Intercostal Nerve Blocks For Shingles / Herpes Zoster

I have written extensively on how nerve root blocks are a necessary part of treatment of shingles. Came across two Chinese articles stating effectiveness – one stating you can get “markedly effective” results in 75% of cases.

Effects of ultrasound-guided intercostal nerve block on patients with herpes zoster in chest and back
Ren J, Liu X, Wang X
Pain Clin J April 2012, 8(2), 99-102
http://www.cqvip.com/Read/Read.aspx?id=41988667

• 60 cases – each had anti-virals
• half were given ultrasound guided blocks every 5-7 days
• earlier disappearance of lesions and pain and increased cure rates were seen p <0.05 in block group

Ultrasound-guided intercostal nerve block treatment of acute herpes zoster neuralgia
woodlands, Barnes, Jiangliu Ming, Xu Xuzhong
http://eng.hi138.com/?i298420_Ultrasound…block-treatment-of-acute-herpes..

• 68 cases an average of 14.5 days after onset with severe neuralgia
• Use of anti-virals and even IV immune globulin (? zoster immune globulin) 2.5 gm/day
• celecoxib 100 mg od, calamine lotion, and antibiotics if bacterially infected
• used “mix – 0.375% ropivacaine +20 mg triamcinolone A +0.2% methylene blue, with 0.9 % saline preparation of 20 mL , each intercostal nerve injection of 3 ~ 5 mL”
• Used ultrasound guided which they found particularly helpful for t1-4 which the state is more difficult to be accurate in achieving otherwise
• markedly effective rate of 75%

Comment – If you don’t have ultrasound and you are in a community where services are stretched to limit as we are, it is possible to do it blind. I inject where rib is closest to skin.  I use 5% lidocaine in D5W and inject using a 30 gauge – 1″ needle which is less likely to damage pleura. 1.5 mls total can be safely used and I put 0.5 mls in each of 3 nerve root levels (start with one and see what it does).  Put a finger on each side of rib, aim for middle and pentrate down.  If you hit rib, walk it down to under it, penetrate intercostal muscle and inject.  I you don’t hit rib, assume you are in intercostal space and just inject it. 5% lidocaine seems to be very forgiving as that concentration can spread enough to catch it even if you are not deep enough. Posteriorly, the nerve runs in the middle between ribs; but with concentration you are using it matters less.  Obese people – sorry – may need help with those..

In Ontario, a colleague had a patient who developed a pneumothorax  after a trigger injection – the day after.  The medical college made him do all his injections in a hospital setting thereafter. Given that many pneumothoraxes appear the day after (the two I had over last 35 years were delayed), this seems rather ludicrous. Perhaps the college is also going to arrange a hospital stay for these cases as well…

Any comments?