Ultrasound-guided erector spinae block and paravertebral block may prevent postherpetic neuralgia

1. Patients randomized to receive the paravertebral block (PVB) and erector spinae plane block (ESPB) had significantly more effective prevention and minimization of the impacts of post-herpetic neuralgia (PHN) in the acute period post-Herpes Zoster infection.

2. Patients randomized to receive PVB or ESPB additionally required less oral rescue analgesics and reported significantly higher quality of life at 15, 30, and 60 days post-block compared to controls. 

Evidence Rating Level: 1 (Excellent)

Herpes Zoster (HZ, or shingles) is a reactivation of the Varicella Zoster virus, and a painful dermatomal rash is usually a defining acute feature of the condition. This zoster-related pain (ZP) can be debilitating for patients, and unfortunately, it may remain or continue to intensify after resolution of infection. This is particularly true in cases where initial pain experienced by the patient is more intense, with post-herpetic neuralgia (PHN) affecting between 5-50% of patients. Initial pain control should thus be a mainstay of treatment in the prevention of PHN, and two novel interfascial nerve blocks, the Paravertebral Block (PVB) and Erector Spinae Plane Block (ESPB), have been observed in case reports and observational studies as potential modulators. This single-blind, parallel arm, prospective randomized trial placed 60 participants either in the control, PVB, or ESPB group (n = 20 in each group) and followed up with patients 15, 30, and 60 days post-block. There was a significant decrease in pain intensity based on Numerical Rating Scores (NRS) in both groups receiving nerve blocks at 15, 30, and 60 days post-block (p = 0.003) when compared to controls. Rates of allodynia were also significantly lower in the groups receiving nerve blocks by 60 day follow-up (p = .04). Patients who received the block also reported a decreased need for oral rescue analgesics, with control patients reporting twice as many days requiring analgesia per week compared to those who received blocks. Improved quality-of-life was observed in both groups receiving blocks compared to the control group (p < .05) via the World Health Organization’s (WHO) quality of life (WHOQOL) scale. Finally, the overall incidence of PHN was significantly higher in the control group compared to both the ESPB and PVB groups (80%, 45% and 40%, respectively; p = .022). Overall, the results of this study demonstrate promise in the prevention and minimization of this debilitating pain, while demonstrating no significant adverse effects in patients receiving the blocks. Limitations of the current study include sample size and a lack of double-blinding, indicating the need for further research on this topic with longer observation periods. However, results indicate the potential for an efficacious, safe, and practical treatment for the early phases of HZ reinfection. 

Click to read the study in the Journal of Clinical Anesthesiology and Clinical Pharmacology

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