The first question I ask a shingles / herpes zoster patient is whether they would mind if what pain they currently had persisted. This is because efficacy of anti-virals could be limited…They are still fighting over whether anti-virals prevents post-herpetic neuralgia as late as November 2009 – in the Journal of the American Medical Association (JAMA):JAMA, November 4, 2009—Vol 302, No. 17, p1862:
“I stand by my statement that “[p]revention of PHN is a major concern because antiviral drugs alone do not reliably prevent this complication.” The US Food and Drug Administration (FDA), using the definition of PHN cited by Zhou et al, concluded that although treatment may decrease the median duration of pain (as a continuum), the data from well-controlled clinical trials did not provide evidence of reduction of PHN for any of the licensed drugs: acyclovir,1 valacyclovir,2 or famciclovir.3 The FDA refused to grant this indication based on its analyses and input from advisory committees. ”
So to make an impact on a potentially quality of life changing disease, nerve blocks appears to be the ticket. I can only assume those who feel there is not enough evidence , have never done one – the relief is immediate and often sustained. Fortunately, there is now a controlled trial of blocks versus anti-virals
Anesth Analg. 2009 Nov;109(5):1651-5.
The effectiveness of repetitive paravertebral injections with local anesthetics and steroids for the prevention of postherpetic neuralgia in patients with acute herpes zoster.
Ji G, Niu J, Shi Y, Hou L, Lu Y, Xiong L. abstract here
control – 68 cases – “oral administration of 800 mg acyclovir, 5 times daily for 7 days, and analgesics as needed). Patients were permitted to take the nonsteroidal antiinflammatory drug diclofenac (50-mg tablets,
up to 4 times daily) at any time during the study.”
Interventional group – 64 cases – above treatment plus “repetitive paravertebral injections with a mixture of 10 mL 0.25% bupivacaine and 40 mg methylprednisolone acetate every 48 h for a week (total 4 injections at each desired level”
Results:
COMMENT – there is no doubt there is a significant difference in post herpetic neuralgia. If one spent the time to inject areas locally with steroids after the fact, the pain levels left would be even better. Their view on paravertebral block:
Paravertebral block (PVB) is one of the easiest and most time-efficient techniques for providing analgesia
by injecting local anesthetic in a space immediately lateral to where the spinal nerves emerge from the
intervertebral foramina. PVB and epidural analgesia provide comparable pain relief, but PVB has a better side effect profile.17 In fact, PVB not only has a favorable effect on resolving the acute phase of HZ but also seems to be capable of preventing the onset of PHN.13,18–21
13. Johnson RW. Consequences and management of pain in herpes zoster. J Infect Dis 2002;186(suppl 1):S83–S90
17. Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and metaanalysis of randomized trials. Br J Anaesth 2006;96:418–2618. Hardy D. Relief of pain in acute herpes zoster by nerve blocks and possible prevention of post-herpetic neuralgia. Can J Anaesth 2005;52:186–90
19. Naja ZM, Maaliki H, Al-Tannir MA, El-Rajab M, Ziade F, Zeidan A. Repetitive paravertebral nerve block using a catheter technique for pain relief in post-herpetic neuralgia. Br J Anaesth 2006;96:381–3
20. Rosenak SS. Paravertebral procaine block for the treatment of herpes zoster. NY State J Med 1956;56:2684–7
21. Johnson LR, Rocco AG, Ferrante FM. Continuous subpleural paravertebral block in acute thoracic herpes zoster. Anesth Analg 1988;67:1105–8
As for my question to the patient, whether s/he would mind if present pain persisted, if s/he would mind, then a block beome essential though now I do rib blocks and find they work as well (though often repeated).
Addendum: Chinese article comfirms epidural blocks make a difference in acute herpes zoster: p <0.05
Efficacy of epidural lateral space injection for the treatment of acute herpes zoster in lower extremity
Li A et al
Pain Clin J, June 2012, 8(3) 183-186
http://www.cqvip.com/Read/Read.aspx?id=43157207
Any comments?