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 Table of Contents  
Year : 2020  |  Volume : 34  |  Issue : 1  |  Page : 53-55

Ultrasound-guided erector spinae plane block for managing postherpetic neuralgia in cancer patients

Department of Onco-Anaesthesia and Palliative Medicine, Dr. B.R.A. IRCH, All India Institute of Medical Sciences, New Delhi, India

Date of Submission21-Aug-2019
Date of Acceptance27-Nov-2019
Date of Web Publication16-Apr-2020

Correspondence Address:
Dr. Sachidanand Jee Bharati
Room No 139, First Floor, Department of Onco-Anaesthesia and Palliative Medicine, Dr. B.R.A. IRCH, All India Institute of Medical Sciences, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpn.ijpn_58_19

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Pain is the most distressing symptom experienced by cancer patients. Postherpetic neuralgia (PHN) is a rare cause of pain in breast cancer survivors that can negatively affect their quality of life. Ultrasound-guided fascial plane blocks are among the most recent addition to anesthesiologist's armamentarium. We describe the successful use of ultrasound-guided erector spinae plane block to provide adequate pain relief in a patient with PHN refractory to pharmacological therapy.

Keywords: Cancer patients, dexmedetomidine, erector spinae plane block, postherpetic neuralgia

How to cite this article:
Ahuja D, Bharati SJ, Kumar V, Gupta N. Ultrasound-guided erector spinae plane block for managing postherpetic neuralgia in cancer patients. Indian J Pain 2020;34:53-5

How to cite this URL:
Ahuja D, Bharati SJ, Kumar V, Gupta N. Ultrasound-guided erector spinae plane block for managing postherpetic neuralgia in cancer patients. Indian J Pain [serial online] 2020 [cited 2022 Aug 12];34:53-5. Available from: https://www.indianjpain.org/text.asp?2020/34/1/53/282552

  Introduction Top

Persistent pain after breast cancer treatment (PPBCT) is an incapacitating side effect occurring in breast cancer survivors with a prevalence rate up to 50%.[1] Different etiologies such as phantom breast pain, intercostobrachial neuralgia, neuroma pain, and pain due to injury to nerves such as intercostal, medial and lateral pectoral, long thoracic, thoracodorsal nerve, administration of radiotherapy, and inclusion of axillary lymph node dissection in surgical technique have been proposed earlier.[2] Herpes zoster (HZ) or shingles, caused by the reactivation of latent varicella zoster virus (VZV) established in cells of the dorsal root ganglia, is a rare cause of PPBCT. As the VZV is maintained in its latent form by intact cell-mediated immunity, immunosuppressed patients are at greater risk of having HZ and postherpetic neuralgia (PHN).[3] Cancer patients are often immunocompromised due to the disease itself or treatment received. Habel et al. studied the epidemiology of HZ in newly diagnosed cancer patients and found that these patients were at substantially increased risk of developing HZ and among those with HZ, complications were relatively common.[4] The treatment of HZ is aimed at inhibiting viral replication, preventing the development of complications by accelerating healing, and providing adequate pain relief.[5] Ultrasound-guided interfascial plane blocks being used for different indications have been the latest addition to an anesthesiologist's armamentarium. Erector spinae plane block (ESPB), a promising interfascial plane block, provides thoracic analgesia in both chronic neuropathic pain and acute postsurgical and posttraumatic pain by blocking dorsal and ventral rami of the thoracic spinal nerves.[6] We report the successful management of PHN refractory to pharmacological treatment in a patient of carcinoma breast with HZ using thoracic ESPB.

  Case Report Top

A 41-year-old female patient, diagnosed case of carcinoma left breast, was admitted in our hospital with complaints of left-sided chest pain for past 3 months. She had received four cycles of epirubicin and carboplatin-based chemotherapy, followed by four cycles of docetaxel-based chemotherapy. She had also undergone left modified radical mastectomy after completion of chemotherapeutic regimen. Almost 3 months later, the patient had reported to the dermatology clinic with complaints of vesicles and pain over the left side of the chest. HZ was diagnosed, and she was prescribed oral acyclovir, pregabalin, and paracetamol. Although HZ had resolved, pain had worsened to the extent that she was not able to wear clothes for the fear of pain. Furthermore, her scheduled radiotherapy was deferred due to pain. On assessment, left-sided chest pain was burning in character, radiating to back, severe in intensity with numerical rating score (NRS) of 10/10, and was present throughout the day. Physical examination showed healed vesicles along with hypertrophic scar overlying T2–T7 dermatomes and extending laterally till 1/3 of the left arm. Tramadol forms second-line therapy, and strong opioids such as morphine are third-line drugs for the management of neuropathic pain. Thus, we initially gave a trial of oral opioids by prescribing tablet tramadol 50 mg thrice daily. As there was persistence of severe pain with NRS of 9/10, we started analgesic titration with intravenous morphine. However, even after morphine infusion was increased to 2 mg/h, NRS values remained 8/10. Thus, we decided to administer ultrasound-guided ESPB at T5 level. The patient was positioned laterally with left side up, and under all aseptic precautions, linear ultrasound transducer (10-12 MHz) was placed in longitudinal direction, 3 cm lateral to T5 spinous process. Three muscles, namely, trapezius, rhomboid major, and erector spinae, from above downward were identified superficial to the hyperechoic transverse process [Figure 1]a. The puncture site was infiltrated subcutaneously with 2 ml of 2% lignocaine. Then, 22G, blunt-tipped, 80-mm long sonoplex needle using in-plane approach was inserted in a caudad-to-cephalad direction until the tip lay in the interfascial plane between erector spinae muscle (ESM) and the transverse process. The plane was then confirmed by hydrodissection by injecting 2 ml saline. Finally, after negative aspiration, 20 ml of 0.375% ropivacaine mixed with 50 μg dexmedetomidine was injected in the interfascial plane between ESM and the transverse process [Figure 1]b. After the administration of ESPB, the patient's preprocedural NRS of 8 gradually reduced to <4 within 15 min. The dermatomal area extended from T1 to T8 at the pinprick test. NRS scores were significantly reduced even 24 h after the completion of procedure [Figure 2] and [Table 1]. Tablet acetaminophen 500 mg was given as rescue analgesic when the patient complained of pain with NRS >4. We also added tablet pregabalin 75 mg at bedtime to her analgesic prescription. Two days later, she was discharged on tablet acetaminophen 500 mg thrice daily and tablet pregabalin 75 mg at bedtime as adequate pain relief had been obtained. The patient was discharged and followed up regularly on a weekly basis till 2 months and was found to have adequate pain relief.
Figure 1: (a) Ultrasound image of erector spinae plane block, and tip of T5 transverse process. (b) Needle tip positioned in the plane between ESM and tip of T5 transverse process plane and local anesthetic is injected. TM: Trapezius muscle, RMM: Rhomboid major muscle, ESM: Erector spinae muscle

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Figure 2: Graphical representation of numerical rating score at different time points after the administration of block

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Table 1: Numerical rating score at different time points after the administration of block

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  Discussion Top

PHN is one of the most resistant chronic pain conditions encountered. In patients with depressed cell-mediated immunity, virus replicates in sensory dorsal root ganglia and migrates down sensory nerve leading to dermatomal distribution of rash. Unilateral thoracic dermatomes and trigeminal nerve, especially ophthalmic branch, are most frequently affected. Despite the multitude of therapies available, 40%–50% of patients suffer from pain. Early institution of antiviral agents and corticosteroids prevents neuronal damage. Different analgesic agents such as acetaminophen, nonsteroidal anti-inflammatory drugs, and anticonvulsants, mainly gabapentenoids, have been used to reduce severity of acute pain during HZ.[7] It is essential to obtain an effective “pain-free period” to interrupt established reverberatory neural circuit between nociceptors, central nervous system, and motor unit.[8] Various techniques from anesthesiologist's armamentarium have been used to obtain this pain-free period. Hwang et al. evaluated relief of acute pain and possible preventive effects on PHN with the use of epidural blockade in acute stages of HZ and found that epidural block reduces the total duration of pain, especially late residual pain, but was associated with mild adverse effects such as headache and backache.[9] In another study, Naja et al. have described successful use of repetitive injections of local anesthetic (LA) mixture (19 ml of 0.5% bupivacaine and 1 ml of 150 μg/ml clonidine) every 48 h for 3 weeks, using a paravertebral catheter inserted at T2–T3 level in case of PHN refractory to medical therapy.[8] In another study, Hardy reported a potential of deep cervical root block at C3 and greater occipital nerve block with bupivacaine, epinephrine, and methylprednisolone in patients presenting with acute HZ of 1–2 weeks duration involving C2, 3, and 4 dermatomes.[10] As previously described techniques of epidural and paravertebral block (PVB) are associated with adverse effects such as hemodynamic instability, closer communication to neuraxial axis, and risk of formation of hematoma in patients with deranged coagulation profile, we decided to administer ultrasound-guided ESPB for providing adequate pain relief in our patient.

ESPB was described by Forero et al. for thoracic chronic pain and involved injection of the anesthetic agent superficial to the ESM in the retrolaminar region (3 cm lateral to midline) at the level of the T5 transverse process, as a safer and relatively simple alternative to PVB.[6] Further, the cadaveric findings indicated that the optimal plane for injection in the ESPB is deep to the ESM rather than superficial to it, as this will deposit local anesthetic closer to the dorsal and ventral rami.[6]

After the administration of ESPB, adequate pain relief was obtained and it was possible to obtain a “pain-free period.” Finally, by the administration of pharmacological agents after a “pain-free period” obtained with the use of ESPB, adequate analgesic effect was achieved. Antidepressants such as duloxetine and venlafaxine that selectively inhibit reuptake of serotonin and norepinephrine are also recommended as first-line agents used for pharmacological management of neuropathic pain along with gabapentin and pregabalin.[11] As our patient was already taking pregabalin among first-line drugs and was more anxious than depressed as persistent pain delayed administration of disease-modifying treatment modality, we did not use antidepressants for her management.

Further, lignocaine 5% patches are recommended as a second-line agent for the management of peripheral neuropathic pain inspite of weak final quality of evidence owing to an excellent safety profile and short-term positive studies.[11] These are, particularly, useful in the management of focal neuropathic pain. We did not prefer to use lignocaine patch in our patient as she mainly complained of multidermatomal neuropathic pain over the left chest wall extending to the left arm.

  Conclusion Top

PHN is a distressing chronic pain condition. The acute pain of severe intensity during HZ contributes significantly to the development of PHN. Adequate pain relief for the management of herpetic neuralgia can be obtained using newer, simple, safe, and effective interfascial plane blocks such as ESPB. However, future randomized controlled trials are required to determine the exact level of application of block, optimal volume, and concentration of LA required and to prove higher efficacy over other methods such as epidural and PVB.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Mejdahl MK, Andersen KG, Gärtner R, Kroman N, Kehlet H. Persistent pain and sensory disturbances after treatment for breast cancer: Six year nationwide follow-up study. BMJ 2013;346:f1865.  Back to cited text no. 1
Smith HS, Wu SX. Persistent pain after breast cancer treatment. Ann Palliat Med 2012;1:182-94.  Back to cited text no. 2
Sampathkumar P, Drage LA, Martin DP. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clin Proc 2009;84:274-80.  Back to cited text no. 3
Habel LA, Ray GT, Silverberg MJ, Horberg MA, Yawn BP, Castillo AL, et al. The epidemiology of herpes zoster in patients with newly diagnosed cancer. Cancer Epidemiol Biomarkers Prev 2013;22:82-90.  Back to cited text no. 4
Johnson RW. Consequences and management of pain in herpes zoster. J Infect Dis 2002;186 Suppl 1:S83-90.  Back to cited text no. 5
Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41:621-7.  Back to cited text no. 6
Singh S, Gupta R, Kaur S, Kaur J. Post-herpetic neuralgia: A review of current management strategies. Indian J Pain 2013;27:12-21.  Back to cited text no. 7
  [Full text]  
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.  Back to cited text no. 8
Hwang SM, Kang YC, Lee YB, Yoon KB, Ahn SK, Choi EH. The effects of epidural blockade on the acute pain in herpes zoster. Arch Dermatol 1999;135:1359-64.  Back to cited text no. 9
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.  Back to cited text no. 10
Finnerup NB, Attal N, Haroutounian S, McNicol E, Baron R, Dworkin RH, et al. Pharmacotherapy for neuropathic pain in adults: A systematic review and meta-analysis. Lancet Neurol 2015;14:162-73.  Back to cited text no. 11


  [Figure 1], [Figure 2]

  [Table 1]

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