Anesth Pain Med 2014; 9: 103-105 ￭Case Report￭
Ultrasound-guided pulsed radiofrequency treatment for postherpetic neuralgia of supraorbital nerve -A case report-
Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, *Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
Jin Young Lee, Woo Seog Sim, Duk Kyung Kim, Hue Jung Park*, Min Seok Oh, and Ji Eun Lee
Pulsed radiofrequency treatment has an analgesic effect by PRF treatment cases of supraorbital neuralgia, it has been neuromodulation of the central pain pathway without neural injury. typically performed using a C-arm or landmark based blind However, lack of knowledge regarding the exact mechanism on technique [1-3], and there is no literature describing an ultra- neuropathic pain makes the use of pulsed radiofrequency treatment controversial. Here, we describe a case of satisfactory pain relief sound-guided PRF technique. Accurate injection technique is after ultrasound-guided pulsed radiofrequency treatment in a patient necessary to limit side effects, especially for ablation-related with supraorbital herpetic pain refractory to medication. This case management. In this report, we performed ultrasound-guided indicates the potential of ultrasound-guided pulsed radiofrequency treatment in patients with postherpetic supraorbital neuralgia. PRF treatment for a patient with severe supraorbital herpetic (Anesth Pain Med 2014; 9: 103-105) pain, with excellent results. Ultrasound-guided PRF treatment can thus be a feasible and safe simple approach for patients Key Words: Pain, Pulsed radiofrequency, Supraorbital neuralgia, with supraorbital herpetic neuralgia. Ultrasound.
CASE REPORT Herpetic neuralgia is a significant source of morbidity following reactivation of dormant varicella zoster virus. Varice- A 59-year-old, 152 cm, 70 kg female patient was referred to lla-zoster viral particles travel down the neural axon to the our pain clinic with severe left facial pain with rash. The rash skin and produce painful, vesicular cutaneous lesions on the had developed 5 weeks previously and clinical evaluation affected dermatome. It must be treated promptly to avoid confirmed acute herpes zoster on the left supraorbital branch progressive pain, sensory dysfunction, and central sensitization. of the trigeminal nerve. Just before her visit, she received Nerve block with local anesthetics may relieve pain by medical treatment with a stellate ganglion block at a local reducing afferent transmission of nociceptive pathway, but it hospital. Even though she had a congestive left eye, herpes usually does not provide long term relief. Recently, pulsed zoster ophthalmicus was ruled out by an ophthalmologist. The radiofrequency (PRF) treatment has drawn interest for its antih- viral skin lesions were almost resolved successfully during the yperalgesic or antiallodynic effect, which acts to influence syn- acute phase. However, supraorbital pain remained severe. apse transmission and excitatory C-fiber responses, resulting in Examination revealed a recently acquired herpetic scar over the a neuromodulation of the central pain pathway. In previous left median eyebrow and forehead. She suffered from continu- ous throbbing pain (6 points on visual analogue scale, VAS, 0
Received: August 26, 2013. = no pain, 10 = worst pain imaginable) with intermittent elec- Revised: September 13, 2013. trical shock-like sensation on this frontal head (VAS score of Accepted: December 9, 2013. 8). Neurological examination showed decreased sensation (3/5, Corresponding author: Hue Jung Park, M.D., Ph.D., Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic 0 = no sensation, 5 = normal sensation), tingling (3/5, 0 = no University of Korea College of Medicine, 505, Banpo-dong, Seocho-gu, tingling, 5 = severe tingling), itching (4/5, 0 = no itching, 5 = Seoul 137-040, Korea. Tel: 82-2-2258-6157, Fax: 82-2-537-1951, E-mail: severe itching) and hyperalgesia (2/5, 0 = no hyperalgesia, 5 = [email protected] severe hyperalgesia) in the distribution of the left supraorbital
103 104 Anesth Pain Med Vol. 9, No. 2, 2014 nerve. She had been treated with 225 mg pregabalin, three medications, including 75 mg pregabalin, one 37.5 mg tablets of 37.5 mg tramadol/375 mg acetaminophen combination tramadol/375 mg acetaminophen combination tablet, and 2.5 (Cetamadol; Ildong, Seoul, Korea), 15 mg oxycodone, and 20 mg nortriptyline in a day without opioid, which was decreased mg nortriptyline in a day, with partial pain relief of VAS 5. by 70% of the requirement, without further nerve block. She refused previous procedure and increasing medications due to systemic side effects of nausea and sedation. She underwent DISCUSSION two supraorbital nerve blocks with 2 ml of 0.375% ropivacaine with 5 mg dexamethasone under ultrasound guidance and Trigeminal herpetic neuralgia is a debilitating facial pain showed a positive response, which provided pain relief for 1 disorder, which is often refractory and may not respond satisf- day with 60% reduction in pain intensity. Therefore, we actorily to standard pain management. The supraorbital nerve, proposed to perform PRF treatment in hopes of achieving a as a terminal branch of the ophthalmic division of the longer duration of pain relief. After informed consent, the trigeminal nerve, innervates the skin of the forehead, eyelid, patient was placed in the supine position. The skin was conjunctiva and the frontal sinus with supratrochlear nerve. In aseptically draped with betadine. Ultrasound was prepared with our case, the patient experienced supraorbital herpetic neuralgia a sterile transparent sheath and aseptic ultrasound gel. Using a as a continuation of that previously experienced with the acute high frequency linear transducer (SonoSite Inc., Washington, herpes zoster eruption, which has been described as a throbbing USA), we tried localizing the left supraorbital foramen. The and burning sensation, itching, or tingling along the course of probe was positioned transversely above the roof of the left the supraorbital nerve. There are various protocols for the pain orbital rim and the bone was scanned slowly in a cephalad to management. The main concerns are adequate pain control and caudad direction to find the break in the linear hyperec- minimization of central neural sensitization. To prevent and hogenicity. The left supraorbital foramen was captured as a reduce the incidence or severity of postherpetic neuralgia (PHN), hypoechoic break in the bony surface. After that, a radiofrequ- significant rapid pain relief is of utmost important during acute ency needle insulated with a 5 mm active tip (22G, phase. Commonly employed therapies are oral anticonvulsants, SMK-C10; Radionics Inc, Burlington, MA, USA) was tricyclic antidepressants, opioids, topical agents, superficial advanced slightly using an out-of-plane approach. For definite trigeminal nerve block and more invasive procedures such as identification between bone touch and supraorbital nerve radiofrequency lesioning, peripheral nerve stimulation and sensation, we performed sensory stimulation of the supraorbital surgical ablation. However, ideal pain management for refrac- nerve at 50 Hz and 0.5 V, then started three cycles of PRF tory supraorbital neuralgia has not yet been determined. treatment at 42oC for 120 sec (Fig. 1). Following the PRF For diagnosis and treatment of trigeminal herpetic neuralgia, treatment, we administered 2 ml of 0.375% ropivacaine with 5 superficial trigeminal nerve block is performed by injecting mg dexamethasone. The treatment was well tolerated, and the local anesthetic and/or steroid in close proximity to the three patient was without discomfort during the procedure. terminal branches of the trigeminal nerve. Traditionally, C-arm Post-procedurally, pain improved significantly with a VAS or landmark based palpation technique has been widely used. score of 3. She has been followed in a pain VAS 2-3, However, block failures may occur when encountering altered improved sensation (4/5), tingling (1/5), and itching (3/5) by bony and/or vessel anatomy. Ultrasound is a safe, simple and our pain clinic for the past 28 weeks. She is controlling her non-invasive tool for visualizing and identifying bone, nerve
Fig. 1. (A) An ultrasound image of supraorbital nerve via out-of-plane approach in the transverse scan. (B) Pulsed radiofrequency procedure of supraorbital nerve. Jin Young Lee, et al：Postherpetic supraorbital neuralgia 105 and vessels. Blocks with ultrasound has increased in pain be needed to provide further evidence on long term efficacy of clinics to locate nerves precisely and enable real-time needle PRF and any difference in outcomes between the traditional advancement. This can potentially avoid unnecessary trauma to C-arm or landmark based versus ultrasound-guided technique. surrounding tissues. Especially, ablation-related procedures need In conclusion, ultrasound-guided PRF could potentially be a more accuracy for preventing possible complications, including safe, simple and effective treatment option for patients, who inadvertent nerve injury or perineural hematoma. cannot tolerate oral medications and who has high risk factors PRF treatment has recently been reported to have promising for developing PHN. results in pain management. It is a non-destructive minimally invasive technique and is felt to be safer than continuous REFERENCES radiofrequency considering neural damage. It has been reported 1. Seo KC, Shin HD, Kim JH, Song SY, Rho WS, Chung JY. Pulsed to produce analgesia, possibly by plastic change of the central radiofrequency treatment of the supraorbital and supratrochlear pain pathway [4]. The exact mechanisms of pain relief remain nerve in a case of trigeminal neuralgia -a case report-. Korean J unknown and several hypotheses have been described. 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