103
Anesth Pain Med 2014 9 103-105 Case Report
Ultrasound-guided pulsed radiofrequency treatment for postherpetic neuralgia of supraorbital nerve -A case report-
Department of Anesthesiology and Pain Medicine Samsung Medical Center Sungkyunkwan University School of Medicine Department of Anesthesiology and Pain Medicine Seoul St Maryrsquos Hospital The Catholic University of Korea College of Medicine Seoul Korea
Jin Young Lee Woo Seog Sim Duk Kyung Kim Hue Jung Park Min Seok Oh and Ji Eun Lee
Received August 26 2013
Revised September 13 2013
Accepted December 9 2013
Corresponding author Hue Jung Park MD PhD Department of
Anesthesiology and Pain Medicine Seoul St Marys Hospital The Catholic
University of Korea College of Medicine 505 Banpo-dong Seocho-gu
Seoul 137-040 Korea Tel 82-2-2258-6157 Fax 82-2-537-1951 E-mail
huejungcatholicackr
Pulsed radiofrequency treatment has an analgesic effect by
neuromodulation of the central pain pathway without neural injury
However lack of knowledge regarding the exact mechanism on
neuropathic pain makes the use of pulsed radiofrequency treatment
controversial Here we describe a case of satisfactory pain relief
after ultrasound-guided pulsed radiofrequency treatment in a patient
with supraorbital herpetic pain refractory to medication This case
indicates the potential of ultrasound-guided pulsed radiofrequency
treatment in patients with postherpetic supraorbital neuralgia
(Anesth Pain Med 2014 9 103-105)
Key Words Pain Pulsed radiofrequency Supraorbital neuralgia
Ultrasound
Herpetic neuralgia is a significant source of morbidity
following reactivation of dormant varicella zoster virus Varice-
lla-zoster viral particles travel down the neural axon to the
skin and produce painful vesicular cutaneous lesions on the
affected dermatome It must be treated promptly to avoid
progressive pain sensory dysfunction and central sensitization
Nerve block with local anesthetics may relieve pain by
reducing afferent transmission of nociceptive pathway but it
usually does not provide long term relief Recently pulsed
radiofrequency (PRF) treatment has drawn interest for its antih-
yperalgesic or antiallodynic effect which acts to influence syn-
apse transmission and excitatory C-fiber responses resulting in
a neuromodulation of the central pain pathway In previous
PRF treatment cases of supraorbital neuralgia it has been
typically performed using a C-arm or landmark based blind
technique [1-3] and there is no literature describing an ultra-
sound-guided PRF technique Accurate injection technique is
necessary to limit side effects especially for ablation-related
management In this report we performed ultrasound-guided
PRF treatment for a patient with severe supraorbital herpetic
pain with excellent results Ultrasound-guided PRF treatment
can thus be a feasible and safe simple approach for patients
with supraorbital herpetic neuralgia
CASE REPORT
A 59-year-old 152 cm 70 kg female patient was referred to
our pain clinic with severe left facial pain with rash The rash
had developed 5 weeks previously and clinical evaluation
confirmed acute herpes zoster on the left supraorbital branch
of the trigeminal nerve Just before her visit she received
medical treatment with a stellate ganglion block at a local
hospital Even though she had a congestive left eye herpes
zoster ophthalmicus was ruled out by an ophthalmologist The
viral skin lesions were almost resolved successfully during the
acute phase However supraorbital pain remained severe
Examination revealed a recently acquired herpetic scar over the
left median eyebrow and forehead She suffered from continu-
ous throbbing pain (6 points on visual analogue scale VAS 0
= no pain 10 = worst pain imaginable) with intermittent elec-
trical shock-like sensation on this frontal head (VAS score of
8) Neurological examination showed decreased sensation (35
0 = no sensation 5 = normal sensation) tingling (35 0 = no
tingling 5 = severe tingling) itching (45 0 = no itching 5 =
severe itching) and hyperalgesia (25 0 = no hyperalgesia 5 =
severe hyperalgesia) in the distribution of the left supraorbital
104 Anesth Pain Med Vol 9 No 2 2014985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103
Fig 1 (A) An ultrasound image of supraorbital nerve via out-of-plane approach in the transverse scan (B) Pulsed radiofrequency procedure of supraorbital nerve
nerve She had been treated with 225 mg pregabalin three
tablets of 375 mg tramadol375 mg acetaminophen combination
(Cetamadol Ildong Seoul Korea) 15 mg oxycodone and 20
mg nortriptyline in a day with partial pain relief of VAS 5
She refused previous procedure and increasing medications due
to systemic side effects of nausea and sedation She underwent
two supraorbital nerve blocks with 2 ml of 0375 ropivacaine
with 5 mg dexamethasone under ultrasound guidance and
showed a positive response which provided pain relief for 1
day with 60 reduction in pain intensity Therefore we
proposed to perform PRF treatment in hopes of achieving a
longer duration of pain relief After informed consent the
patient was placed in the supine position The skin was
aseptically draped with betadine Ultrasound was prepared with
a sterile transparent sheath and aseptic ultrasound gel Using a
high frequency linear transducer (SonoSite Inc Washington
USA) we tried localizing the left supraorbital foramen The
probe was positioned transversely above the roof of the left
orbital rim and the bone was scanned slowly in a cephalad to
caudad direction to find the break in the linear hyperec-
hogenicity The left supraorbital foramen was captured as a
hypoechoic break in the bony surface After that a radiofrequ-
ency needle insulated with a 5 mm active tip (22G
SMK-C10 Radionics Inc Burlington MA USA) was
advanced slightly using an out-of-plane approach For definite
identification between bone touch and supraorbital nerve
sensation we performed sensory stimulation of the supraorbital
nerve at 50 Hz and 05 V then started three cycles of PRF
treatment at 42oC for 120 sec (Fig 1) Following the PRF
treatment we administered 2 ml of 0375 ropivacaine with 5
mg dexamethasone The treatment was well tolerated and the
patient was without discomfort during the procedure
Post-procedurally pain improved significantly with a VAS
score of 3 She has been followed in a pain VAS 2-3
improved sensation (45) tingling (15) and itching (35) by
our pain clinic for the past 28 weeks She is controlling her
medications including 75 mg pregabalin one 375 mg
tramadol375 mg acetaminophen combination tablet and 25
mg nortriptyline in a day without opioid which was decreased
by 70 of the requirement without further nerve block
DISCUSSION
Trigeminal herpetic neuralgia is a debilitating facial pain
disorder which is often refractory and may not respond satisf-
actorily to standard pain management The supraorbital nerve
as a terminal branch of the ophthalmic division of the
trigeminal nerve innervates the skin of the forehead eyelid
conjunctiva and the frontal sinus with supratrochlear nerve In
our case the patient experienced supraorbital herpetic neuralgia
as a continuation of that previously experienced with the acute
herpes zoster eruption which has been described as a throbbing
and burning sensation itching or tingling along the course of
the supraorbital nerve There are various protocols for the pain
management The main concerns are adequate pain control and
minimization of central neural sensitization To prevent and
reduce the incidence or severity of postherpetic neuralgia (PHN)
significant rapid pain relief is of utmost important during acute
phase Commonly employed therapies are oral anticonvulsants
tricyclic antidepressants opioids topical agents superficial
trigeminal nerve block and more invasive procedures such as
radiofrequency lesioning peripheral nerve stimulation and
surgical ablation However ideal pain management for refrac-
tory supraorbital neuralgia has not yet been determined
For diagnosis and treatment of trigeminal herpetic neuralgia
superficial trigeminal nerve block is performed by injecting
local anesthetic andor steroid in close proximity to the three
terminal branches of the trigeminal nerve Traditionally C-arm
or landmark based palpation technique has been widely used
However block failures may occur when encountering altered
bony andor vessel anatomy Ultrasound is a safe simple and
non-invasive tool for visualizing and identifying bone nerve
Jin Young Lee et alPostherpetic supraorbital neuralgia 105985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103
and vessels Blocks with ultrasound has increased in pain
clinics to locate nerves precisely and enable real-time needle
advancement This can potentially avoid unnecessary trauma to
surrounding tissues Especially ablation-related procedures need
more accuracy for preventing possible complications including
inadvertent nerve injury or perineural hematoma
PRF treatment has recently been reported to have promising
results in pain management It is a non-destructive minimally
invasive technique and is felt to be safer than continuous
radiofrequency considering neural damage It has been reported
to produce analgesia possibly by plastic change of the central
pain pathway [4] The exact mechanisms of pain relief remain
unknown and several hypotheses have been described Some
authors have reported that electrical fields have effects on
immune modulation as there are studies that show proinflam-
matory cytokines such as interleukin-1β tumor necrosis
factor-α and interleukin-6 that are attenuated by electric fields
[56] In human neutrophils treated with generated electric
fields upregulation of adenosine A2A receptor density which
is associated with inhibition of the catabolic cytokines has
also been observed [7] Hagiwara et al [8] reported that PRF
may enhance the descending noradrenergic and serotonergic
inhibitory pathways which are intimately involved in the
modulation of neuropathic pain Although this treatment around
the neural tissues carries inherent risk of nerve damage
bleeding infection and burns no complications related to PRF
were reported until now These favorable outcomes have
facilitated the application of this technique to herpetic pain
management PRF treatment showed 6 to 12 months pain relief
in some case series involving postherpetic pain of trigeminal
nerve branch [910] However clinical evidence of ultraso-
und-guided PRF treatment on supraorbital neuralgia is lacking
In our case post-procedurally the patient showed over 50
reduction in pain severity and significant decrease in analgesics
requirements for more than 28 weeks without adverse effects
Perhaps this reflects an important role of early intervention for
severe pain as one of risk factors for PHN We believe that
early PRF treatment of supraorbital herpetic neuralgia has
analgesic and preventive effects on PHN due to attenuation of
inflammatory mediators and enhancing inhibitory pain pathway
hence reducing nerve ischemic damage and central sensitization
However further research including large clinical trials will
be needed to provide further evidence on long term efficacy of
PRF and any difference in outcomes between the traditional
C-arm or landmark based versus ultrasound-guided technique
In conclusion ultrasound-guided PRF could potentially be a
safe simple and effective treatment option for patients who
cannot tolerate oral medications and who has high risk factors
for developing PHN
REFERENCES
1 Seo KC Shin HD Kim JH Song SY Rho WS Chung JY Pulsed
radiofrequency treatment of the supraorbital and supratrochlear
nerve in a case of trigeminal neuralgia -a case report- Korean J
Pain 2009 22 167-70
2 Lee JH Kim TY Ha SH Kwon YE Yoon CS Pulsed
radiofrequency lesioning of supraorbital and supratrochlear nerve
in postherpetic neuralgia -a report of 2 cases- J Korean Pain Soc
2004 17 239-42
3 Bae HM Kim YH Kim SW Moon DE The effect of pulsed
radiofrequency (PRF) for the treatment of supraorbital neuropathic
pain -a report of three cases- Anesth Pain Med 2012 7 117-20
4 Higuchi Y Nashold BS Jr Sluijter M Cosman E Pearlstein RD
Exposure of the dorsal root ganglion in rats to pulsed
radiofrequency currents activates dorsal horn lamina I and II
neurons Neurosurgery 2002 50 850-5
5 Igarashi A Kikuchi S Konno S Correlation between
inflammatory cytokines released from the lumbar facet joint tissue
and symptoms in degenerative lumbar spinal disorders J Orthop
Sci 2007 12 154-60
6 Chua NH Vissers KC Sluijter ME Pulsed radiofrequency treatment
in interventional pain management mechanisms and potential
indications-a review Acta Neurochir (Wien) 2011 153 763-71
7 Varani K Gessi S Merighi S Iannotta V Cattabriga E Spisani
S et al Effect of low frequency electromagnetic fields on A2A
adenosine receptors in human neutrophils Br J Pharmacol 2002
136 57-66
8 Hagiwara S Iwasaka H Takeshima N Noguchi T Mechanisms
of analgesic action of pulsed radiofrequency on adjuvant-induced
pain in the rat roles of descending adrenergic and serotonergic
systems Eur J Pain 2009 13 249-52
9 Lim SM Park HL Moon HY Kang KH Kang H Baek CH et
al Ultrasound-guided infraorbital nerve pulsed radiofrequency
treatment for intractable postherpetic neuralgia - a case report-
Korean J Pain 2013 26 84-8
10 Kim SH Shin JW Leem JG Suh JH Pulsed radiofrequency
treatment of the anterior ethmoidal nerve under nasal endoscopic
guidance for the treatment of postherpetic neuralgia Anaesthesia
2011 66 1057-8
104 Anesth Pain Med Vol 9 No 2 2014985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103
Fig 1 (A) An ultrasound image of supraorbital nerve via out-of-plane approach in the transverse scan (B) Pulsed radiofrequency procedure of supraorbital nerve
nerve She had been treated with 225 mg pregabalin three
tablets of 375 mg tramadol375 mg acetaminophen combination
(Cetamadol Ildong Seoul Korea) 15 mg oxycodone and 20
mg nortriptyline in a day with partial pain relief of VAS 5
She refused previous procedure and increasing medications due
to systemic side effects of nausea and sedation She underwent
two supraorbital nerve blocks with 2 ml of 0375 ropivacaine
with 5 mg dexamethasone under ultrasound guidance and
showed a positive response which provided pain relief for 1
day with 60 reduction in pain intensity Therefore we
proposed to perform PRF treatment in hopes of achieving a
longer duration of pain relief After informed consent the
patient was placed in the supine position The skin was
aseptically draped with betadine Ultrasound was prepared with
a sterile transparent sheath and aseptic ultrasound gel Using a
high frequency linear transducer (SonoSite Inc Washington
USA) we tried localizing the left supraorbital foramen The
probe was positioned transversely above the roof of the left
orbital rim and the bone was scanned slowly in a cephalad to
caudad direction to find the break in the linear hyperec-
hogenicity The left supraorbital foramen was captured as a
hypoechoic break in the bony surface After that a radiofrequ-
ency needle insulated with a 5 mm active tip (22G
SMK-C10 Radionics Inc Burlington MA USA) was
advanced slightly using an out-of-plane approach For definite
identification between bone touch and supraorbital nerve
sensation we performed sensory stimulation of the supraorbital
nerve at 50 Hz and 05 V then started three cycles of PRF
treatment at 42oC for 120 sec (Fig 1) Following the PRF
treatment we administered 2 ml of 0375 ropivacaine with 5
mg dexamethasone The treatment was well tolerated and the
patient was without discomfort during the procedure
Post-procedurally pain improved significantly with a VAS
score of 3 She has been followed in a pain VAS 2-3
improved sensation (45) tingling (15) and itching (35) by
our pain clinic for the past 28 weeks She is controlling her
medications including 75 mg pregabalin one 375 mg
tramadol375 mg acetaminophen combination tablet and 25
mg nortriptyline in a day without opioid which was decreased
by 70 of the requirement without further nerve block
DISCUSSION
Trigeminal herpetic neuralgia is a debilitating facial pain
disorder which is often refractory and may not respond satisf-
actorily to standard pain management The supraorbital nerve
as a terminal branch of the ophthalmic division of the
trigeminal nerve innervates the skin of the forehead eyelid
conjunctiva and the frontal sinus with supratrochlear nerve In
our case the patient experienced supraorbital herpetic neuralgia
as a continuation of that previously experienced with the acute
herpes zoster eruption which has been described as a throbbing
and burning sensation itching or tingling along the course of
the supraorbital nerve There are various protocols for the pain
management The main concerns are adequate pain control and
minimization of central neural sensitization To prevent and
reduce the incidence or severity of postherpetic neuralgia (PHN)
significant rapid pain relief is of utmost important during acute
phase Commonly employed therapies are oral anticonvulsants
tricyclic antidepressants opioids topical agents superficial
trigeminal nerve block and more invasive procedures such as
radiofrequency lesioning peripheral nerve stimulation and
surgical ablation However ideal pain management for refrac-
tory supraorbital neuralgia has not yet been determined
For diagnosis and treatment of trigeminal herpetic neuralgia
superficial trigeminal nerve block is performed by injecting
local anesthetic andor steroid in close proximity to the three
terminal branches of the trigeminal nerve Traditionally C-arm
or landmark based palpation technique has been widely used
However block failures may occur when encountering altered
bony andor vessel anatomy Ultrasound is a safe simple and
non-invasive tool for visualizing and identifying bone nerve
Jin Young Lee et alPostherpetic supraorbital neuralgia 105985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103
and vessels Blocks with ultrasound has increased in pain
clinics to locate nerves precisely and enable real-time needle
advancement This can potentially avoid unnecessary trauma to
surrounding tissues Especially ablation-related procedures need
more accuracy for preventing possible complications including
inadvertent nerve injury or perineural hematoma
PRF treatment has recently been reported to have promising
results in pain management It is a non-destructive minimally
invasive technique and is felt to be safer than continuous
radiofrequency considering neural damage It has been reported
to produce analgesia possibly by plastic change of the central
pain pathway [4] The exact mechanisms of pain relief remain
unknown and several hypotheses have been described Some
authors have reported that electrical fields have effects on
immune modulation as there are studies that show proinflam-
matory cytokines such as interleukin-1β tumor necrosis
factor-α and interleukin-6 that are attenuated by electric fields
[56] In human neutrophils treated with generated electric
fields upregulation of adenosine A2A receptor density which
is associated with inhibition of the catabolic cytokines has
also been observed [7] Hagiwara et al [8] reported that PRF
may enhance the descending noradrenergic and serotonergic
inhibitory pathways which are intimately involved in the
modulation of neuropathic pain Although this treatment around
the neural tissues carries inherent risk of nerve damage
bleeding infection and burns no complications related to PRF
were reported until now These favorable outcomes have
facilitated the application of this technique to herpetic pain
management PRF treatment showed 6 to 12 months pain relief
in some case series involving postherpetic pain of trigeminal
nerve branch [910] However clinical evidence of ultraso-
und-guided PRF treatment on supraorbital neuralgia is lacking
In our case post-procedurally the patient showed over 50
reduction in pain severity and significant decrease in analgesics
requirements for more than 28 weeks without adverse effects
Perhaps this reflects an important role of early intervention for
severe pain as one of risk factors for PHN We believe that
early PRF treatment of supraorbital herpetic neuralgia has
analgesic and preventive effects on PHN due to attenuation of
inflammatory mediators and enhancing inhibitory pain pathway
hence reducing nerve ischemic damage and central sensitization
However further research including large clinical trials will
be needed to provide further evidence on long term efficacy of
PRF and any difference in outcomes between the traditional
C-arm or landmark based versus ultrasound-guided technique
In conclusion ultrasound-guided PRF could potentially be a
safe simple and effective treatment option for patients who
cannot tolerate oral medications and who has high risk factors
for developing PHN
REFERENCES
1 Seo KC Shin HD Kim JH Song SY Rho WS Chung JY Pulsed
radiofrequency treatment of the supraorbital and supratrochlear
nerve in a case of trigeminal neuralgia -a case report- Korean J
Pain 2009 22 167-70
2 Lee JH Kim TY Ha SH Kwon YE Yoon CS Pulsed
radiofrequency lesioning of supraorbital and supratrochlear nerve
in postherpetic neuralgia -a report of 2 cases- J Korean Pain Soc
2004 17 239-42
3 Bae HM Kim YH Kim SW Moon DE The effect of pulsed
radiofrequency (PRF) for the treatment of supraorbital neuropathic
pain -a report of three cases- Anesth Pain Med 2012 7 117-20
4 Higuchi Y Nashold BS Jr Sluijter M Cosman E Pearlstein RD
Exposure of the dorsal root ganglion in rats to pulsed
radiofrequency currents activates dorsal horn lamina I and II
neurons Neurosurgery 2002 50 850-5
5 Igarashi A Kikuchi S Konno S Correlation between
inflammatory cytokines released from the lumbar facet joint tissue
and symptoms in degenerative lumbar spinal disorders J Orthop
Sci 2007 12 154-60
6 Chua NH Vissers KC Sluijter ME Pulsed radiofrequency treatment
in interventional pain management mechanisms and potential
indications-a review Acta Neurochir (Wien) 2011 153 763-71
7 Varani K Gessi S Merighi S Iannotta V Cattabriga E Spisani
S et al Effect of low frequency electromagnetic fields on A2A
adenosine receptors in human neutrophils Br J Pharmacol 2002
136 57-66
8 Hagiwara S Iwasaka H Takeshima N Noguchi T Mechanisms
of analgesic action of pulsed radiofrequency on adjuvant-induced
pain in the rat roles of descending adrenergic and serotonergic
systems Eur J Pain 2009 13 249-52
9 Lim SM Park HL Moon HY Kang KH Kang H Baek CH et
al Ultrasound-guided infraorbital nerve pulsed radiofrequency
treatment for intractable postherpetic neuralgia - a case report-
Korean J Pain 2013 26 84-8
10 Kim SH Shin JW Leem JG Suh JH Pulsed radiofrequency
treatment of the anterior ethmoidal nerve under nasal endoscopic
guidance for the treatment of postherpetic neuralgia Anaesthesia
2011 66 1057-8
Jin Young Lee et alPostherpetic supraorbital neuralgia 105985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103985103
and vessels Blocks with ultrasound has increased in pain
clinics to locate nerves precisely and enable real-time needle
advancement This can potentially avoid unnecessary trauma to
surrounding tissues Especially ablation-related procedures need
more accuracy for preventing possible complications including
inadvertent nerve injury or perineural hematoma
PRF treatment has recently been reported to have promising
results in pain management It is a non-destructive minimally
invasive technique and is felt to be safer than continuous
radiofrequency considering neural damage It has been reported
to produce analgesia possibly by plastic change of the central
pain pathway [4] The exact mechanisms of pain relief remain
unknown and several hypotheses have been described Some
authors have reported that electrical fields have effects on
immune modulation as there are studies that show proinflam-
matory cytokines such as interleukin-1β tumor necrosis
factor-α and interleukin-6 that are attenuated by electric fields
[56] In human neutrophils treated with generated electric
fields upregulation of adenosine A2A receptor density which
is associated with inhibition of the catabolic cytokines has
also been observed [7] Hagiwara et al [8] reported that PRF
may enhance the descending noradrenergic and serotonergic
inhibitory pathways which are intimately involved in the
modulation of neuropathic pain Although this treatment around
the neural tissues carries inherent risk of nerve damage
bleeding infection and burns no complications related to PRF
were reported until now These favorable outcomes have
facilitated the application of this technique to herpetic pain
management PRF treatment showed 6 to 12 months pain relief
in some case series involving postherpetic pain of trigeminal
nerve branch [910] However clinical evidence of ultraso-
und-guided PRF treatment on supraorbital neuralgia is lacking
In our case post-procedurally the patient showed over 50
reduction in pain severity and significant decrease in analgesics
requirements for more than 28 weeks without adverse effects
Perhaps this reflects an important role of early intervention for
severe pain as one of risk factors for PHN We believe that
early PRF treatment of supraorbital herpetic neuralgia has
analgesic and preventive effects on PHN due to attenuation of
inflammatory mediators and enhancing inhibitory pain pathway
hence reducing nerve ischemic damage and central sensitization
However further research including large clinical trials will
be needed to provide further evidence on long term efficacy of
PRF and any difference in outcomes between the traditional
C-arm or landmark based versus ultrasound-guided technique
In conclusion ultrasound-guided PRF could potentially be a
safe simple and effective treatment option for patients who
cannot tolerate oral medications and who has high risk factors
for developing PHN
REFERENCES
1 Seo KC Shin HD Kim JH Song SY Rho WS Chung JY Pulsed
radiofrequency treatment of the supraorbital and supratrochlear
nerve in a case of trigeminal neuralgia -a case report- Korean J
Pain 2009 22 167-70
2 Lee JH Kim TY Ha SH Kwon YE Yoon CS Pulsed
radiofrequency lesioning of supraorbital and supratrochlear nerve
in postherpetic neuralgia -a report of 2 cases- J Korean Pain Soc
2004 17 239-42
3 Bae HM Kim YH Kim SW Moon DE The effect of pulsed
radiofrequency (PRF) for the treatment of supraorbital neuropathic
pain -a report of three cases- Anesth Pain Med 2012 7 117-20
4 Higuchi Y Nashold BS Jr Sluijter M Cosman E Pearlstein RD
Exposure of the dorsal root ganglion in rats to pulsed
radiofrequency currents activates dorsal horn lamina I and II
neurons Neurosurgery 2002 50 850-5
5 Igarashi A Kikuchi S Konno S Correlation between
inflammatory cytokines released from the lumbar facet joint tissue
and symptoms in degenerative lumbar spinal disorders J Orthop
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