Department of Anesthesiology, Mackay Memorial Hospital, Taipei City, Taiwan.
Pain Physician. 2019 May;22(3):209-228.
Postherpetic neuralgia, a persistent pain condition often characterized by allodynia and hyperalgesia, is a deleterious consequence experienced by patients after an acute herpes zoster vesicular eruption has healed. The pain associated with postherpetic neuralgia can severely affect a patient's quality of life, quality of sleep, and ability to participate in activities of daily living. Currently, first-line treatments for this condition include the administration of medication therapies such as tricyclic antidepressants, pregabalin, gabapentin, and lidocaine patches, followed by the application of tramadol and capsaicin creams and patches as second- or third-line therapies. As not all patients respond to such conservative options, however, interventional therapies are valuable for those who continue to experience pain.
This review focuses on interventional therapies that have been subjected to randomized controlled trials for the treatment of postherpetic neuralgia, including transcutaneous electrical nerve stimulation; local botulinum toxin A, cobalamin, and triamcinolone injection; intrathecal methylprednisolone and midazolam injection; stellate ganglion block; dorsal root ganglion destruction; and pulsed radiofrequency therapy.
Systematic review.
Hospital department in Taiwan.
Search of PubMed database for all randomized controlled trials regarding postherpetic neuralgia that were published before the end of May 2017.
The current evidence is insufficient for determining the single best interventional treatment. Considering invasiveness, price, and safety, the subcutaneous injection of botulinum toxin A or triamcinolone, transcutaneous electrical nerve stimulation, peripheral nerve stimulation, and stellate ganglion block are recommended first, followed by paravertebral block and pulsed radiofrequency. If severe pain persists, spinal cord stimulation could be considered. Given the destructiveness of dorsal root ganglion and adverse events of intrathecal methylprednisolone injection, these interventions should be carried out with great care and only following comprehensive discussion.
Although few adverse effects were reported, these procedures are invasive, and a careful assessment of the risk-benefit ratio should be conducted prior to administration.
With the exception of intrathecal methylprednisolone injection for postherpetic neuralgia, the evidence for most interventional procedures used to treat postherpetic neuralgia is Level 2, according to "The Oxford Levels of Evidence 2". Therefore, these modalities have received only grade B recommendations. Despite the lack of a high level of evidence, spinal cord stimulation and peripheral nerve stimulation are possibly useful for the treatment of postherpetic neuralgia.
Interventional treatment, postherpetic neuralgia, botulinum toxin, steroid, stellate ganglion block, peripheral nerve stimulation, paravertebral block, radiofrequency, spinal cord stimulation.
带状疱疹后神经痛是一种持续性疼痛疾病，常表现为痛觉过敏和痛觉超敏，是患者在急性带状疱疹水疱发作愈合后所经历的有害后果。带状疱疹后神经痛相关的疼痛会严重影响患者的生活质量、睡眠质量和日常生活活动参与能力。目前，这种疾病的一线治疗方法包括三环类抗抑郁药、普瑞巴林、加巴喷丁和利多卡因贴剂等药物治疗，其次是曲马多和辣椒素乳膏和贴片作为二线或三线治疗。然而，由于并非所有患者对这些保守治疗方案都有反应，因此介入治疗对于那些仍有疼痛的患者很有价值。
本综述重点介绍了经随机对照试验证实的用于治疗带状疱疹后神经痛的介入治疗方法，包括经皮神经电刺激；局部肉毒毒素 A、钴胺素和曲安奈德注射；鞘内甲泼尼龙和咪达唑仑注射；星状神经节阻滞；背根神经节破坏；脉冲射频治疗。
系统评价。
中国台湾医院科室。
在 PubMed 数据库中搜索所有发表于 2017 年 5 月底之前的关于带状疱疹后神经痛的随机对照试验。
目前的证据尚不足以确定单一的最佳介入治疗方法。考虑到侵袭性、价格和安全性，建议首先选择皮下注射肉毒毒素 A 或曲安奈德、经皮神经电刺激、周围神经刺激和星状神经节阻滞，其次是椎旁阻滞和脉冲射频。如果疼痛持续严重，可考虑脊髓刺激。鉴于背根神经节的破坏性和鞘内注射甲泼尼龙的不良事件，这些干预措施应在全面讨论后谨慎进行。
尽管报告的不良事件很少，但这些操作具有侵袭性，在给药前应仔细评估风险-效益比。
除鞘内注射甲泼尼龙治疗带状疱疹后神经痛外，用于治疗带状疱疹后神经痛的大多数介入治疗程序的证据均为“牛津证据等级 2”的 2 级，因此这些治疗方法仅获得 B 级推荐。尽管缺乏高水平的证据，但脊髓刺激和周围神经刺激可能对治疗带状疱疹后神经痛有用。
介入治疗、带状疱疹后神经痛、肉毒毒素、类固醇、星状神经节阻滞、周围神经刺激、椎旁阻滞、射频、脊髓刺激。
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