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      Post Herpetic Neuralgia: A Retrospective Study to Evaluate Response to Modified Jaipur Block with Increased Concentration of Dexamethasone

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          Abstract

          Background:

          Postherpetic neuralgia (PHN) is a complication of herpes zoster characterized by persistent dermatomal pain. It has a negative impact on the quality of life. There is no gold standard therapy for PHN, and various local and systemic treatments have been tried. There are studies reporting the use of combination of steroids and local anesthetics but there is no standardized method.

          Aim:

          To evaluate the response of modified Jaipur block with increased concentration of dexamethasone.

          Methods:

          We conducted a retrospective study in patients who were given Jaipur block. The patients age, sex, duration of PHN, type and severity of pain were observed. A combination of 2% lignocaine and 0.5% bupivacaine and dexamethasone was injected subcutaneously. The pain was scored using visual analogue scale at the baseline, and 1 month after 1 st, 2 nd, and 3 rd session of block and follow up after 6 months and 1 year.

          Results:

          The mean age of our patient was 63.33 ± 9.5 years. The males outnumbered females. Thoracic dermatomes were more commonly involved. The mean duration of PHN was 11.58 ± 12.76 months; stimulus evoked PHN was the commonest type of pain seen. The mean visual analogue score (VAS) decreased progressively after each session of the block. Maximum patients (50%) had excellent response, whereas 1.9% did not respond to the block. Relapse of pain was seen in 5.6% of the patients. There was no significant side effect noted.

          Limitations:

          There was no objective method used to assess pain.

          Conclusion:

          PHN is chronic neuropathic pain. Response to modified Jaipur block is good, but if the duration of PHN is more, the recurrence rate is higher. Modified Jaipur block is an effective and safe treatment for PHN

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          Most cited references24

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          Postherpetic neuralgia: irritable nociceptors and deafferentation.

          M Rowbotham, Alfred Baron, H Fields (1998)
          Postherpetic neuralgia (PHN) is a common and often devastatingly painful condition. It is also one of the most extensively investigated of the neuropathic pains. Patients with PHN have been studied using quantitative testing of primary afferent function, skin biopsies, and controlled treatment trials. Together with insights drawn from an extensive and growing literature on experimental models of neuropathic pain these patient studies have provided a preliminary glimpse of the pain-generating mechanisms in PHN. It is clear that both peripheral and central pathophysiological mechanisms contribute to PHN pain. Some PHN patients have abnormal sensitization of unmyelinated cutaneous nociceptors (irritable nociceptors). Such patients characteristically have minimal sensory loss. Other patients have pain associated with small fiber deafferentation. In such patients pain and temperature sensation are profoundly impaired but light moving mechanical stimuli can often produce severe pain (allodynia). In these patients, allodynia may be due to the formation of new connections between nonnociceptive large diameter primary afferents and central pain transmission neurons. Other deafferentation patients have severe spontaneous pain without hyperalgesia or allodynia and presumably have lost both large and small diameter fibers. In this group the pain is likely due to increased spontaneous activity in deafferented central neurons and/or reorganization of central connections. These three types of mechanism may coexist in individual patients and each offers the possibility for developing new therapeutic interventions.
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            Corticosteroids suppress ectopic neural discharge originating in experimental neuromas.

            M. Devor, P Raber, R. Lippmann (1985)
            Some injured sensory fibers ending in an experimental neuroma in the rat sciatic nerve discharge spontaneously. Furthermore, many become sensitive to a range of physical and chemical stimuli. The resulting afferent barrage is thought to contribute to paresthesias and pain associated with peripheral nerve injury. We report that the development of such ectopic neuroma discharge is largely prevented when the freshly cut nerve end is treated with any of 3 commercially available corticosteroid preparations including two in depot form, triamcinolone hexacetonide (Lederspan) and triamcinolone diacetate (Ledercort), and one in soluble form, dexamethasone (Dexacort). These corticosteroids also produce a rapid and prolonged suppression of ongoing discharge in chronic neuromas that have already become active. The kinetics of corticosteroid suppression of neuroma discharge suggest a direct membrane action rather than an anti-inflammatory action.
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              Intrathecal methylprednisolone for intractable postherpetic neuralgia.

              A Matsuki, M Yodono, M Asai … (2000)
              There is no effective treatment for intractable postherpetic neuralgia. Because there is evidence that postherpetic neuralgia has an inflammatory component, we assessed treatment with intrathecally administered methylprednisolone to reduce pain in patients with this disorder. We enrolled 277 patients who had had intractable postherpetic neuralgia for at least one year, 270 of whom were followed for two years. The patients were randomly assigned to receive intrathecal methylprednisolone and lidocaine (3 ml of 3 percent lidocaine with 60 mg of methylprednisolone acetate, 89 patients), lidocaine alone (3 ml of 3 percent lidocaine, 91 patients), or no treatment (90 patients) once per week for up to four weeks. Each weekly dose was injected into the lumbar intrathecal space. Pain was evaluated before randomization, at the end of the treatment period, and then four weeks, one year, and two years later. Samples of cerebrospinal fluid were obtained for measurement of interleukin-8 before and at the end of the treatment period. There was minimal change in the degree of pain in the lidocaine-only and control groups during and after the treatment period. In the methylprednisolone-lidocaine group, the intensity and area of pain decreased, and the use of the nonsteroidal antiinflammatory drug diclofenac declined by more than 70 percent four weeks after the end of treatment. No complications related to intrathecal methylprednisolone were observed. Before treatment, the concentrations of interleukin-8 in the cerebrospinal fluid were inversely related to the duration of neuralgia in all the patients (r=-0.49, P<0.001). In the patients who received methylprednisolone, interleukin-8 concentrations decreased by 50 percent, and this decrease correlated with the duration of neuralgia and with the extent of global pain relief (P<0.001 for both comparisons). The results of this trial indicate that the intrathecal administration of methylprednisolone is an effective treatment for postherpetic neuralgia.
              Article 0 comments Cited 37 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Indian J Dermatol
                Journal ID (iso-abbrev): Indian J Dermatol
                Journal ID (publisher-id): IJD
                Title: Indian Journal of Dermatology
                Publisher: Wolters Kluwer - Medknow (India )
                ISSN (Print): 0019-5154
                ISSN (Electronic): 1998-3611
                Publication date (Print): Sep-Oct 2021
                Volume: 66
                Issue: 5
                Pages: 459-464
                Affiliations
                [1] From the Department of Dermatology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
                Author notes
                Address for correspondence: Dr. Mudita Gupta, Department of Dermatology, Venereology and Leprosy, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India. E-mail: muditadrgupta@ 123456yahoo.com
                Article
                Publisher ID: IJD-66-459
                DOI: 10.4103/ijd.IJD_390_20
                PMC ID: 8751723
                PubMed ID: 35068498
                SO-VID: ae399349-b610-41b0-8db4-7c51924f72cf
                Copyright © Copyright: © 2021 Indian Journal of Dermatology
                License:

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                Date received : May 2020
                Date accepted : August 2021
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Dermatology
                Keywords: higher concentration of dexamethasone,modified jaipur block,post herpetic neuralgia
                Data availability:
                ScienceOpen disciplines: Dermatology
                Keywords: higher concentration of dexamethasone, modified jaipur block, post herpetic neuralgia

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