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Notalgia Paresthetica: Clinical Features, Radiological Evaluation, and a Novel Therapeutic Option Cevriye Mülkoğlu* and Barış Nacır

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Notalgia Paresthetica: Clinical Features, Radiological Evaluation, and a Novel Therapeutic Option Cevriye Mülkoğlu* and Barış Nacır Mülkoğlu and Nacır BMC Neurology (2020) 20:191 https://doi.org/10.1186/s12883-020-01773-6 RESEARCH ARTICLE Open Access Notalgia paresthetica: clinical features, radiological evaluation, and a novel therapeutic option Cevriye Mülkoğlu* and Barış Nacır Abstract Background/objective: Notalgia paresthetica (NP) is a sensory neuropathy characterized by localized pruritus and pain, presenting with or without a well-circumscribed hyperpigmented patch in the upper back. Abnormal sensations, such as burning, numbness, and paresthesia are often present in patients with NP. In this study, we clinically and radiologically analyzed patients with NP. The literature contains studies describing lidocaine treatments involving intravenous and topical applications for NP. We also investigated the effect of intradermal lidocaine injection on patients with NP. Methods: A total of 80 patients (45 patients with NP and 35 suffering from dorsalgia without NP) were included in the study. The age, gender and body mass index (BMI) of the patients, and the characteristics of their symptoms were recorded. The severity of pain and pruritus was assessed by the Visual Analog Scale (VAS). Radiography and magnetic resonance imaging of the spine were performed. In this study, we intradermally administered lidocaine diluted with saline into the upper back over three sessions. 1 cc 2% lidocaine was diluted with 5 cc 0.9% saline, and a total of 6 cc lidocaine mixture was obtained. The injection was performed locally at 1-cm intervals around the hyperpigmented patch and segmentally along the C2-T6 spinous processes. These patients were called for a follow- up at the second and fourth weeks and third month. Results: There was no statistically significant difference between the two groups in terms of age, BMI, VAS-pain score, and duration of symptoms (p > 0.05 for all). Forty-six cervical and/or thoracic degenerative changes or herniated nucleus pulposus (HNP) were detected in patients with NP. There was a significantly higher number of HNP at the C6–7 segment and cervical degenerative changes in the NP group (p < 0.05). The VAS-pain and VAS- pruritus scores were significantly decreased at all follow-up sessions, and improvement was sustained by lidocaine up to the third month. Conclusion: Cervical degenerative changes and HNP of the C6–7 segment seem to be contributing factors for NP. Local lidocaine can be effective for pain relief and pruritus in NP. Keywords: Notalgia paresthetica, Dorsalgia, Itching, Lidocaine, Spine * Correspondence: [email protected] Department of Physical Medicine and Rehabilitation, Health Sciences University Ankara Training and Research Hospital, Ulucanlar street, Ankara, Turkey © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Mülkoğlu and Nacır BMC Neurology (2020) 20:191 Page 2 of 8 Background [3]. Muscle strain and spasm can cause these nerve fibers Notalgia paresthetica (NP) is characterized by localized to impingement. chronic pruritus medial or inferior to the scapulae with There are no primary cutaneous lesions in NP, these le- or without an associated hyperpigmented macule. It is sions are just secondary to chronic scratching and rubbing believed that NP is relatively common but perhaps [8, 9]. Although the occurrence of NP is not rare, most underdiagnosed [1]. NP can exacerbate from time to cases are overlooked; therefore, it is often undiagnosed. time and lasts for months to years. It is widely accepted The studies performed to date provide only limited data that NP is a sensory neuropathy which occurs as a result concerning the clinical and radiological findings of NP. of the alteration of the cutaneous branches of the poster- The treatment of NP is multidisciplinary, including ior rami, especially the upper branches of the T2-T6 topical agents (intralesional steroids, botulinum toxin A, spinal nerves [2, 3]. capsaicin, and lidocaine), systemic drug treatments Although the etiology of NP has not yet been com- (gabapentin, oxcarbazepine, and amitriptyline) and phys- pletely elucidated, degenerative changes of the cervical ical therapy methods (TENS, cervical traction, exercise, spine are considered to be associated with its pathogenesis and manipulation) [2, 3, 10]. In the literature, there are [4, 5]. NP mostly occurs in women aged 54 to 62 years [6]. studies describing lidocaine treatments for NP. Cruz The condition is usually unilateral and rarely bilateral. et al. reported a 39-years-old woman diagnosed with NP Clinical symptoms in NP vary, including pain, burning, and treated by the daily application of topical lidocaine coldness, pruritus, numbness, tingling, paresthesia, allody- patches on the symptomatic region and exercises (pos- nia, hyperalgesia, and hypoesthesia. Hypo/hyperpigmented tural corrective exercises, scapular muscle strengthening, well-circumscribed patches, macules, and hyperkeratosis and pectoral muscle stretching). The patient was men- may be observed secondary to scratching on the mid- tioned that if she stopped using the lidocaine patches, upper portion of the back associated with the distribution the symptoms reappeared, at 2 weeks after the first of the T2-T6 dermatome [3, 7](Fig.1). Most studies sug- examination. Three months later, she presented with gested a thoracic polyradiculopathy due to spinal nerve complete symptom relief without the need for topical entrapment is the primary etiology for pruritus. Another lidocaine treatment. The patient was symptom-free at attributed factor is the anatomical right angle of sensory the seventh-month follow-up [11]. Chtompel et al. pre- nerve fibers penetration through the multifidus muscle sented a 50-year-old female with spinal cord injury. The patient was diagnosed with NP and treated with intra- venous lidocaine for the management of NP. Three infu- sions of lidocaine at two-week intervals at a dose of 1 mg/kg bolus followed by 4 mg/kg infusion over 1 h were administered. Following the first two infusions, neuro- pathic pain was not relieved; however, significant relief of pruritus was observed [2]. We also previously re- ported a 73-year-old male case with NP treated with therapeutic lidocaine injections. In that case, we locally administered lidocaine into the upper back to relieve pain and obtained successful results related to neuro- pathic back pain. At the second-week follow-up, the VAS score of the patient was observed to have decreased from 7 to 1 [12]. The primary aim of this study was to investigate the clinical findings and localization of damage radiologically in patients with NP. Secondly, we aimed to evaluate the effect of therapeutic lidocaine injections on NP patients. Methods In this cross-sectional study, a total of 80 patients who presented to our outpatient clinic between August 2018 and June 2019 were included in this study. Forty-five pa- tients diagnosed with NP were recruited for the NP group and 35 who had dorsalgia without NP were included in Fig. 1 The arrow shows unilateral hyperpigmented macule in the the control group. Patients under 18 years of age, those medio-inferior scapulae with chronic inflammatory, infectious, neurological, Mülkoğlu and Nacır BMC Neurology (2020) 20:191 Page 3 of 8 psychiatric, rheumatologic and malignant diseases, local and segmentally along the C2-T6 spinous processes or diffuse other skin diseases, and those with history of (Fig. 2). After the first application, the injections were re- trauma to the cervical and/or thoracic spine were peated at the second and fourth weeks, taking the total excluded. number of sessions to three. Topical capsaicin was pre- The study was approved by the local ethics committee scribed to the remaining patients in the NP group. All of and was conducted in accordance with the ethical stan- the patients were called for a follow-up at the second dards specified in the 1964 Declaration of Helsinki and and fourth weeks and third month. The VAS-pain and its later amendments. The patients were informed by the VAS-pruritus scores were assessed at these visits. researchers about the aim of the study and the confiden- tiality of their personal information. The informed con- Statistical analysis sent was obtained from all participants. Statistical analyses were conducted using the Statistical The patients’ age, gender, weight and height were re- Package for the Social Sciences (SSPS) software (SPPS corded. The body mass index (BMI) was calculated in Inc., Chicago, USA), version 21.0. The Shapiro-Wilk test kg/cm2. The characteristics and duration of the symp- was used to evaluate the normality of data distribution. toms and dermatomal localization of the lesions were The normally distributed data were presented as mean ± noted. The presence of spinal trauma history was ques- standard deviation (SD) and for the data without normal tioned, and the patients with such history were not in- distribution, the median (minimum-maximum) and cluded in the study. The visual analogue scale (VAS) was interquartile range (IQR) values were used. The categor- used to assess the severity of current pain and pruritus ical variables were given as numbers (n) and frequency based on a chart numbered from 0 (no symptoms) to 10 rates (%).
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