Rethinking the causes of pain in herpes zoster and postherpetic neuralgia: the ectopic pacemaker hypothesis

Efficacy and Safety of Pulsed Radiofrequency of Dorsal Root Ganglion in Elderly Patient Population With Acute and Subacute Zoster-Related Pain

Background: Herpes zoster (HZ) is typically characterized by a burning, stabbing pain, hyperalgesia, and allodynia. In some patients, despite the lesions resolving, the pain persists and becomes chronic. If the pain continues for more than 6 months after the onset of the pain phase, this condition is called postherpetic neuralgia (PHN). The frequency and severity of PHN increase with advancing age. The pain in PHN can be severe, sometimes resistant to medications, significantly impacting the patients' quality of life. The elderly patient population cannot tolerate the medications due to their side effects. In this situation, interventional pain treatment should be applied in the elderly patient group who have a high risk of developing PHN compared to other age groups. Method: We included patients over 65 years of age with HZ-related pain who underwent dorsal root ganglion (DRG) pulsed radiofrequency (PRF) within the first 6 months from the onset of pain. We divided these patients into 2 groups: patients who underwent intervention within the first 1 month from the onset of pain and patients who underwent intervention between 1 and 6 months. We recorded medication doses and Numeric Rating Scale (NRS) scores before the procedure and at 1 week, 1 month, 3 months, and 6 months after the procedure. Results: After the DRG PRF treatment, NRS scores improved significantly in both groups (p < 0.05). The mean NRS score in the early DRG PRF group was significantly lower than that in the late DRG PRF group (p < 0.05). The medication doses in the early DRG PRF group were significantly lower than those in the other group (p < 0.05). Conclusions: Interventional pain treatment should be applied as soon as possible in the elderly patient group who do not respond to first-line medical treatment or cannot tolerate medical treatment due to its side effects and who have a high risk of developing PHN compared to other age groups. DRG PRF, applied in the early period of medical treatment-resistant acute HZ, is safe and effective, preventing the progression to PHN.

Pain in the Context of Sensory Deafferentation

Pain that accompanies deafferentation is one of the most mysterious and misunderstood medical conditions. Prevalence rates for the assorted conditions vary considerably but the most reliable estimates are greater than 50% for strokes involving the somatosensory system, brachial plexus avulsions, spinal cord injury, and limb amputation, with controversy surrounding the mechanistic contributions of deafferentation to ensuing neuropathic pain syndromes. Deafferentation pain has also been described for loss of other body parts (e.g., eyes and breasts) and may contribute to between 10% and upwards of 30% of neuropathic symptoms in peripheral neuropathies. There is no pathognomonic test or sign to identify deafferentation pain, and part of the controversy surrounding it stems from the prodigious challenges in differentiating cause and effect. For example, it is unknown whether cortical reorganization causes pain or is a byproduct of pathoanatomical changes accompanying injury, including pain. Similarly, ascertaining whether deafferentation contributes to neuropathic pain, or whether concomitant injury to nerve fibers transmitting pain and touch sensation leads to a deafferentation-like phenotype can be clinically difficult, although a detailed neurologic examination, functional imaging, and psychophysical tests may provide clues. Due in part to the concurrent morbidities, the physical, psychologic, and by extension socioeconomic costs of disorders associated with deafferentation are higher than for other chronic pain conditions. Treatment is symptom-based, with evidence supporting first-line antineuropathic medications such as gabapentinoids and antidepressants. Studies examining noninvasive neuromodulation and virtual reality have yielded mixed results.

Satellite Glial Cells in Human Disease

Satellite glial cells (SGCs) are the main type of glial cells in sensory ganglia. Animal studies have shown that these cells play essential roles in both normal and disease states. In a large number of pain models, SGCs were activated and contributed to the pain behavior. Much less is known about SGCs in humans, but there is emerging recognition that SGCs in humans are altered in a variety of clinical states. The available data show that human SGCs share some essential features with SGCs in rodents, but many differences do exist. SGCs in DRG from patients suffering from common painful diseases, such as rheumatoid arthritis and fibromyalgia, may contribute to the pain phenotype. It was found that immunoglobulins G (IgG) from fibromyalgia patients can induce pain-like behavior in mice. Moreover, these IgGs bind preferentially to SGCs and activate them, which can sensitize the sensory neurons, causing nociception. In other human diseases, the evidence is not as direct as in fibromyalgia, but it has been found that an antibody from a patient with rheumatoid arthritis binds to mouse SGCs, which leads to the release of pronociceptive factors from them. Herpes zoster is another painful disease, and it appears that the zoster virus resides in SGCs, which acquire an abnormal morphology and may participate in the infection and pain generation. More work needs to be undertaken on SGCs in humans, and this review points to several promising avenues for better understanding disease mechanisms and developing effective pain therapies.

CDDO regulates central and peripheral sensitization to attenuate post-herpetic neuralgia by targeting TRPV1/PKC-δ/p-Akt signals

Postherpetic neuralgia (PHN) is a notorious neuropathic pain featuring persistent profound mechanical hyperalgesia with significant negative impact on patients' life quality. CDDO can regulate inflammatory response and programmed cell death. Its derivative also protects neurons from damages by modulating microglia activities. As a consequence of central and peripheral sensitization, applying neural blocks may benefit to minimize the risk of PHN. This study aimed to explore whether CDDO could generate analgesic action in a PHN-rats' model. The behavioural test was determined by calibrated forceps testing. The number of apoptotic neurons and degree of glial cell reaction were assessed by immunofluorescence assay. Activation of PKC-δ and the phosphorylation of Akt were measured by western blots. CDDO improved PHN by decreasing TRPV1-positive nociceptive neurons, the apoptotic neurons, and reversed glial cell reaction in adult rats. It also suppressed the enhanced PKC-δ and p-Akt signalling in the sciatic nerve, dorsal root ganglia (DRG) and spinal dorsal horn. Our research is the promising report demonstrating the analgesic and neuroprotective action of CDDO in a PHN-rat's model by regulating central and peripheral sensitization targeting TRPV1, PKC-δ and p-Akt. It also is the first study to elucidate the role of oligodendrocyte in PHN.

Effect of Korean Medicine Treatment on Patients with Postherpetic Neuralgia: A Retrospective Chart Review

Evidence regarding Korean medicine treatment (KMT) for neuropathic pain is lacking. We aimed to identify the effects of integrative KMT in patients with postherpetic neuralgia (PHN). We retrospectively analyzed the electronic medical records of patients with PHN who received KMT at Kyung Hee University Korean Medicine Hospital between August 2021 and July 2022. We evaluated the effects of KMT-comprising acupuncture, pharmacopuncture, herbal medicine, cupping, and moxibustion-on pain intensity using the numerical rating scale (NRS), Short-Form McGill Pain Questionnaire (SF-MPQ), Hospital Anxiety and Depression Scale-Anxiety (HADS-A), Hospital Anxiety and Depression Scale-Depression (HADS-D), Daily Sleep Interference Scale (DSIS), Fatigue Severity Scale (FSS), and EuroQol-5D. Among 53 patients with PHN, 13 were included. The NRS score for worst pain over 1 week decreased from 6.54 ± 0.64 at baseline to 3.85 ± 0.63 at 8 weeks (41% reduction, p < 0.01), while that for average pain over 1 week decreased from 4.93 ± 0.67 at baseline to 3.08 ± 0.46 at 8 weeks (37% reduction, p < 0.01). From baseline to 8 weeks, there were significant reductions in the SF-MPQ, HADS-A, FSS, and EuroQol-5D scores. No adverse events were reported after KMT. Therefore, KMT may be an effective treatment option for patients with PHN.

[Neurosurgical treatment of postherpetic neuralgia]

Postherpetic neuralgia is a chronic and debilitating condition that can occur following an episode of herpes zoster (shingles). It is characterized by severe, persistent pain in the area where the shingles rash occurred. While various treatment approaches exist, including medications and non-invasive therapies, some cases of postherpetic neuralgia may require neurosurgical intervention. Neurosurgical treatment options for postherpetic neuralgia aim to alleviate the pain by targeting the affected nerves or neural pathways. One common approach is spinal cord stimulation (SCS). In SCS, electrodes are implanted along the spinal cord, and electrical impulses are delivered to interfere with the transmission of pain signals. This technique can modulate pain perception and significantly reduce the intensity and frequency of postherpetic neuralgia symptoms. Neurosurgical treatment of postherpetic neuralgia is typically considered when conservative measures have failed to provide sufficient relief. However, it is crucial for patients to undergo a comprehensive evaluation and consultation with a neurosurgeon to determine the most appropriate treatment approach based on their specific condition and medical history. The risks, benefits, and potential outcomes of neurosurgical interventions should be carefully discussed between the patient and their healthcare provider to make an informed decision.

Medicinal Plants for the Treatment of Neuropathic Pain: A Review of Randomized Controlled Trials

Neuropathic pain is a disabling condition caused by various diseases and can profoundly impact the quality of life. Unfortunately, current treatments often do not produce complete amelioration and can be associated with potential side effects. Recently, herbal drugs have garnered more attention as an alternative or a complementary treatment. In this article, we summarized the results of randomized clinical trials to evaluate the effects of various phytomedicines on neuropathic pain. In addition, we discussed their main bioactive components and potential mechanisms of action to provide a better view of the application of herbal drugs for treating neuropathic pain.

A bibliometric and visualization analysis of global research on postherpetic neuralgia from 2000 to 2022: A review

Postherpetic neuralgia (PHN) represents a notable clinical challenge as it is the most prevalent and severe complication of herpes zoster (HZ). The primary objective was to investigate the current research status and hotspots of PHN research during the period from 2000 to 2022. The literature pertaining to PHN was gathered through the utilization of the Web of Science Core Collection, spanning from January 2000 to December 2022. The software, CiteSpace version 6.2.R2, was employed to produce visual depictions of publications related to PHN across various dimensions such as year, country/region, institution, journal, author, keyword, and reference. This study involved a total of 3505 papers. The USA held a dominant position in the production of scholarly articles. Argentina exhibited the highest frequency of participation in international collaboration. Out of all the institutions, Pfizer exhibited the highest degree of productivity. Harvard University exhibited the highest frequency of participation in international collaboration. The Pain exhibited the most noteworthy productivity rate and citation count among all other journals. Ralf Baron was identified as the most productive author, whereas DWORKIN RH attained the highest citation count. Contemporary scholarly investigations are predominantly centered on identifying risk factors, devising preventative measures, and exploring novel and secure methods of pain management. The current investigation has revealed the focal areas and patterns of studies pertaining to PHN. Presently, the research in this field is focused on identifying the risk factors and preventive measures for PHN, alongside exploring novel and secure pain management strategies.

Analysis of the Risk Factors for Mechanical Allodynia in Herpetic Neuralgia: A Retrospective Cross-Sectional Study

Purpose

Mechanical allodynia is reportedly common during herpetic neuralgia. The purpose of this study was to establish a risk prediction model to predict the individual risk of allodynia in herpetic neuralgia.

Methods

Three hundred and eighty-six patients with trunk herpetic neuralgia were divided into two regions, T2-5 and T6-11. The causality between allodynia and other factors was analyzed by a binary logistic regression model.

Results

42.2% of subjects had allodynia, 137 suffered from dynamic allodynia, and 110 with dynamic allodynia experienced local sweating. The following 5 items as predictors determined this model: local sweating (Odd Ratio = 27.57, P<0.001), lesion location (Odd Ratio=2.46, P =0.017), pain intensity (Odd Ratio=1.38, P =0.020), pain duration (Odd Ratio=0.94, P =0.006), and local scars (Odd Ratio=0.07, P<0.001). The presence and development of allodynia are associated with local sweating. The positive proportion of the Iodine-starch test between the T2-5 (50.0%) with the T6-11 (23.7%) had a statistically significant difference (χ2=5.36, P=0.021). 29.5% of patients at the T2-6 had obvious sweating, which was different from only sticky feelings at the T6-11 (70.5%, χ2=10.88, P=0.001). 19.2% of patients with residual scars and allodynia was significantly lower than 48.5% of patients without allodynia (χ2=15.28, P<0.001).

Conclusion

This analysis suggests that local sweating is a concomitant symptom in dynamic allodynia, which imply the sympathetic nerves innervating the sweat glands of the skin were also involved during herpetic neuralgia. This may assist in the evaluation of dynamic allodynia and prove the role of sympathetic nerve intervention for herpetic neuralgia.

Metabolomics profiling in predicting of post-herpetic neuralgia induced by varicella zoster

To explore potential metabolomics biomarkers in predicting post-herpetic neuralgia (PHN) induced by herpes zoster (HZ). A total of 90 eligible patients were prospectively enrolled and assigned into an acute pain (ACP) group and a PHN group. Serum samples were collected before clinical intervention to perform metabolomics profiling analyses using gas chromatography mass spectrometry (GC-MS). Key metabolites were identified using partial least squares discriminant analysis (PLS-DA). A binary logistic regression was used to build a combined biomarker model to predict PHN from ACP. The discriminating efficiency of the combined biomarker model was investigated and validated by internal validation. Six metabolites were identified as the key metabolites related to PHN. All these metabolites (N-Acetyl-5-hydroxytryptaMine, glucose, dehydroascorbic acid, isopropyl-beta-D-thiogalactopyranoside, 1,5-anhydro-D-sorbitol, and glutamic acid) were found elevated in the PHN group. Pathway analyses showed that glucose-alanine cycle, tryptophan metabolism, tyrosine metabolism, lactose degradation, malate-aspartate shuttle were top five metabolic pathways evolved in PHN. The AUC was 0.85 (95% CI 0.76-0.93) for the combined biomarker model, and was 0.91 (95% CI 0.84-1.00) for the internal validation data set to predict PHN. Metabolomics analyses of key metabolites could be used to predict PHN induced by HZ.

Therapeutic Strategies for Postherpetic Neuralgia: Mechanisms, Treatments, and Perspectives

PURPOSE OF REVIEW

Postherpetic neuralgia is an annoying pain that mainly affects older people. In order to give patients more options, this review summarizes the pharmacological and interventional treatments for postherpetic neuralgia and updates the research on the efficacy, thereby providing doctors with more treatment options. The adverse effects and effective doses of its various treatments are also presented so that the therapy can be prescribed according to their concrete physical conditions. In a word, this review is dedicated to providing a comprehensive overview of the treatment options for postherpetic neuralgia and offering patients more choices.

RECENT FINDINGS

Combinational therapy is more excellent than monotherapy. The local anesthesia and gabapentin comprised outstanding compatibility. In addition, two therapeutic tools for PHN patients, especially for the intractable ones, electroacupuncture (EA), and osteopathic manipulative treatment (OMT), show their efficacy and become potential options to alleviate pain. In terms of treatment, guidelines recommend patients use tricyclic antidepressants (TCAs), gabapentin, pregabalin, and 5% lidocaine patches as the first-line medications, and gabapentin is investigated most, especially the gabapentin enacarbil (GEn). And drug efficacy can be limited by adverse effects and tolerated doses. Interventional treatments, with their invasiveness and operational difficulty, are usually considered for intractable patients. Combinational therapies may be used when a single therapy cannot achieve the desired effect. Therapies such as OMT and EA have also been proposed to palliate pain in some cases, and future directions of treatment may be investigated in Chinese medicine and acupuncture.

Evaluation of the correlation of dorsal root ganglia and spinal nerves with clinical symptoms in patients with postherpetic neuralgia using magnetic resonance neurography

Purpose

To assess changes of dorsal root ganglia (DRG) and spinal nerves in patients with postherpetic neuralgia (PHN), and investigate the correlation between DRG morphology and clinical symptoms in PHN patients using magnetic resonance neurography (MRN).

Methods

In this case-control study, forty-nine lesioned DRG in 30 patients and 49 normal DRG in 30 well-matched (age, sex, height, weight) healthy controls were assessed. Clinical symptoms of patients (pain, allodynia, itching, and numbness) were assessed. MRN features (DRG volume (VDRG), the largest diameter (Dmax) of spinal nerves, signal intensity of DRG and spinal nerves (M-value)) were measured in all participants. Multilinear regression analysis was used to evaluate the relationship between the DRG morphology and clinical symptoms in patients.

Results

The volume and relative M-value of lesioned DRG in patients were significantly higher than those on the same side of healthy controls (p = 0.013, p < 0.001, respectively). The mean Dmax and relative M-value of spinal nerves on the lesioned side were significantly higher than those on the contralateral and same side of healthy controls (p < 0.0001, p = 0.0001, p = 0.0011, p = 0.0053, respectively). No difference was found between the mean VDRG of the lesioned and contralateral sides. Multiple linear regression analysis revealed that disease duration was independent risk factor for the maximum rate of VDRG differences (p = 0.013).

Conclusions

DRG and spinal nerves on the lesioned side are swollen during PHN. Disease duration is an independent risk factor for morphological differences in the lesioned DRG of PHN patients. This study provides important guidance for individualized treatments of PHN.

Comparison of the Severity of Zoster-Associated Pain and Incidence of Postherpetic Neuralgia in Patients with and without Pre-Existing Spinal Disorders at the Same Spinal Nerve Level: A Retrospective Multicenter Study

The incidences of herpes zoster (HZ) and postherpetic neuralgia (PHN) are significantly influenced by age. As individuals age, the occurrence of spinal disorders increases, thereby raising the likelihood of HZ and PHN coexistence. Considering this, our study aimed to explore the potential impact of pre-existing spinal disorders at the nerve level where HZ developed, on the severity of zoster-associated pain (ZAP) and the incidence of PHN. For our investigation, we retrospectively analyzed a total of 237 patients who presented with HZ and ZAP at various sensory levels (cervical, thoracic, lumbar, and sacral) with or without pre-existing spinal disorders. The presence or absence of spinal disorders at the sensory level affected by HZ was determined using computed tomography or magnetic resonance imaging. Our study results revealed that the group with spinal disorders at the sensory level where HZ developed did not exhibit an increased incidence of PHN. However, 3-6 months after HZ onset, this same group showed significantly higher ZAP scores compared to the group without spinal disorders. It implies a need for heightened pain management, as the coexistence of these conditions can increase pain severity. This study furnishes an initial standpoint to delve into intricate interactions between two diseases.

Clinical and Epidemiological Profile of Herpes Zoster and Its Complications in a Tertiary Care Center of Bihar: A Prospective Study

Background Herpes zoster is a common viral infection caused by reactivation of the varicella-zoster virus (VZV) characterized by the presence of a segmental distribution of painful grouped vesicles on an erythematous base. It is associated with several complications like zoster-associated pain (ZAP), postherpetic neuralgia (PHN), pigmentary changes, scarring, secondary infections, and dermatosis as well as severe systemic complications. Aims/objectives The aim of the study was to analyze the various clinical and epidemiological patterns of herpes zoster and post-herpetic complications. Materials and methods We conducted a single-center observational cross-sectional study on 72 patients with herpes zoster and post-herpetic complications attending the dermatology outpatient department (OPD) to understand its various clinical and epidemiological patterns. A detailed history taking regarding the onset, progression, and complications of the disease, as well as the type, duration, and severity of pain, was taken, followed by a general physical, systemic, and cutaneous examination, along with investigations wherever needed. Results A total of 72 patients were included in the study, comprising 32 (44.4%) patients suffering from herpes zoster and 40 (55.5%) patients suffering from post-herpetic complaints. The minimum age was 14 years, the maximum age was 83 years, and the mean age in our study was 52 ± 17 years. The most commonly affected age group was 41-60 years. A total of 52 males and 22 females were included in the study, resulting in a male-to-female ratio of 2.3:1. The thoracic dermatome was the most commonly involved dermatome, observed in 43 (59.7%) patients, and the left side was more commonly affected, seen in 41 (56.9%) patients. Among the total 72 patients, 26 (36.1%) had co-morbidities, with hypertension (18%) being the most common, followed by diabetes mellitus (12.5%). Regarding the post-herpetic complaints encountered in our study, the most common was post-herpetic neuralgia, seen in 31 (77.5%) patients, followed by post-herpetic pigmentation (macular), observed in 22 (55%) patients, and scarring (papules, plaques, hypertrophic scar, and keloid), observed in 17 (42.5%) patients. Conclusion A broader understanding of the clinical and epidemiological factors of herpes zoster and post-herpetic complications is important as this disease constitutes a considerable burden in a tertiary care center and if not treated adequately, the after-effects might last for many years altogether. Hence, early diagnosis and initiation of adequate antiviral therapy as well as pain management is the key aspect of management.

Low Trend for VZV-Associated Disease Patients to Visit Neurologists

Background

Herpes zoster (HZ) is a skin disease that can also cause virus-infectious peripheral neuropathies. Despite this, there is limited information on patient preferences for seeking medical attention for HZ and zoster-associated pain (ZAP). Our study aimed to evaluate how frequently patients with ZAP choose to visit neurologists for their symptoms.

Methods

This study conducted a retrospective review of electronic health records in three general hospitals from January 2017 to June 2022. Using association rule mining, the study analyzed referral behaviors.

Results

We identified 33,633 patients with 111,488 outpatient visits over 5.5 years. The study found that the majority of patients (74.77-91.22%) visited dermatologists during their first outpatient visit, while only a small percentage (0.86-1.47%) preferred to consult a neurologist. The proportion of patients referred to a specialist during their medical visit varied significantly between different specialties within the same hospital (p <0.05) and even within the same specialty (p<0.05). There was a weak association (Lift:1.00-1.17) of referral behaviors between dermatology and neurology. Across the three hospitals, the average number of visits to a neurologist for ZAP was 1.42-2.49, with an average electronic health record duration of 11-15 days per patient. After consulting with a neurologist, some patients were referred to other specialists.

Conclusion

It was observed that patients with HZ and ZAP tended to visit a variety of specialists, with only a small number seeking the assistance of neurologists. However, from the perspective of neuroprotection, it is the duty of neurologists to provide more means.

Chronic pain and local pain in usually painless conditions including neuroma may be due to compressive proximal neural lesion

It has been unexplained why chronic pain does not invariably accompany chronic pain-prone disorders. This question-driven, hypothesis-based article suggests that the reason may be varying occurrence of concomitant peripheral compressive proximal neural lesion (cPNL), e.g., radiculopathy and entrapment plexopathies. Transition of acute to chronic pain may involve development or aggravation of cPNL. Nociceptive hypersensitivity induced and/or maintained by cPNL may be responsible for all types of general chronic pain as well as for pain in isolated tissue conditions that are usually painless, e.g., neuroma, scar, and Dupuytren's fibromatosis. Compressive PNL induces focal neuroinflammation, which can maintain dorsal root ganglion neuron (DRGn) hyperexcitability (i.e., peripheral sensitization) and thus fuel central sensitization (i.e., hyperexcitability of central nociceptive pathways) and a vicious cycle of chronic pain. DRGn hyperexcitability and cPNL may reciprocally maintain each other, because cPNL can result from reflexive myospasm-induced myofascial tension, muscle weakness, and consequent muscle imbalance- and/or pain-provoked compensatory overuse. Because of pain and motor fiber damage, cPNL can worsen the causative musculoskeletal dysfunction, which further accounts for the reciprocity between the latter two factors. Sensitization increases nerve vulnerability and thus catalyzes this cycle. Because of these mechanisms and relatively greater number of neurons involved, cPNL is more likely to maintain DRGn hyperexcitability in comparison to distal neural and non-neural lesions. Compressive PNL is associated with restricted neural mobility. Intermittent (dynamic) nature of cPNL may be essential in chronic pain, because healed (i.e., fibrotic) lesions are physiologically silent and, consequently, cannot provide nociceptive input. Not all patients may be equally susceptible to develop cPNL, because occurrence of cPNL may vary as vary patients' predisposition to musculoskeletal impairment. Sensitization is accompanied by pressure pain threshold decrease and consequent mechanical allodynia and hyperalgesia, which can cause unusual local pain via natural pressure exerted by space occupying lesions or by their examination. Worsening of local pain is similarly explainable. Neuroma pain may be due to cPNL-induced axonal mechanical sensitivity and hypersensitivity of the nociceptive nervi nervorum of the nerve trunk and its stump. Intermittence and symptomatic complexity of cPNL may be the cause of frequent misdiagnosis of chronic pain.

Pain Fluctuations of Women with Subacute Herpetic Neuralgia During Local Methylcobalamin in Combination with Lidocaine Treatment: A Single-Blinded Randomized Controlled Trial

Purpose

To evaluate the efficacy and pain fluctuations of methylcobalamin in combination with lidocaine local injection treatment for subacute herpetic neuralgia (SHN).

Methods

Seventy-nine women (60.4 ± 2.7 years) with thoracic SHN were enrolled and randomized to receive a combination of methylcobalamin and lidocaine local injection (MI, N=40), or a combination of lidocaine patch 5% and oral methylcobalamin (PO, N=39) for four weeks. Repeated-measures analyses of variance were used to evaluate the effect on pain levels. Generalized estimation equations were used to analyze the cause-effect relationship between pain fluctuations and influencing factors.

Results

At the treatment endpoint, the group, treatment time, and group interacted with treatment time effects of the pain scores and area were statistically significant (P<0.001), The pain scores were 2.9 ±0.9 (MI) and 4.3 ± 1.5 (PO). 80.00% (MI) or 28.21% (PO) of patients had pain scores ≤ 3, the odds ratio was 2.84 (95% CI: 1.68 to 4.79). The incidence of postherpetic neuralgia was 5.0% (2/40) at 3 months. Pain fluctuated repeatedly during treatment. The pain fluctuation increased from 8.75 log folds in the afternoon, to 79.85 log folds at night. With the ADLs level increasing from 1 to 3, the pain fluctuated from 4.28 to 17.70 log folds. Allodynia, itching, sleep quality, and ADLs were the significant influencing factors (P<0.05).

Conclusion

This study validated the efficacy of methylcobalamin combined with lidocaine for SHN, and confirmed that pain levels in patients with SHN had an obvious circadian rhythm. ADLs were an important cause of pain fluctuations.

The Effectiveness of Various Types of Electrical Stimulation of the Spinal Cord for Chronic Pain in Patients with Postherpetic Neuralgia: A Literature Review

Introduction

Postherpetic neuralgia (PHN) is a severe condition that remains a challenge to treat. Spinal cord stimulation (SCS) is used in cases of insufficient efficacy of conservative treatment. However, in contrast to many other neuropathic pain syndromes, there is a huge problem in reaching long-term stable pain relief in patients with PHN using conventional tonic SCS. The objective of this article was to present a review of the current management strategies of PHN, their efficacy, and safety.

Materials and Methods

We searched for articles containing the keywords "spinal cord stimulation AND postherpetic neuralgia," "high-frequency stimulation AND postherpetic neuralgia," "burst stimulation AND postherpetic neuralgia" and "dorsal root ganglion stimulation AND postherpetic neuralgia" in Pubmed, Web of Science, and Scopus databases. The search was limited to human studies published in the English language. There were no publication period limitations. Bibliographies and references of selected publications on neurostimulation for PHN were further manually screened. The full text of each article was studied once the abstract was analyzed by the searching reviewer and found appropriate. The initial search yielded 115 articles. Initial screening based on abstract and title allowed us to exclude 29 articles (letters, editorials, and conference abstracts). The full-text analysis allowed us to exclude another 74 articles (fundamental research articles, research utilizing animal subjects, and systemic and nonsystemic reviews) and results of PHN treatment presented with other conditions, leaving 12 articles for the final bibliography.

Results

12 articles reporting on the treatment of 134 patients with PHN were analyzed, with a disproportionally large amount of traditional SCS treatment than that to alternative SCS: DRGS (13 patients), burst SCS (1 patient), and high-frequency SCS (2 patients). Long-term pain relief was achieved in 91 patients (67.9%). The mean VAS score improvement was 61.4% with a mean follow-up time of 12.85 months. Although the number of patients in alternative SCS studies was very limited, almost all of them showed good responses to therapy with more than 50% VAS improvement and reduction of analgesic dosage. The article contains a review analysis of 12 articles concerning the current methods of treatment for postherpetic neuralgia including conservative treatment, spinal cord stimulation, and novel neuromodulation strategies. Available information on the pathophysiology of PHN and the effect or stimulation on its course, together with a number of technical nuances concerning various types of neurostimulation are also elucidated in this article. A number of alternative invasive treatments of PHN are also discussed.

Conclusions

Spinal cord stimulation is an established treatment option for patients with pharmacologically resistant PHN. High-frequency stimulation, burst stimulation, and dorsal root ganglion stimulation are promising options in the management of PHN due to the absence of paresthesias which can be painful for patients with PHN. But more research is still required to recommend the widespread use of these new methods.

The Contrasting Seasonality Patterns of Some Cancer-Types and Herpes Zoster Can Be Explained by a Binary Classification of Immunological Reactions

A binary classification of the pathogenic immune reactions as anti-inflammatory high-Treg reactions or pro-inflammatory low-Treg reactions explains both the relatively low incidence rate of several types of cancer, and the relatively high incidence rate of herpes zoster cases diagnosed in the summer compared to cases diagnosed in the winter (in regions with temperate climate). This binary model also elucidates the longer survival of cancer patients diagnosed during the summer compared to these diagnosed in the winter. The three key elements of this explanation are: (a) the effect of sunlight on Treg production; (b) the evolvement of cancer from a low-Treg condition at early stage, to a high-Treg condition at advanced stage, and (c) the evolvement of herpes zoster from a high-Treg condition at pre-exudative stage to a low-Treg condition at acute exudative stage. A significant proportion of indolent tumors at the time of diagnosis (>20%) is a prerequisite for a beneficial effect of sunlight on cancer incidence rate and prognosis. This prerequisite restricts the beneficial effect of diagnosis during summer to certain types of cancer. Clinical implication: the prognosis of early stage tumors may be improved by a course of corticosteroid (or other immunosuppressant) treatment.

A Guide to Preclinical Models of Zoster-Associated Pain and Postherpetic Neuralgia

Reactivation of latent varicella-zoster virus (VZV) causes herpes zoster (HZ), which is commonly accompanied by acute pain and pruritus over the time course of a zosteriform rash. Although the rash and associated pain are self-limiting, a considerable fraction of HZ cases will subsequently develop debilitating chronic pain states termed postherpetic neuralgia (PHN). How VZV causes acute pain and the mechanisms underlying the transition to PHN are far from clear. The human-specific nature of VZV has made in vivo modeling of pain following reactivation difficult to study because no single animal can reproduce reactivated VZV disease as observed in the clinic. Investigations of VZV pathogenesis following primary infection have benefited greatly from human tissues harbored in immune-deficient mice, but modeling of acute and chronic pain requires an intact nervous system with the capability of transmitting ascending and descending sensory signals. Several groups have found that subcutaneous VZV inoculation of the rat induces prolonged and measurable changes in nociceptive behavior, indicating sensitivity that partially mimics the development of mechanical allodynia and thermal hyperalgesia seen in HZ and PHN patients. Although it is not a model of reactivation, the rat is beginning to inform how VZV infection can evoke a pain response and induce long-lasting alterations to nociception. In this review, we will summarize the rat pain models from a practical perspective and discuss avenues that have opened for testing of novel treatments for both zoster-associated pain and chronic PHN conditions, which remain in critical need of effective therapies.

Analysis of Efficacy and Factors Associated with Reccurence After Radiofrequency Thermocoagulation in Patients with Postherpetic Neuralgia: a Long-Term Retrospective and Clinical Follow-Up Study

INTRODUCTION

Postherpetic neuralgia (PHN) is a painful condition that persists for 1 month or more after herpes zoster rash has healed. Radiofrequency thermocoagulation (RF-TC) provides analgesia by destroying the dorsal root ganglion and blocking the pain upload pathway; nonetheless, the concomitant neurological-related side effects and recurrence remain a concern.

METHODS

In this study, 228 patients with PHN in the thoracic segment treated with RF-TC of the dorsal root ganglion of the spinal nerve were included, and were followed up regularly after surgery. The numerical rating scale (NRS) scores, time to recurrence, and intraoperative and postoperative adverse events were recorded and analyzed. The Kaplan-Meier method was used to plot survival curves and calculate the cumulative effective rate and recurrence rate. Cox regression analyses were performed to identify factors associated with postoperative recurrence. Predictive models were built to assess the value of applications.

RESULTS

The NRS scores decreased in all postoperative periods compared with preoperative ones. At 10-year-follow-up, recurrence was observed in 34.6% (79/228) of patients that underwent PHN. The main postoperative complications were numbness and reduced abdominal muscle strength, which gradually decreased with time, while the abdominal muscle strength gradually recovered. No other adverse events occurred. Interval-censored multivariable Cox regression analysis demonstrated that disease course, complications, pain grade, and type of RF electrode were associated with a significantly higher risk of relapse. The main intraoperative adverse effect was a transient increase in pain during RF-TC.

CONCLUSION

CT-guided RF-TC of the dorsal root ganglion of the spinal nerve for PHN is a relatively safe and effective surgical option. Disease course, type of RF electrode, complications, and pain grade are risk factors for postoperative recurrence and can assist in clinical decision-making before the RF-CT procedure.

Effects of Palmitoylethanolamide (PEA) on Nociceptive, Musculoskeletal and Neuropathic Pain: Systematic Review and Meta-Analysis of Clinical Evidence

Some 30−50% of the global population and almost 20% of the European population actually suffer from chronic pain, which presents a tremendous burden to society when this pain turns into a disability and hospitalization. Palmitoylethanolamide (PEA) has been demonstrated to improve pain in preclinical contexts, but an appraisal of clinical evidence is still lacking. The present study aimed at addressing the working hypothesis for the efficacy of PEA for nociceptive musculoskeletal and neuropathic pain in the clinical setting. The systematic search, selection and analysis were performed in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 recommendations. The primary outcome was pain reduction, as measured by a pain assessment scale. The secondary outcome was improvement in quality of life and/or of parameters of function. The results obtained for a total of 933 patients demonstrate the efficacy of PEA over the control (p < 0.00001), in particular in six studies apart from the two randomized, double-blind clinical trials included. However, the results are downgraded due to the high heterogeneity of the studies (I2 = 99%), and the funnel plot suggests publication bias. Efficacy in achieving a reduction in the need for rescue medications and improvement in functioning, neuropathic symptoms and quality of life are reported. Therefore, adequately powered randomized, double-blind clinical trials are needed to deepen the domains of efficacy of add-on therapy with PEA for chronic pain. PROSPERO registration: CRD42022314395.

Analgesic Characteristics of NanoBEO Released by an Airless Dispenser for the Control of Agitation in Severe Dementia

Chronic pain is one of the most common causes of the need for clinical evaluation, acquiring more importance in the elderly with cognitive impairment. Reduced self-reporting capabilities cause unrelieved pain contributing to the development of agitation. Safe and effective pain treatment can afford the management of agitation without the serious increase in death risk associated with neuroleptics. To this aim, the essential oil of bergamot (BEO), proven by rigorous evidence to have strong preclinical anti-nociceptive and anti-allodynic properties, has been engineered (NanoBEO, patent EP 4003294) to allow randomized, double-blind, placebo-controlled trials (BRAINAID, NCT04321889). The present study: (1) assesses the analgesic effects of a single therapeutic dose of NanoBEO, as supplied by an airless dispenser for clinical translation, in models of inflammatory, neuropathic, and sensitization types of pain relevant to clinic; (2) provides a dose-response analysis of the efficacy of NanoBEO on scratching behavior, a typical behavioral disturbance occurring in dementia. A single therapeutic dose of NanoBEO confirms efficacy following thirty minutes pre-treatment with capsaicin and on the central sensitization phase induced by formalin. Moreover, it has an ID50 of 0.6312 mg and it is efficacious on static and dynamic mechanical allodynia. Altogether, the gathered results strengthen the potential of NanoBEO for clinical management of pain and agitation.

Phenotypes and Genotypes in Postherpetic Neuralgia Drug Therapy: A Narrative Mini-review

Neuropathic pain is a debilitating symptom reported by patients presenting with postherpetic neuralgia (PHN). Efforts to alleviate this pain have been projected to lie in individualization of pharmacological treatment through pain phenotyping and subsequent investigations into the genetic basis of PHN therapy. Understanding the various mechanisms related to these phenotypes can aid in improvement of available treatment options and discovery of new ones. Knowledge and application of genetic variations in PHN, structural proteins, and genes can aid in ascertaining risk, susceptibility to, severity of, and protection from PHN. This review summarizes the most recent information that has been published on phenotypes and genotypes with possible clinical applications and directions for future research.

Efficacy and Safety of Botulinum Toxin A and Pulsed Radiofrequency on Postherpetic Neuralgia: A Randomized Clinical Trial

This study evaluated the effectiveness and safety of botulinum toxin type A (BoNT-A) and pulsed radiofrequency (RF) in the clinical treatment of postherpetic neuralgia (PHN). A total of 100 patients with PHN were randomly divided into two groups (n = 50 per group): RF group and BoNT-A group. Based on conventional drug treatment, patients were treated with either a single nerve root pulsed radiofrequency therapy or a single local subcutaneous injection of BoNT-A in the lesion area. All the patients were followed up for 24 weeks on pain scores, sleep quality, anxiety, and depression scores, etc. In the last follow-up at the end of 24 weeks postoperation, the pain scores of patients in both groups were significantly lower than those before the operation (P < 0.05), indicating that both treatments were effective against PHN; however, there was no significant difference between these two groups (P > 0.05). It is noteworthy that the subcutaneous injection of BoNT-A is relatively easy to administer and less expensive compared to RF. Therefore, we believe that the subcutaneous injection of BoNT-A is an effective and safe method for the treatment of PHN.

Ultrasound-Guided Stellate Ganglion Block Combined with Extracorporeal Shock Wave Therapy on Postherpetic Neuralgia

OBJECTIVES

To evaluate the effect of ultrasound-guided stellate ganglion block combined with extracorporeal shock wave therapy (ESWT) on postherpetic neuralgia.

METHODS

Thirty-six patients with craniofacial postherpetic neuralgia, whose skin lesions were healed and natural course more than 1 month, were selected for the study and then randomly divided into 3 groups: the ultrasound-guided stellate ganglion block group (group A, n = 12), the extracorporeal shock wave therapy group (group B, n = 12), and the combined treatment group (group C, n = 12). Each group received basic drug treatment. The Visual Analogue Scale (VAS) and the Pain Disability Index (PDI) were used to evaluate the clinical effects of the 3 groups of patients before treatment, after twice treatments, after treatment for four times, and after treatment for six times.

RESULTS

The VAS and PDI were significantly declined in each group after the treatment (P < 0.05), and the declination in group C was more obvious than the other two groups (P < 0.05). After treatment for six times, the VAS score of group A, group B, and group C was 3.1 ± 1.2, 3.3 ± 1.3, and 1.9 ± 0.7, respectively. After treatment for six times, the PDI of group A, group B, and group C was 11.7 ± 8.4, 12.3 ± 7.8, and 4.6 ± 3.2, respectively. Three patients developed skin bruising and slight swelling, which were relieved by themselves.

CONCLUSIONS

Ultrasound-guided stellate ganglion block combined with shock wave therapy could significantly improve the pain symptoms of patients with postherpetic neuralgia, which is a safe and effective treatment for postherpetic neuralgia.

Analgesic Effect of Electroacupuncture on Postherpetic Neuralgia: A Trial Protocol for a Multicenter Randomized Controlled Trial

INTRODUCTION

The chronic neuropathic pain associated with postherpetic neuralgia (PHN) can last for several months or even many years, seriously affecting the affected person's work, sleep, mood, and daily life activities. In generaly, current treatments for PHN are at best limited and unsatisfactory, and adverse reactions are common, especially in elderly patients. Electroacupuncture (EA) is widely used clinically to manage painful diseases, but there remains a lack of evidence to support the effectiveness of EA on PHN. This study is designed to assess the efficacy and safety of EA on PHN, and to provide evidence-based medical evidence for EA treatment of PHN.

METHODS

This multicenter, prospective, randomized controlled trial will recruit 448 patients with PHN at seven clinical centers. Multicenter stratified variable block randomization will be used, and the eligible patients will be randomly allocated in a ratio of 1:1 to the EA group or sham EA group. The EA group will receive 4 weeks of EA treatment, given as 30-min treatment sessions, once daily, 5 times per week, for a total of 20 treatments; the sham EA group will receive sham EA treatment under the same conditions.

PLANNED OUTCOMES

The primary outcome measure is the 11-point Numeric Rating Scale pain score at week 4. The secondary outcome measures, including mechanical pain threshold, pain area of PHN, average number of pain episodes, the short-form McGill Pain Questionnaire 2, Zoster Brief Pain Inventory, the Depression, Anxiety, and Positive Outlook Scale, Patient Global Impression of Change, safety of EA, and use of concomitant medications, among others. The primary analysis of the outcomes will be the mixed-effect model with repeated measurement between groups on an intent-to-treat population.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT04560361. Registered 23 September 2020 ( https://clinicaltrials.gov/ct2/show/NCT04560361?term=NCT04560361&draw=2&rank=1 ).

Cutaneous pain in disorders affecting peripheral nerves

Our ability to quickly detect and respond to harmful environmental stimuli is vital for our safety and survival. This inherent acute pain detection is a "gift" because it both protects our body from harm and allows healing of damaged tissues [1]. Damage to tissues from trauma or disease can result in distorted or amplified nociceptor signaling and sensitization of the spinal cord and brain (Central Nervous System; CNS) pathways to normal input from light touch mechanoreceptors. Together, these processes can result in nagging to unbearable chronic pain and extreme sensitivity to light skin touch (allodynia). Unlike acute protective pain, chronic pain and allodynia serve no useful purpose and can severely reduce the quality of life of an affected person. Chronic pain can arise from impairment to peripheral neurons, a phenomenon called "peripheral neuropathic pain." Peripheral neuropathic pain can be caused by many insults that directly affect peripheral sensory neurons, including mechanical trauma, metabolic imbalance (e.g., diabetes), autoimmune diseases, chemotherapeutic agents, viral infections (e.g., shingles). These insults cause "acquired" neuropathies such as small-fiber neuropathies, diabetic neuropathy, chemotherapy-induced peripheral neuropathy, and post herpetic neuralgia. Peripheral neuropathic pain can also be caused by genetic factors and result in hereditary neuropathies that include Charcot-Marie-Tooth disease, rare channelopathies and Fabry disease. Many acquired and hereditary neuropathies affect the skin, our largest organ and protector of nearly our entire body. Here we review how cutaneous nociception (pain perceived from the skin) is altered following diseases that affect peripheral nerves that innervate the skin. We provide an overview of how noxious stimuli are detected and encoded by molecular transducers on subtypes of cutaneous afferent endings and conveyed to the CNS. Next, we discuss several acquired and hereditary diseases and disorders that cause painful or insensate (lack of sensation) cutaneous peripheral neuropathies, the symptoms and percepts patients experience, and how cutaneous afferents and other peripheral cell types are altered in function in these disorders. We highlight exciting new research areas that implicate non-neuronal skin cells, particularly keratinocytes, in cutaneous nociception and peripheral neuropathies. Finally, we conclude with ideas for innovative new directions, areas of unmet need, and potential opportunities for novel cutaneous therapeutics that may avoid CNS side effects, as well as ideas for improved translation of mechanisms identified in preclinical models to patients.

The role of circular RNAs in neuropathic pain

Neuropathic pain (NP) results from a lesion or disease of the nervous system and accompanied by chronic pain, leading a serious public health issue and economic burden. In terms of the NP mechanisms remaining poorly understood, circular RNAs (circRNAs), owing to their high stability and evolutionary conservation, are expected to be used as potential therapeutic targets or diagnostic biomarkers. In this review, we concisely discuss the characteristics and biological functions of circRNAs. As emerging evidence we reviewed, deregulation of circRNAs (e.g., circ-Filip1l, circHIPK3, ciRS-7, circRNA.2837, circ-Ankib1 and circAnks1a) were involved in NP development. It suggested that specific circRNAs modulated through sponging their target miRNAs and thus regulated the homologous downstream mRNAs and proteins in neuropathic pain. These findings provide a theoretical basis for circRNAs use as biomarkers and therapeutic targets in neuropathic pain.

AAAPT Diagnostic Criteria for Acute Neuropathic Pain

OBJECTIVE

Acute neuropathic pain is a significant diagnostic challenge, and it is closely related to our understanding of both acute pain and neuropathic pain. Diagnostic criteria for acute neuropathic pain should reflect our mechanistic understanding and provide a framework for research on and treatment of these complex pain conditions.

METHODS

The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the U.S. Food and Drug Administration (FDA), the American Pain Society (APS), and the American Academy of Pain Medicine (AAPM) collaborated to develop the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) for acute pain. A working group of experts in research and clinical management of neuropathic pain was convened. Group members used literature review and expert opinion to develop diagnostic criteria for acute neuropathic pain, as well as three specific examples of acute neuropathic pain conditions, using the five dimensions of the AAAPT classification of acute pain.

RESULTS

AAAPT diagnostic criteria for acute neuropathic pain are presented. Application of these criteria to three specific conditions (pain related to herpes zoster, chemotherapy, and limb amputation) illustrates the spectrum of acute neuropathic pain and highlights unique features of each condition.

CONCLUSIONS

The proposed AAAPT diagnostic criteria for acute neuropathic pain can be applied to various acute neuropathic pain conditions. Both the general and condition-specific criteria may guide future research, assessment, and management of acute neuropathic pain.

Cutaneous Neuroimmune Interactions in Peripheral Neuropathic Pain States

Bidirectional interplay between the peripheral immune and nervous systems plays a crucial role in maintaining homeostasis and responding to noxious stimuli. This crosstalk is facilitated by a variety of cytokines, inflammatory mediators and neuropeptides. Dysregulation of this delicate physiological balance is implicated in the pathological mechanisms of various skin disorders and peripheral neuropathies. The skin is a highly complex biological structure within which peripheral sensory nerve terminals and immune cells colocalise. Herein, we provide an overview of the sensory innervation of the skin and immune cells resident to the skin. We discuss modulation of cutaneous immune response by sensory neurons and their mediators (e.g., nociceptor-derived neuropeptides), and sensory neuron regulation by cutaneous immune cells (e.g., nociceptor sensitization by immune-derived mediators). In particular, we discuss recent findings concerning neuroimmune communication in skin infections, psoriasis, allergic contact dermatitis and atopic dermatitis. We then summarize evidence of neuroimmune mechanisms in the skin in the context of peripheral neuropathic pain states, including chemotherapy-induced peripheral neuropathy, diabetic polyneuropathy, post-herpetic neuralgia, HIV-induced neuropathy, as well as entrapment and traumatic neuropathies. Finally, we highlight the future promise of emerging therapies associated with skin neuroimmune crosstalk in neuropathic pain.

Post herpetic neuralgia: A retrospective study to evaluate response to modified Jaipur block with increased concentration of dexamethasone

Background:

Postherpetic neuralgia (PHN) is a complication of herpes zoster characterized by persistent dermatomal pain. It has a negative impact on the quality of life. There is no gold standard therapy for PHN, and various local and systemic treatments have been tried. There are studies reporting the use of combination of steroids and local anesthetics but there is no standardized method.

Aim:

To evaluate the response of modified Jaipur block with increased concentration of dexamethasone.

Methods:

We conducted a retrospective study in patients who were given Jaipur block. The patients age, sex, duration of PHN, type and severity of pain were observed. A combination of 2% lignocaine and 0.5% bupivacaine and dexamethasone was injected subcutaneously. The pain was scored using visual analogue scale at the baseline, and 1 month after 1^st, 2^nd, and 3^rd session of block and follow up after 6 months and 1 year.

Results:

The mean age of our patient was 63.33 ± 9.5 years. The males outnumbered females. Thoracic dermatomes were more commonly involved. The mean duration of PHN was 11.58 ± 12.76 months; stimulus evoked PHN was the commonest type of pain seen. The mean visual analogue score (VAS) decreased progressively after each session of the block. Maximum patients (50%) had excellent response, whereas 1.9% did not respond to the block. Relapse of pain was seen in 5.6% of the patients. There was no significant side effect noted.

Limitations:

There was no objective method used to assess pain.

Conclusion:

PHN is chronic neuropathic pain. Response to modified Jaipur block is good, but if the duration of PHN is more, the recurrence rate is higher. Modified Jaipur block is an effective and safe treatment for PHN

Inflammatory cytokine expression in the skin of patients with postherpetic neuralgia

Objective

To assess the expression of inflammatory cytokines in the affected and normal skin of postherpetic neuralgia (PHN) patients.

Methods

Affected skin and normal skin samples were collected from PHN patients. Inflammatory cell infiltration in the dermis were evaluated by hematoxylin-eosin (HE) staining. A human inflammatory protein array containing 40 cytokines was used to assess expression differences between PHN and control skin. Enzyme linked immunosorbent assay (ELISA) kits were used to confirm cytokine expression in 10 PHN patients.

Results

HE staining showed that the epidermis of PHN skin was thicker than that of contralateral normal skin. Compared with normal skin, there was more infiltration of inflammatory cells into the dermis of PHN skin. The cytokine array detected the presence of 21/40 cytokines; however, only interleukin (IL)-1α showed differential expression between PHN skin and normal skin. ELISA results for IL-1α, IL-16, intercellular adhesion molecule-1, and monocyte chemoattractant protein-1 were consistent with those of cytokine arrays.

Conclusions

Expression of inflammatory cytokines in PHN skin was not significantly altered compared with normal skin. Chronic refractory pain in PHN is not necessarily associated with increased inflammation in the affected skin.

Segmental zoster paresis of unilateral upper extremity: A case report and literature review

RATIONALE

Segmental zoster paresis (SZP) is a relatively rare neurologic complication of herpes zoster (HZ), and is characterized by focal asymmetric motor weakness in the myotome that corresponds to skin lesions of the dermatome. The upper extremities are the second most commonly involved regions after the face, and predominantly involve proximal muscles. The pathogenesis of SZP remains unclear; however, most of the reports indicate that it is the inflammation because of the spread of the herpes virus.

PATIENT CONCERNS

A 72-year-old man without trauma history of the left shoulder joint developed weakness of the left proximal upper extremity 10 days after vesicular eruption of HZ.

DIAGNOSES

His left shoulder girdle paresis was diagnosed with the upper truncus of the brachial plexus as a HZ complication according to a series of tests, including cervical magnetic resonance imaging (MRI), cerebral fluid analysis, sonography, and electrophysiological studies.

INTERVENTIONS

Acyclovir and prednisolone were administered during hospitalization to treat SZP. Meanwhile, analgesics and gabapentin were administered to control the patient's neuralgic pain. He also received inpatient (daily) and outpatient (3 times per week) physical therapy along with range of motion and strengthening exercises.

OUTCOMES

Partial improvement of the strength of the left shoulder girdle, and no improvement of the left deltoid muscle was observed 2 months after the interventions.

LESSONS

This case emphasizes that HZ infections may be complicated by segmental paresis and they should be considered in the differential diagnosis of acute paresis in the upper limb. Awareness of this disorder is important because it avoids unnecessary invasive investigations and interventions, leading to suitable treatments with favorable prognosis.

Effectiveness of pregabalin as a secondary treatment for neuropathic pain from postherpetic neuralgia

Herpes zoster or shingles causes a severe painful rash that spreads along dermatomes in the face or chest wall, which leads to a condition known as postherpetic neuralgia (PHN). There is no cure for PHN, but there are many treatments to reduce pain duration and severity. In this case report, we describe a patient treated for PHN using pregabalin (Lyrica) after failure with gabapentin. Despite being listed as a controlled substance by the Food and Drug Administration, pregabalin may be an effective first-line therapy for PHN and other forms of neuropathic and chronic pain.

Local Administration of Methylcobalamin for Subacute Ophthalmic Herpetic Neuralgia: A Randomized, Phase III Clinical Trial

OBJECTIVES

The ophthalmic branch of the trigeminal nerve is one of the most frequently involved sites of postherpetic neuralgia. A single-center randomized controlled study was conducted to evaluate the efficacy of local methylcobalamin injection for subacute ophthalmic herpetic neuralgia (SOHN).

METHODS

One hundred and five patients with a pain score of 4 or greater were randomized to receive a combination of methylcobalamin and lidocaine via local injection (LM group, n = 35), intramuscular methylcobalamin and local lidocaine injection (IM group, n = 35), and oral methylcobalamin tablet and lidocaine local injection (OM group, n = 35) for 4 weeks. Multilevel mixed modeling was employed to examine treatment responses.

RESULTS

Pain scores were reduced in all groups, but this reduction was significantly greater in the LM group (6.7 at baseline vs. 2.8 at endpoint) when compared with systemic administration (IM group 6.8 vs. 4.9, OM group 6.7 vs. 5.1). Clinically relevant reduction of pain (>30%) was seen in 91% of patients in the LM group, a significantly greater proportion than in the systemic groups (66% IM group, 57% OM group). Analgesic use reduced significantly in the LM group (94% at baseline vs. 6% at endpoint) but not in systemic groups (IM group 97% vs. 86%, OM group 94% vs. 80%). Health-related quality of life was higher in the LM group than in the systemic groups. In mixed modelling, increased age was associated with a lower response to methylcobalamin.

CONCLUSIONS

This study indicates that local injection of methylcobalamin produces significant pain relief from SOHN and is superior to systemic administration.

Efficacy of extracorporeal shockwave therapy in the treatment of postherpetic neuralgia: A pilot study

Established conventional treatments for postherpetic neuralgia (PHN) and postherpetic itch (PHI) are difficult and often disappointing. In this study, the authors investigated the effect and mechanisms of extracorporeal shockwave therapy (ESWT) on pain and itch associated with PHN and PHI.Thirteen patients, 50 to 80 years of age, with symptoms associated with PHN or PHI (duration of persistent pain >3 months) and complaints of pain or itch rated >4 on a numerical rating scale (NRS), were included. ESWT was administered using a shockwave device (Piezo Shockwave, Richard Wolf GmbH, Knittlingen, Germany) to skin areas affected by pain or itch. An energy flux density of 0.09 to 0.16 mJ/mm at a frequency of 5 Hz and 2000 impulses was administered at 3-day intervals for 6 sessions. The NRS, 5D-Itch Scale, and Patients Global Impression of Change (PGIC) scale were used to evaluate the efficacy of ESWT.NRS scores of pain and itch and 5D-Itch Scale scores decreased significantly compared with before treatment and at the end of the treatment sessions (P < .0001, P = .001, P = .0002, respectively). There was a statistically significant difference between PGIC scores, which were checked every 2 sessions (P < .0001).ESWT is a noninvasive modality that significantly reduced PHN-associated pain and itch.

Impaired hemodynamic activity in the right dorsolateral prefrontal cortex is associated with impairment of placebo analgesia and clinical symptoms in postherpetic neuralgia

The dorsolateral prefrontal cortex (dlPFC) is functionally linked to the descending pain modulation system and has been implicated in top down pain inhibition, including placebo analgesia. Therefore, functions of the dlPFC may be impaired in patients with chronic pain. Postherpetic neuralgia (PHN) is one of several syndromes with chronic neuropathic pain. In the present study, we investigated possible dysfunction of the dlPFC in chronic pain using patients with PHN. In a conditioning phase, heathy controls (n = 15) and patients with PHN (n = 7) were exposed to low (LF) and high (HF) frequency tones associated with noxious stimuli: weak (WS) and strong (SS) electrical stimulation, respectively. After the conditioning, cerebral hemodynamic activity was recorded from the bilateral dlPFC while the subjects were subjected to the cue tone-noxious electrical stimulation paradigm, in which incorrectly cued noxious stimuli were sometimes delivered to induce placebo and nocebo effects. The results indicated that hemodynamic responses to the LF tone in the right dlPFC was significantly lower in patients with PHN compared to the healthy controls. Furthermore, the same hemodynamic responses in the right dlPFC were correlated with placebo effects. In addition, clinical symptoms of PHN were negatively correlated to cerebral hemodynamic responses in the right dlPFC and magnitudes of the placebo effects. The results suggest that the right dlPFC, which is closely associated with the descending pain modulation system, is disturbed in PHN.

MicroRNA And Circular RNA Expression In Affected Skin Of Patients With Postherpetic Neuralgia

Mechanisms of postherpetic neuralgia (PHN) are still not clear. Transcripts such as microRNA (miRNA) and circular RNA (circRNA) in the affected skin may take part in the initiation and development of this neuropathic pain; however, their expression profiles in skins of PHN patients have not been reported. The PHN affected skin and the mirror skin were collected and subjected to miRNA and circRNA microarray, and expression profiles were comparatively analyzed. There were 317 differently expressed miRNAs in PHN affected skin compared with mirror skin (fold change ≥2.0), and 13 of them showed fold change >10 in the PHN skin. Only one circRNA, hsa_circRNA_405463 showed fold change >2 in PHN skin, however, 31 circRNAs with fold change ≥1.5. To evaluate functions of differential miRNAs, their target mRNAs were predicted and bioinformatics analyses including gene ontology, Kyoto Encyclopedia of Genes and Genomes pathway were conducted. Target mRNAs significantly (P<0.05) enriched in 85 pathways, such as FoxO, AMPK, MAPK and pathway. These data reported for the first time that miRNA and circRNA differentially expressed in the PHN skin and these transcripts with abnormal expression could be potential targets to treat PHN.

Modeling Varicella Zoster Virus Persistence and Reactivation - Closer to Resolving a Perplexing Persistent State

The latent state of the human herpesvirus varicella zoster virus (VZV) has remained enigmatic and controversial. While it is well substantiated that VZV persistence is established in neurons after the primary infection (varicella or chickenpox), we know little of the types of neurons harboring latent virus genomes, if all can potentially reactivate, what exactly drives the reactivation process, and the role of immunity in the control of latency. Viral gene expression during latency has been particularly difficult to resolve, although very recent advances indicate that it is more restrictive than was once thought. We do not yet understand how genes expressed in latency function in the maintenance and reactivation processes. Model systems of latency are needed to pursue these questions. This has been especially challenging for VZV because the development of in vivo models of VZV infection has proven difficult. Given that up to one third of the population will clinically reactivate VZV to develop herpes zoster (shingles) and suffer from its common long term problematic sequelae, there is still a need for both in vivo and in vitro model systems. This review will summarize the evolution of models of VZV persistence and address insights that have arisen from the establishment of new in vitro human neuron culture systems that not only harbor a latent state, but permit experimental reactivation and renewed virus production. These models will be discussed in light of the recent data gleaned from the study of VZV latency in human cadaver ganglia.