Trigeminal extracranial thermocoagulation along with patient-controlled analgesia with esketamine for refractory postherpetic neuralgia after herpes zoster ophthalmicus: A case report

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Abstract

BACKGROUND

Primary trigeminal neuralgia can achieve satisfactory results through clinical treatment and intervention. The pathogenesis of neuralgia caused by varicella-zoster virus infection of the trigeminal nerve is more complex, and it is still difficult to relieve the pain in some patients simply by drug treatment or surgical intervention.

CASE SUMMARY

A 66-year-old woman was hospitalized with herpetic neuralgia after herpes zoster ophthalmicus (varicella-zoster virus infects the ophthalmic branch of the trigeminal nerve). On admission, the patient showed spontaneous, electric shock-like and acupuncture-like severe pain in the left frontal parietal region, and pain could be induced by touching the herpes area. The numerical rating scale (NRS) was 9. There was no significant pain relief after pulsed radiofrequency and thermocoagulation of the ophthalmic branch of the trigeminal nerve. Combined with patient-controlled intravenous analgesia (PCIA) with esketamine, neuralgia was significantly improved. The patient had no spontaneous pain or allodynia at discharge, and the NRS score decreased to 2 points. The results of follow-up 2 mo after discharge showed that the NRS score was ≤ 3, and the Pittsburgh Sleep Quality Index score was 5 points. There were no adverse reactions.

CONCLUSION

Trigeminal extracranial thermocoagulation combined with esketamine PCIA may be a feasible method for the treatment of refractory herpetic neuralgia after herpes zoster ophthalmicus.

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Most cited references 20

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Ketamine for chronic pain: risks and benefits.

Marieke Niesters, Christian Martini, Albert Dahan (2014)

The anaesthetic ketamine is used to treat various chronic pain syndromes, especially those that have a neuropathic component. Low dose ketamine produces strong analgesia in neuropathic pain states, presumably by inhibition of the N-methyl-D-aspartate receptor although other mechanisms are possibly involved, including enhancement of descending inhibition and anti-inflammatory effects at central sites. Current data on short term infusions indicate that ketamine produces potent analgesia during administration only, while three studies on the effect of prolonged infusion (4-14 days) show long-term analgesic effects up to 3 months following infusion. The side effects of ketamine noted in clinical studies include psychedelic symptoms (hallucinations, memory defects, panic attacks), nausea/vomiting, somnolence, cardiovascular stimulation and, in a minority of patients, hepatoxicity. The recreational use of ketamine is increasing and comes with a variety of additional risks ranging from bladder and renal complications to persistent psychotypical behaviour and memory defects. Blind extrapolation of these risks to clinical patients is difficult because of the variable, high and recurrent exposure to the drug in ketamine abusers and the high frequency of abuse of other illicit substances in this population. In clinical settings, ketamine is well tolerated, especially when benzodiazepines are used to tame the psychotropic side effects. Irrespective, close monitoring of patients receiving ketamine is mandatory, particularly aimed at CNS, haemodynamic, renal and hepatic symptoms as well as abuse. Further research is required to assess whether the benefits outweigh the risks and costs. Until definite proof is obtained ketamine administration should be restricted to patients with therapy-resistant severe neuropathic pain.

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Ketamine produces effective and long-term pain relief in patients with Complex Regional Pain Syndrome Type 1.

Digna van Schaik, Marnix J Sigtermans, J Marinus … (2009)

Complex Regional Pain Syndrome Type 1 (CRPS-1) responds poorly to standard pain treatment. We evaluated if the N-methyl-D-aspartate receptor antagonist S(+)-ketamine improves pain in CRPS-1 patients. Sixty CRPS-1 patients (48 females) with severe pain participated in a double-blind randomized placebo-controlled parallel-group trial. Patients were given a 4.2-day intravenous infusion of low-dose ketamine (n=30) or placebo (n=30) using an individualized stepwise tailoring of dosage based on effect (pain relief) and side effects (nausea/vomiting/psychomimetic effects). The primary outcome of the study was the pain score (numerical rating score: 0-10) during the 12-week study period. The median (range) disease duration of the patients was 7.4 (0.1-31.9) years. At the end of infusion, the ketamine dose was 22.2+/-2.0 mg/h/70 kg. Pain scores over the 12-week study period in patients receiving ketamine were significantly lower than those in patients receiving placebo (P<0.001). The lowest pain score was at the end of week 1: ketamine 2.68+/-0.51, placebo 5.45+/-0.48. In week 12, significance in pain relief between groups was lost (P=0.07). Treatment did not cause functional improvement. Patients receiving ketamine more often experienced mild to moderate psychomimetic side effects during drug infusion (76% versus 18%, P<0.001). In conclusion, in a population of mostly chronic CRPS-1 patients with severe pain at baseline, a multiple day ketamine infusion resulted in significant pain relief without functional improvement. Treatment with ketamine was safe with psychomimetic side effects that were acceptable to most patients.

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Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists

Eric S. Schwenk, Eugene R. Viscusi, Asokumar Buvanendran … (2018)

Background Ketamine infusions have been used for decades to treat acute pain, but a recent surge in usage has made the infusions a mainstay of treatment in emergency departments, in the perioperative period in individuals with refractory pain, and in opioid-tolerant patients. The widespread variability in patient selection, treatment parameters, and monitoring indicates a need for the creation of consensus guidelines. Methods The development of acute pain ketamine guidelines grew as a corollary from the genesis of chronic pain ketamine guidelines. The charge for the development of acute pain ketamine guidelines was provided by the Boards of Directors of both the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine, who approved the document along with the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters. The committee chair developed questions based on input from the committee during conference calls, which the committee then refined. Groups of 3 to 5 panel members and the committee chair were responsible for answering individual questions. After preliminary consensus was achieved, the entire committee made further revisions via e-mail and conference calls. Results Consensus guidelines were prepared in the following areas: indications, contraindications for acute pain and whether they differ from those for chronic pain, the evidence for the use of ketamine as an adjunct to opioid-based therapy, the evidence supporting patient-controlled ketamine analgesia, the use of nonparenteral forms of ketamine, and the subanesthetic dosage range and whether the evidence supports those dosages for acute pain. The group was able to reach consensus on the answers to all questions. Conclusions Evidence supports the use of ketamine for acute pain in a variety of contexts, including as a stand-alone treatment, as an adjunct to opioids, and, to a lesser extent, as an intranasal formulation. Contraindications for acute pain are similar to those for chronic pain, partly based on the observation that the dosage ranges are similar. Larger studies evaluating different acute pain conditions are needed to enhance patient selection, determine the effectiveness of nonparenteral ketamine alternatives, define optimal treatment parameters, and develop protocols optimizing safety and access to care.

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Author and article information

Contributors

Jia-Chun Tao

Bing Huang

Ge Luo

Zhi-Qiang Zhang

Bing-Yue Xin

Ming Yao

Journal

Journal ID (nlm-ta): World J Clin Cases

Journal ID (publisher-id): WJCC

Title: World Journal of Clinical Cases

Publisher: Baishideng Publishing Group Inc

ISSN (Electronic): 2307-8960

Publication date (Print): 6 May 2022

Publication date (Electronic): 6 May 2022

Volume: 10

Issue: 13

Pages: 4220-4225

Affiliations

Department of Anesthesiology and Pain Medicine, The Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China

Department of Anesthesiology and Pain Medicine, The Affiliated Hospital of Jiaxing University, Jiaxing 314000, Zhejiang Province, China. jxyaoming666@ 123456163.com

Author notes

Author contributions: Tao JC performed the literature research and drafted the manuscript; Xin BY and Zhang ZQ collected the data; Luo G analyzed the data Huang B and Yao M conceived the study design and revised the manuscript in depth; All authors have read and approved final version of this manuscript for publication.

Corresponding author: Ming Yao, PhD, Professor, Department of Anesthesiology and Pain Medicine, The Affiliated Hospital of Jiaxing University, No. 1882 Zhong Huan South Road, Jiaxing 314000, Zhejiang Province, China. jxyaoming666@ 123456163.com

Article

Other ID: jWJCC.v10.i13.pg4220

DOI: 10.12998/wjcc.v10.i13.4220

PMC ID: 9131206

PubMed ID: 35665100

SO-VID: 5f571795-fdb8-47e5-b686-83f1c24500e9

License:

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.

History

Date received : 12 September 2021

Date revision received : 23 February 2022

Date accepted : 15 March 2022

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Trigeminal extracranial thermocoagulation along with patient-controlled analgesia with esketamine for refractory postherpetic neuralgia after herpes zoster ophthalmicus: A case report

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Abstract

BACKGROUND

CASE SUMMARY

CONCLUSION

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Most cited references 20

Ketamine for chronic pain: risks and benefits.

Ketamine produces effective and long-term pain relief in patients with Complex Regional Pain Syndrome Type 1.

Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists

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