Successful Percutaneous Neurostimulation for the Management of Postherpetic Ophthalmic Neuralgia: Case Report
After rash healing, many patients with herpes zoster can develop chronic pain, a complication known as postherpetic neuralgia. The ophthalmic branch (V1) of the trigeminal nerve and the thoracic nerves are the most commonly affected structures. Symptoms can persist for months or even years, and this condition can profoundly affect a patient’s quality of life. The proper management of this condition is arduous and troublesome, and for that reason many therapeutic options are available. Here we report a case that was successfully managed by a novel technique of combining supraorbital nerve stimulation for intractable ophthalmic postherpetic neuralgia.
Case of a 56-year-old male who was referred to the Pain Management Clinic of the University of Puerto Rico due to intermittent lancinating pain on the left side of his forehead and face. He reported that six months prior to the onset of his symptoms, multiple vesicles covered with hemorrhagic crusts appeared on his left pre-auricular, auricular and scalp region. The dermatological rash resolved in approximately 14 days, however the surrounding skin was left with hyperpigmented and hypopigmented macules and associated hyperalgesia, hyperpathia, and allodynia. Initially he was managed using acyclovir, gabapentin, amitriptyline, tramadol, lidocaine patch, and oxycodone; all with poor results. As a last resort, multiple blocks of the supraorbital nerve using bupivacaine 0.5% and triamcinolone were performed, obtaining partial improvement of the neurological symptoms for a short period of time. Due to the lack of proper management, it was decided to perform a trial of peripheral neurostimulation. Under conscious sedation and local anesthetic, two electrodes were placed around the most painful area in the left supraorbital and fronto-temporal regions. For one week the patient reported an improvement of above 80%. For this reason, it was decided to place the neurostimulator definitely. Under general anesthesia, the electrodes were placed in the designated area and the wires were tunneled through the neck to localize the IPG in the left infraclavicular region. One week later, the neurostimulation was initiated with excellent results. To this moment the patient is experiencing a considerable decrease in analgesic drug use and reports a very good coverage of the painful area.
I declare that there are no conflicts of interest or support that may cause bias in my presentation.
Management of postherpetic neuralgia remains a challenge, especially because monotherapy with available therapeutic alternatives has been ineffective in providing adequate pain relief to some patients. Peripheral neurostimulation is a novel alternative for treatment; however, like any other procedure, it has a number of technical and surgical challenges. Nonetheless, neurostimulation in patients with postherpetic neuralgia have proven excellent results with regards to pain management and quality of life improvements.