Neuropathic Pruritus Relieved
by Epidural Steroid Injection:
A Case Report
Results
The initial L2
3 LESI provided 100% relief of
itching for six months, with significant
improvements in sleep and energy levels.
Symptoms returned after six months,
prompting a repeat LESI with similar
outcomes. Adjunct therapies, including
gabapentin and low dose naltrexone, provided
sustained symptom relief with minimal side
effects. The patient reported a significant
overall improvement in quality of life.
Discussion
This case demonstrates the importance of a
comprehensive and interdisciplinary approach
in managing refractory neuropathic pruritus.
Although dermatological treatments addressed
potential primary skin conditions, the lack of
response and history of a back injury
highlighted a neuropathic etiology.
There are currently no widely published
studies directly addressing the treatment of NP
with epidural injections. This case report
introduces a novel application of
interventional pain management techniques,
suggesting that epidural steroid injections may
alleviate nerve root inflammation and improve
symptoms in NP.
The marked response to epidural steroid
injections underscores the role of targeted
anti inflammatory interventions in managing
nerve root irritation. Additionally, the
integration of dermatological insights into
diagnosis and treatment highlights the
importance of interdisciplinary collaboration
in achieving optimal outcomes. Further
studies are warranted to explore this treatment
modality in NP.
References
1.
Huang W, Soto E, Friedman TC. Notalgia paresthetica: Updates on
pathogenesis and treatment options. Clin Dermatol. 2021;39(4):518 524.
doi:10.1016/j.clindermatol.2021.03.012
2.
Weisshaar E, Szepietowski JC. Itch: Management in chronic pruritus.
Front Med (Lausanne). 2019;6:124. doi:10.3389/fmed.2019.00124
3.
Manchikanti L, Hirsch JA, Falco FJE, Boswell MV. Lumbar epidural
steroid injections: Current controversies and future perspectives. Pain
Physician. 2015;18(4):E493 E550.
4.
Stander S, Luger TA. Neuropathic itch: Diagnosis and treatment.
Dermatol Ther. 2020;33(5):e13679. doi:10.1111/dth.13679
Paulina Giacomeli MD, Keshin Purohit MD, Armand
Ardestani DO, Daniel Yadegari MD, Alexa Lean MD.
UC Irvine Department of Pain Medicine
Needle Placement and Contrast Spread During LESI
Anterior
posterior with AP fluoroscopic view demonstrating
needle placement at the L2 3 interlaminar space with contrast
spread confirming epidural entry during the lumbar epidural
steroid injection (LESI).
Lateral View of Needle Placement During LESI
Lateral fluoroscopic view confirming accurate needle
placement at the L2 3 interlaminar space during the lumbar
epidural steroid injection (LESI).
Introduction
Neuropathic pruritus, including conditions
such as notalgia paresthetica (NP), is
characterized by chronic itching without an
identifiable dermatological cause. NP often
arises from posterior rami nerve involvement
and is associated with degenerative spine
changes. This case highlights the successful
management of severe neuropathic pruritus in a
93 year old male using a combination of
dermatological, pharmacological, and
interventional therapies.
Case Report
A 93
year old male presented with a three year
history of severe, intermittent pruritus localized
to the upper and lower back, predominantly on
the left side. Symptoms were worse at night,
disrupting sleep and quality of life. He denied
pain, sensitivity, bowel or bladder dysfunction,
or saddle anesthesia.
The patient was initially treated by
dermatology for presumed seborrheic keratoses
or xerosis using topical steroids, moisturizers,
and dupilumab, but these treatments were
ineffective. Dermatology later attributed the
pruritus to a previous back injury from a roller
skating incident, suggesting a neuropathic
origin. After unsuccessful trials of neuropathic
agents, including gabapentin, the patient was
referred for interventional pain management.
Imaging revealed lumbar spondylosis,
including moderate degenerative changes at
L4 5 and L5 S1. Based on symptom
localization and imaging findings, the patient
was diagnosed with NP. Treatment included a
multimodal regimen of low dose naltrexone,
capsaicin cream, and an L2 3 interlaminar
epidural steroid injection (LESI).