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PM R 7 (2015) 443-446

www.pmrjournal.org

Case Presentation

Treatment of Postherpetic Neuralgia Using a Thoracic


Transforaminal Epidural Steroid Injection
Priyesh Mehta, DO, Patrick Maher, BS, Jaspal Ricky Singh, MD

Abstract
A 64-year-old male patient with a history of herpes zoster exposure presented with severe, constant, burning pain in the left
T10 dermatome consistent with postherpetic neuralgia. Previous treatment included oral and topical medications as well as an
intercostal nerve block; however, these treatment options did not provide significant relief. The patient was treated with a singlelevel T10 thoracic transforaminal epidural steroid injection for refractory postherpetic neuralgia. He reported complete resolution of his symptoms at 2- and 12-week follow-ups. This case illustrates transforaminal epidural steroid injections may be a
successful treatment option for postherpetic neuralgia.

Introduction
Approximately 1 million cases of herpes zoster (HZ)
occur in the United States each year [1]. HZ is the result
of reactivation of latent varicella zoster virus after a
primary infection in the form of chicken pox. Latent
infection may persist for years in the dorsal root ganglia
of cranial or spinal nerves after resolution of the original
infection. Reactivation of latent infection in the form of
HZ can result in significant morbidity, especially to
elderly subjects and in those with decreased cellmediated immunity [1,2]. The decrease in cellmediated immunity allows the virus to transport along
peripheral nerves producing an acute neuritis. Clinically, common symptoms of HZ include pain in a
dermatomal distribution, pruritus, paresthesia, as well
as development of a vesicular rash. The vesicular rash
can persist for 3-4 weeks before resolving [1].
The most common complication of HZ is postherpetic
neuralgia (PHN), for an estimated 120,000-200,000
cases are reported per year [3]. The risk of developing
PHN after HZ increases with age. PHN frequently is
defined as pain in the region of the affected dermatome
that persists for 1 month after the resolution of the rash
[3]. The pain of PHN can be severe and may result in
anorexia, weight loss, fatigue, depression, as well as
interfere with the ability to sleep, which in turn may

have an effect on work, quality of life, activities of daily


living, social activities, and employment. If not treated
early, PHN can become chronic and persistent, posing
significant challenges to the health care community [3].
Two main pathophysiologic mechanisms have been
proposed to explain the symptoms of PHN [4]. First,
there may be a peripheral sensitization in which pain
receptors become sensitized after the acute tissue
injury that occurs during the primary HZ infection [4].
This process leads to a supranormal response of the
dorsal horn neurons to afferent signals, leading to
allodynia. The second mechanism is deafferentation of
central neurons or reorganization of central connections
resulting in severe spontaneous pain without hyperalgesia or allodynia [5]. Nerve damage leading to
neuropathic pain may be caused directly by reactivation
of the varicella zoster virus in the dorsal root ganglion
or as a result of inflammatory changes [3,4].
Multiple medical therapies have been described to
prevent or treat PHN. These treatments range from
antiviral medications, topical anesthetics, and medications aimed at treating neuropathic pain (gabapentin,
amitriptyline, etc) [6]. For cases refractory to medical
therapy, invasive treatment techniques have been used.
Intercostal nerve blocks have been used in the treatment of acute HZ pain in the thoracic dermatomes and
have demonstrated to have up to 80% improvement of

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Thoracic Transforaminal Epidural Injection for PHN

symptoms at 1 and 3 months [6]. With the intercostal


techniques, however, there is an associated risk of
pneumothorax [6,7].
Intrathecal administration of corticosteroids had
been used successfully in some studies. Kotani et al [8]
randomized 270 patients to receive intrathecal steroids
with lidocaine versus lidocaine alone versus no treatment. They found that patients in the intrathecal steroid group had more than 50% pain relief relative to the
other groups at the end of treatment (90% versus 15%
versus 5% of patients in each group). In addition, other
randomized studies found greater symptom reduction in
the intrathecal steroids; however, several authors have
reported a risk of arachnoiditis [3,9]. The risk of this
significant complication may limit widespread adoption
of this technique in the treatment of medically refractory PHN.
Previous studies in which authors used an interlaminar epidural approach for the treatment of PHN have
found mixed results. Van Wijck et al [10] reported a
randomized controlled trial in which they examined
medical treatment versus medical treatment with an
interlaminar epidural injection for HZ. They found
modest reduction in HZ pain at 1 month of follow-up but
found no effect in reducing subsequent PHN. Perkins
and Hanlon [11] reported on the use of an interlaminar
approach for HZ and PHN. The authors reported substantial immediate and lasting pain relief in all HZ patients (70%-100% reduction immediately); however, in
the patients with PHN, no patient reported greater than
50% pain relief at 1- and 5-month follow-up. From these
results it appears that interlaminar administration may
not be adequate to address PHN pain because it is not
directly accessing the nerve root.
Herein, we report a case of PHN with medically refractory pain in the T10 dermatome that was treated
successfully with a transforaminal epidural steroid
injection.
Case Presentation
A 64-year-old male patient with no significant medical history reported having stripes of blisters consistent
with shingles located in his left torso lateral to his umbilicus approximately 1.5 years before presentation. At
that time, he received a 2-week course of oral steroids,
which significantly helped resolve the outbreak.
At the time of initial presentation to the Spine Pain
Center, he reported severe, constant, burning pain in
the left T10 dermatome, with intermittent electrical
shock-like sensations radiating to the mid-axillary line.
The burning pain was 6 of 10 but occasionally reached
8 of 10 on the visual analog scale. On initial examination,
the patient had skin discoloration and trophic changes in
the left T10 dermatome, with hyperalgesia and allodynia. The pain greatly interfered with his ability to function and was worse with activity involving lifting

overhead or playing basketball. Before presentation, the


patient was treated with a number of oral and topical
treatment options, including opioids, pregabalin, gabapentin, duloxetine, amitriptyline, lidocaine 5% patch,
and capsaicin 8% cream. These treatment options did not
provide adequate relief.
At this point, the decision to perform intercostal
nerve blocks was made, and the patient underwent left
T8 through T10 intercostal nerve blocks under fluoroscopic guidance. Each level was targeted and identified
under fluoroscopic guidance and after negative aspiration; 3 mL of 0.25% bupivacaine and 3.3 mg of triamcinolone were injected at each level. The patient
reported immediate relief of the burning sensation;
however, after 2 weeks the original symptoms recurred.
Subsequently, as the result of severe refractory pain,
a left T10 single-level thoracic transforaminal epidural
steroid injection was performed under the guidelines of
the International Spine Intervention Society [12]. The
patient was placed in the prone position, and the region
overlying the affected dermatome was identified at the
left T10 vertebral body. True anteroposterior imaging
was obtained by squaring off the inferior endplate of
T10. The junction of the lamina and transverse process
was identified as the armpit of the lamina. The skin of
the back was prepped in sterile fashion and a 25-g, 1.5inch spinal needle was inserted targeting the armpit
of the lamina (Figure 1A). The lateral view was obtained
to confirm posterior needle placement within the foramen (Figure 1B).
Once the target was attained, contrast medium was
injected into the epidural space outlining the spinal
nerve (Figure 2). Aspiration did not reveal any blood or
cerebrospinal fluid. Digital subtraction angiography was
performed to confirm the absence of intravascular
contrast spread. Subsequently, a test dose of 1% lidocaine test dose was performed without any changes.
Two minutes later, 20 mg of dexamethasone was
injected.
The patient was seen at follow-up 2 weeks after injection, at which time he reported 100% relief of pain.
He no longer felt burning, electric-like pain in the left
T10 dermatome. In addition, he was back to playing
basketball and activities as tolerated. The patient was
later seen at 12-week follow-up; he reported pain of
1 of 10 and significant improvement in symptoms with
no functional limitations.
Discussion
Medical management of PHN has proved inadequate
for many patients [6]. Accordingly, several interventional procedures have been attempted for management of symptoms. Previous authors have described
using an interlaminar epidural approach, stellate ganglion blocks, or using intrathecal administration of
medication [3]. These techniques have been shown to

P. Mehta et al. / PM R 7 (2015) 443-446

445

Figure 1. (A) Thoracic transforaminal epidural injection at T10/T11. Fluoroscopic view with needle is in proper position in the lower third of the
foramen. (B) Fluoroscopic view in lateral position with the needle in ideal position.

be efficacious in reducing symptoms but have additional


risks associated with them. In particular, the intrathecal
administration of steroids has been shown particularly
to be efficacious in the treatment of PHN but has been
associated with the risk of arachnoiditis and has limited
adoption. Moreover, the risk of arachnoiditis appears to
be increased with treatment in the thoracic region [9],
rendering this modality a particularly poor choice for
our patient.
Because of the limitations of the previous interventional techniques, some authors have considered using a
transforaminal approach to deliver epidural steroids for
PHN [3,4]. This approach has the advantage of delivering medication in close proximity to the affected
dorsal root ganglion, with the expectation of interrupting the inflammatory cascade that is directly
responsible for the symptoms, thereby reducing tissue
damage and pain [3]. A transforaminal injection should
provide the greatest concentration of medication
directly at the involved site.
Our search of the literature uncovered 2 previous
case reports discussing the use of TFESI in the treatment
of PHN [3,4]. Shakir et al [3] reported using a transforaminal approach for the C5 dermatome in a 66-yearold woman with severe refractory PHN. The authors
reported significant pain reduction at 15 minutes postinjection and 2 weeks follow-up and reported that the
patient was pain free at 1-month and 3-month followup. Conliffe et al [13] reported using a transforaminal
approach for the L5 dermatome in a 75-year-old man

Figure 2. Contrast injection shows the dye spreading into the epidural
space and along the T10 nerve root.

446

Thoracic Transforaminal Epidural Injection for PHN

with PHN and right foot drop. The patient reported


improvement of his pain from 7 of 10 to 3 of 10 after a
single injection. The patient was treated with a second
injection again via a transforaminal approach 2 weeks
later and then reported pain of only 1 of 10; he also
was noted to have improved motor strength on the
affected side.
Conclusion
To our knowledge, this is the first reported case of
using a transforaminal epidural steroid injection for the
treatment of refractory PHN in a thoracic dermatome.
Theoretically, localizing medication to the affected
dorsal root ganglion should provide more effective pain
relief. Further controlled trials will be necessary to
confirm efficacy of this technique.
References
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the right C5 dermatome treated with a cervical transforaminal
epidural steroid injection: A case report. Arch Phys Med Rehabil
2007;88:255-258.

4. Opstelten W, van Wijck AJ, Stolker RJ. Interventions to prevent


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Disclosure
P. Mehta Department of Rehabilitation, New York Presbyterian Hospital, New
York, NY. Address correspondence to: P.M.; e-mail: Priyesh.Mehta@gmail.com
Disclosure: nothing to disclose
P. Maher Weill Cornell Medical College, New York, NY
Disclosure: nothing to disclose

J.R.S. Department of Rehabilitation, New York Presbyterian Hospital, New York,


NY
Disclosure: nothing to disclose
Submitted for publication March 4, 2014; accepted November 22, 2014.

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