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7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 1/57
Acute Herpes Zoster&
Post herpetic
Neuralgia
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 2/57
Herpes zoster
Herpes zoster is an infectious diseasethat is caused by the varicellazostervirus
!t is postulated that during the courseof pri"ary infection with #Z#$ thevirus "igrates to the dorsal root orcranial ganglia
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 3/57
Herpes zoster
!n so"e individuals the virus "ayreactivate and travel along peripheralor cranial sensory pathways to the
nerve endings$ producing the pain ands%in lesions characteristic of shingles
he reason for reactivation 'decrease in cell"ediated i""unity
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 4/57
Ris% factors
(u)ering fro" "alignancies *particularly
ly"pho"a+
Receiving i""unosuppressive therapy
*che"otherapy$ steroids$ radiation+
,enerally debilitated by chronicdiseases
Patients older than 60 years
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 5/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 6/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 7/57
(!,N( AND (-MP.M(
Herpetic pain/ 01 day before of skin lesions
May be acco"panied by 2uli%e sy"pto"s
Progresses fro" a dull$ aching sensation tounilateral$(eg"ental$ bandli%e dysesthesias andhyperpathia
3urning pain $ hyperesthesia$ allodynia Zoster sine herpete
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 8/57
(!,N( AND (-MP.M(
4ro" a "ild selfli"ited proble" to adebilitating$ constantly burning painthat is e5acerbated by light touch$
"ove"ent$ an5iety$and6orte"perature change
7an lead to suicide
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 9/57
(!,N( AND (-MP.M(
horacic der"ato"es 089
7ervical region 8:9
rige"inal nerve ;19lu"bosacral region !! 9
Ra"say Hunt syndro"e
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 10/57
(!,N( AND (-MP.M(
Skin lesions
7rops of "acular lesions
Papules
#esicles7rusting
7rusts fall away *(cabs+
Pin% scars
Hypopig"ented and atrophic scars
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 11/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 12/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 13/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 14/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 15/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 16/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 17/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 18/57
Diferential Diagnosis< Appendicitis< !ntervertebral discdisease< Myocardial infarction< Pleurisy
< Renal stone< rige"inal neuralgia< 7holecystitis< ,lauco"a< 3ell=s palsy< 3rachioradial pruritus< 3ullous i"petigo< 3ullous pe"phigoid< 7andidiasis
< 7aterpillar der"atitis
< 7ontact der"atitis< >rysipelas< 4olliculitis< !ncontinentia pig"enti< ?elly@sh sting
< ichen striatus< Pe"phigus< Photoallergic reaction< Phytophotoder"atitis< Rhus der"atitis< Brticaria< Zosterifor" herpes< Zosterifor" "etastasis< 7ellulitis
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 19/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 20/57
7.MP!7A!.N(
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 21/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 22/57
TREATMENT
Relief of acute pain and sy"pto"s
Prevention of co"plications$ includingpostherpetic neuralgia
>arlier treat"entless li%ely postherpetic
neuralgia
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 23/57
TREATMENT
7areful initial evaluation$ including athorough history and physicale5a"ination$ is indicated to rule out
occult "alignancy or syste"icdisease
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 24/57
TREATMENT
(y"pathetic neural bloc%ade appears
to be the treat"ent of choice torelieve the sy"pto"s of acuteherpes zoster as well as to preventthe occurrence of postherpeticneuralgia
Noordenbos C@ber dissociationC
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 25/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 26/57
TREATMENT
Herpes zoster in trige"inal nerve & geniculate$cervical$ and high thoracic regions/
stellate ganglionbloc%ade with
A daily basisHerpes zoster thoracic$ lu"bar$ and sacral
regions/
epidural neural bloc%ade with
Adaily basis
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 27/57
TREATMENT
• !f the pain is not as severe$ N(A!Ds oraceta"inophen "ay be all that isneeded
• !n acute eruption oral narcotics "aybe
ad"inistered in the short ter"$especially with *N(A!Ds+
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 28/57
TREATMENT
Narcotic analgesics "ay be useful inrelieving the aching pain
Antidepressants will help / Alleviate the signi@cant sleep disturbance
A"eliorate the neurotic co"ponent of the pain
May e5ert a "oodelevating
May cause urinary retention and constipation
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 29/57
TREATMENT
Anticonvulsants
May be of value as an adunct to sy"pathetic
neural bloc%ade
hey "ay be particularly useful in persistentparesthetic or dysesthetic pain
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 30/57
TREATMENT
An5iety "ay be treated
Hydro5yzine3ehavioral interventions*eEgE$ "onitored rela5ation training and hypnosis+
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 31/57
TREATMENT
Antiviral agents/
Acyclovir $ valacyclovir$ fa"cyclovir and perhaps interferon have beenshown to shorten the course of acuteherpes zoster
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 32/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 33/57
TREATMENT
7orticosteroids
• !n syste"ic ' *the ris% of disse"ination'+
• ocal in@ltration of a)ected s%in areas with
corticosteroid with or without localanesthetic"ay be of value as an adunct to
sy"pathetic neural bloc%ade
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 34/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 35/57
TREATMENT
• ocal application of ice pac%s
• Application of heat
•
ranscutaneous electrical nervesti"ulation
• #ibration
•
(pinal cord sti"ulation
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 36/57
TREATMENT
• opical applicationAlu"inu" sulfat
Zinc o5ide oint"ent
opical lidocaine patches for PHN
opical capsaicin for PHN
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 37/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 38/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 39/57
Postherpetic
Neuralgia
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 40/57
Pain persisting after the rash hashealed *usually ; "onth *or8$ F$ or
even G"onths after the disease onset+ is
ter"ed PHN
Zosterassociated pain/
all pain beginning before$ at onset$ and afterthe rash
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 41/57
Negative and positive sy"pto"s
Allodynia is a characteristic feature ofPHN that occurs in the a)ected s%in
der"ato"esDysesthesias in the a)ected der"ato"e
spontaneous pain
Areas of sensory loss that lac% responsesto ther"al$ tactile$ pinpric%$ or vibratorysti"uli
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
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7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
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PHN
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 44/57
Di)erential Diagnosis
horacic nerve roots include
horacic radiculopathy
Peripheral neuropathy !ntrathoracic and intraabdo"inal
pathology
.phtal"ic trige"inal nerve Diseases of the eye$ ear$ nose$ and
throat !ntracranial pathology
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 45/57
TREATMENT
• he anticonvulsant gabapentinrepresents a @rstline
• 7arba"azepine
• Phenytoin
• Antidepressants "ay also be useful
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 46/57
TREATMENT
(y"pathetic neural bloc%ade with localanesthetics and steroids via eitherepidural nerve bloc% or bloc%ade of
the sy"pathetic nerves "ay be ne5tstep '
• (o"e te5ts/ peripheral nerve$
epidural$ or sy"pathetic anestheticbloc%s do not appear to be useful
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 47/57
TREATMENT
Neurodestructive procedures have avery low success rate
.pioid analgesics have a li"ited role
Application of ice pac%s
Application of heat
ranscutaneous electrical nervesti"ulation
#ibration
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 48/57
4DA APPR.#>D
gabapentin
Pregabalin
opical lidocaine patch097apsaicin crea"
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 49/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 50/57
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 51/57
TREATMENT
opical local anesthetics$ such as>MA crea"
(ubcutaneous lidocaine in@ltration
!ntrathecal "ethylprednisolone
!"planted spinal catheters andpu"ps
Dorsal root entry zone lesion
3ehavioral therapy
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 52/57
TREATMENT
!n one controlled trial *otani et alE8:::+$
repeated intrathecal ad"inistrationof "ethylprednisolone acetateresulted in sustained pain relief inI:9 of PHN
he treat"ent was well tolerated
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 53/57
TREATMENT
!f the pain is severe$ and all other"ethods fail$ i""ediate pain relief"ay be obtained in hospitalized
patients with a short course of highdose chlorprothi5ene *0:"g every Ghours for 0 days+
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
http://slidepdf.com/reader/full/post-herpetic-neuralgia-and-herpes-zoster 54/57
Neurolytic bloc%s "ay be consideredin patients with PHN when otherbloc%s have not given the patient
signi@cantrelief (igni@cant pain relief has been
obtained in patientswith PHN using
acupuncture
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
S d N
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
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Surgery and Neurosurgery
the last resort for the treat"ent ofsevere intractable postherpeticneuralgia/
7ordoto"y
Dorsal colu"n sti"ulators
Deep brain sti"ulators
Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
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Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist
7/25/2019 Post Herpetic Neuralgia and Herpes Zoster
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