMID: 29079160
3. Mallick-Searle T, Snodgrass B, Brant JM. Postherpetic neuralgia: epidemiology,
pathophysiology, and pain management pharmacology. J Multidiscip Healthc. 2016;
9;447-454 PMID: 27703368
4. Kim ED, Lee YI, Park HJ. Comparison of efficacy of continuous epidural block and
pulsed radiofrequency to the dorsal root ganglion for management of pain persisting
beyond the acute phase of herpes zoster. PLoS One. 2017; 12(8):e0183559 PMID:
28827823
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J Anaesth. 2017;118(3):474-475. PMID: 28203765