Effect of Repetitive Intracutaneous Injections with Local Anesthetics and Steroids for Acute Thoracic Herpes Zoster and Incidence of Postherpetic Neuralgia

Efficacy of Gasserian Ganglion High-Voltage, Long-Duration Pulsed Radiofrequency Combined With Block on Acute/Subacute Zoster-Related Trigeminal Neuralgia

Background: Trigeminal postherpetic neuralgia (TPHN) is a severe chronic pain that can lead to various socioeconomic consequences. Therefore, it is necessary to explore optimal treatment options for acute/subacute herpes zoster (HZ)-related trigeminal neuralgia and prevent the further development of TPHN. High-voltage, long-duration pulsed radiofrequency (HL-PRF) of the Gasserian ganglion is a new surgical intervention used to treat PHN. A ganglion block has been reported to possess anti-inflammatory effects and potential analgesic benefits. Methods: We included 83 patients with HZ-related acute/subacute trigeminal neuralgia admitted from January 1, 2021, to June 1, 2023, and received Gasserian ganglion HL-PRF combined with block. A 6-month follow-up was conducted, including Numerical Rating Scale (NRS) scores, Pittsburgh Sleep Quality Index (PSQI), the incidence of TPHN, the dosage of anticonvulsants and analgesics, efficacy, and adverse events. Results: All patients showed a significant decrease in postoperative NRS scores (p < 0.05). The NRS scores of the acute HZ group were consistently lower than those of the subacute HZ group at different time points (p < 0.01). The overall incidence of TPHN from the onset of HZ to 12 weeks is 21.68%. The incidence of TPHN in the acute phase group was 12.77%, significantly lower than the 33.33% in the subacute phase group (p=0.024). The effective rate was 74.7% in all patients, at 3 months after the treatment. The effective rate was 82.98% in the acute phase group and 63.89% in the subacute phase group, showing a statistically significant difference (p=0.047). The PSQI score of the acute group was consistently lower than that of the subacute group (p < 0.01). The dosage of analgesics and anticonvulsants used in the acute HZ group was lower than that in the subacute group (p < 0.01). All patients did not experience serious adverse reactions. Conclusions: Gasserian ganglion HL-PRF combined with block can be an effective and safe technique to relieve the pain of acute/subacute zoster-related trigeminal neuralgia and prevent the incidence of TPHN.

Effect of use of NSAIDs or steroids during the acute phase of pain on the incidence of chronic pain: a systematic review and meta-analysis of randomised trials

BACKGROUND

This study is the first to summarize the evidence on how the use of anti-inflammatory drugs during acute pain has an impact on the development of chronic pain.

METHODS

Randomized controlled trials retrieved from nine databases included anti-inflammatory drugs (NSAIDs or steroids) versus non-anti-inflammatory drugs in patients with acute pain and reported the incidence of chronic pain. No specified date, age, sex, or language restrictions. Subgroup analyses were performed according to pain classification, follow-up time, and medication. The GRADE method was used to evaluate quality of evidence.

RESULTS

A total of 29 trials (5220 patients) were included. Steroids or NSAIDs did not reduce the incidence of chronic nociceptive pain. Steroid use in acute phase significantly reduced the incidence of chronic neuropathic pain. In subgroup analysis, benefits were observed for methylprednisolone and dexamethasone, with some adverse effects. Steroids or NSAIDs were statistically significant in reducing pain intensity over 1 year, but the effect size was too small, and whether the long-term effect is clinically relevant needs to be further studied.

CONCLUSION

Quality of the evidence was low to moderate. No drug can be recommended to prevent chronic nociceptive pain. Injections of steroids (methylprednisolone or dexamethasone) during the acute phase reduce the incidence of chronic neuropathic pain, but most included studies also used local anesthetics. The results are indirect and need to be interpreted with caution. The pooled data effect sizes for pain intensity were small, so the clinical relevance was unclear. Study registration PROSPERO (CRD42022367030).

A clinical study of C arm-guided selective spinal nerve block combined with low-temperature plasma radiofrequency ablation of dorsal root ganglion in the treatment of zoster-related neuralgia

Background

This study evaluated the analgesic efficacy and psychological response of low-temperature plasma ablation of dorsal root ganglion (DRG) combined with selective spinal nerve block in patients with acute or subacute zoster-related neuralgia (ZRN).

Methods

Totally 90 ZRN patients were randomly and evenly divided into three groups. Treatment was given to Group A using C arm-guided selective spinal nerve block (C-SSVB), Group B using C-SSVB and pulsed radiofrequency (PRF), and Group C using C-SSVB and low-temperature plasma ablation of the DRG. The outcomes were examined using the Visual Analog Scale (VAS). Anxiety and depression of patients were evaluated using the Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS). Quality of life was assessed using the Pittsburgh Sleep Quality Index (PSQI) and postoperative Satisfaction scale. In addition, data on adverse events and medication usage rates were collected.

Results

The 90 patients were eligible for this study. The three treatments reduced VAS scores with no significant difference between groups A and B at the same time points; however, group B tended to have numerically lower VAS scores. Comparatively, group C had significantly reduced VAS scores on day 1 and 1 month after treatment compared with the other two groups. In terms of the decreasing SAS, SDS and PSQI scores, all the three treatments improved the anxiety, depression and sleep quality of the patients. In addition, significant alleviation in anxiety was found in group C compared with group A at all- time points. However, there was no statistically significant difference among the three groups in treatment-related adverse events that mainly focused on puncture pain at the surgical-site, skin numbness and medication usage rates.

Conclusions

C-SSVB and LTPRA of DRG will be considered as a promising treatment option for ZRN patients if those results can be confirmed after further validation.

Effect of CT-Guided Gasserian Ganglion Block with Local Anesthetics and Steroids on Acute/Subacute Zoster-Related Trigeminal Neuralgia: A Multicenter Retrospective Study

Purpose

To further evaluate the effects of gasserian ganglion block treatment with local anesthetics and steroids on patients with acute/subacute zoster-related trigeminal neuralgia.

Patients and Methods

This is a multicenteric retrospective study which included patients between the ages of 26–92 years, who suffered from acute/subacute zoster-related trigeminal neuralgia and had undergone CT-guided gasserian ganglion block. The medical records of these patients between January 13, 2016 and August 25, 2021 were retrieved, and the patients were followed up for 6 months. Follow-up outcomes were Numerical Rating Scale (NRS) scores, medications and dosage. The effective rate was defined as the number of cases with NRS score reduction of >50%/total number of cases×100% at 12 weeks postoperatively.

Results

The postoperative NRS scores were significantly decreased in all patients (P < 0.05), and NRS scores in acute zoster group were lower than those in subacute zoster group at different time points (P < 0.05). The percentage of patients who had a reduction of medication use value of >50% was 56.4% and the effective rate was 66.7% in all patients, at 3 months after the block treatment. There was no significant difference in the reduction of medication use value of >50% and the effective rates between the two groups. There were no intracranial hemorrhage, infection or other serious adverse effects in either groups.

Conclusion

CT-guided gasserian ganglion block with local anesthetics and steroids can be an effective and safe technique to relieve the pain of acute/subacute zoster-related trigeminal neuralgia.

Methylprednisolone and local anesthetic for Long-term Postherpetic Neuralgia: a meta-analysis

OBJECTIVE

The purpose was to evaluate the efficacy of methylprednisolone combined with local anesthetics on the incidence or intensity of long-term PHN.

METHODS

We have performed comprehensive literature research in PubMed, Web of Science, Cochrane library, and China national knowledge infrastructure (CNKI) databases (inception through October 19, 2021). Relevant randomized controlled trials(RCTs) with long-term duration were included, regardless of the injection method. The indicators were the incidence of PHN and the Visual Analog Scale (VAS) scores.

RESULTS

Five randomized controlled trials with 980 patients were retrieved. Compared with standard treatment (antivirals) alone, the combination of methylprednisolone, local anesthetic and standard treatment exhibited a significant decrease in the incidence of PHN in 1 month (RR =0.38, 95%CI: 0.19 to 0.76), 3 months (RR =0.40, 95%CI: 0.19 to 0.84) and 6 months (RR =0.37, 95%CI: 0.15 to 0.94) after zoster onset. In VAS scores, there was also a significant difference between the two groups in long-term PHN (3 months: WMD=-1.57, 95%CI: -2.84 to -0.30; 6 months: WMD=-0.72, 95%CI: -1.29 to -0.16).

CONCLUSION

The combination of Methylprednisolone, local anesthetic, and standard treatment appears to be an ideal option for patients with PHN. Further investigation is needed for the safety of this therapy.

Pharmacological and non-pharmacological strategies for preventing postherpetic neuralgia: a systematic review and network meta-analysis

Background

Postherpetic neuralgia (PHN) is a refractory complication of herpes zoster (HZ). To prevent PHN, various strategies have been aggressively adopted. However, the efficacy of these strategies remains controversial. Therefore, we aimed to estimate the relative efficacy of various strategies used in clinical practice for preventing PHN using a network meta-analysis (NMA).

Methods

We performed a systematic and comprehensive search to identify all randomized controlled trials. The primary outcome was the incidence of PHN at 3 months after acute HZ. We performed both frequentist and Bayesian NMA and used the surface under the cumulative ranking curve (SUCRA) values to rank the interventions evaluated.

Results

In total, 39 studies were included in the systematic review and NMA. According to the SUCRA value, the incidence of PHN was lower in the order of continuous epidural block with local anesthetics and steroids (EPI-LSE), antiviral agents with subcutaneous injection of local anesthetics and steroids (AV + sLS), antiviral agents with intracutaenous injection of local anesthetics and steroids (AV + iLS) at 3 months after acute HZ. EPI-LSE, AV + sLS and AV + iLS were also effective in preventing PHN at 1 month after acute HZ. And paravertebral block combined with antiviral and antiepileptic agents was effective in preventing PHN at 1, 3, and 6 months.

Conclusions

The continuous epidural block with local anesthetics and steroid, antiviral agents with intracutaneous or subcutaneous injection of local anesthetics and a steroid, and paravertebral block combined with antiviral and antiepileptic agents are effective in preventing PHN.

[Therapy of herpes zoster and postherpetic neuralgia]

Herpes zoster (HZ) is caused by the reactivation of varicella zoster virus. The incidence of herpes zoster and associated problems increases with age. With a life-long prevalence of 30%, every second 85-year-old person experiences HZ once in his lifetime. Three therapeutic columns are based on antiviral, topical and analgetic therapies. An extreme handicap is acute and persistent pain which can develop into postherpetic neuralgia (PHN). Those pain symptoms are predominantly neuropathic. The management of acute and chronic manifestation of pain may be challenging. HZ vaccination represents a substantial improvement in terms of prevention of herpes zoster and reduction of long-term complications, such as PHN. The permanent vaccination commission of the Robert Koch Institute recommends vaccination with dead virus for all persons over the age of 60 years. Risk groups like immunosuppressed patients are advised to be vaccinated starting at the age of 50 years.

Single intracutaneous injection of local anesthetics and steroids alleviates acute nonspecific neck pain: A CONSORT-perspective, randomized, controlled clinical trial

Acute nonspecific neck pain is one of the major public health problems lacking efficient treatments. The present study was designed to observe the analgesic effect of intracutaneous injection of local anesthestics and steroids on acute nonspecific neck pain.Thirty-six newly diagnosed with acute nonspecific neck pain patients were randomized to receive ibuprofen (IPB group) or intracutaneous injection of local anesthetics (lidocaine and bupivacaine) and steroid (methylprednisolone) (MLB group). The pain intensity was the primary outcome and evaluated with visual analog scale (VAS). Neck disability index (NDI) and patient global impression of changes (PGIC) were monitored for overall outcomes.Following treatments, patients from the 2 groups have decreased VAS scores and NDI when compared with their baseline level at 3 hours, day 1, and day 3 time points. Interestingly, the MLB group patients have lower VAS scores and NDI than IPB group. MLB patients also had a greater PGIC than IPB group.This study indicates that single intracutaneous injection of local anesthetics and steroids is sufficient to alleviate acute nonspecific neck pain.