CT-Scan Guided Gasserian Ganglion Injection of Dexamethasone CT-Scan Guided Gasserian Ganglion Injection of Dexamethasone

and Lidocaine for the Treatment of Recalcitrant Pain Associated with HSV-1 and Lidocaine for the Treatment of Recalcitrant Pain Associated with HSV-1 _ Infection of the Ophthalmic Division of the Trigeminal Nerve _ Infection of the Ophthalmic Division of the Trigeminal Nerve

K. D. Candido, MD, A. Germanovich, DO, R. F. Ghaly MD, G. Gorelick, MD*, N. N. Knezevic, MD, PhD

Department of Anesthesiology, *Department of Radiology Advocate Illinois Masonic Medical Center, Chicago, IL 60657 USA

Abstract

References

Case Description

We describe the case of a 17-year old boy with dermatologic Herpes Simplex Virus type-1 (HSV-1) outbreaks with incapacitating facial pain requiring multiple hospitalizations. He failed to respond to aggressive treatments including antiviral drugs, opioid analgesics, stellate ganglion, supra-orbital and supra-trochlear nerve blocks. The patient elected to undergo dexamethasone and lidocaine Gasserian ganglion block under CT-scan guidance. He had immediate and complete relief of his pain for the first time in almost two years. The patient remained pain free during 6 month follow-up visits. This is the first reported use of Gasserian ganglion block for treatment of HSV-1 infection of the trigeminal nerve.

Figure 1. CT scan images – Sagittal viewA. Needle tip seen slightly above the level of foramen ovale (circled)B. Magnified view of “A”- contrast opacifies Meckel’s cave (in triangle)

Figure 2. CT scan images – Coronal viewA. Needle tip seen slightly above the level of foramen ovale (circled)B. Magnified coronal view of “A”- High density contrast opacifies the anterior aspect of the left Meckel’s cave. Vertical linear lucency coursing through the Meckel’s cave likely represents V3 branch of trigeminal nerve (double arrows), superior (arrowhead) and medial (dotted arrow) impressions likely represent ophthalmic (V1) and maxillary (V2) branches of the left trigeminal nerve. Other structures: foramen ovale (*), clivus (1) and vertical ramus of the mandible (2)

Figure 3. CT scan images - Axial view A. A needle tip seen slightly above the level of foramen ovale (circled)B. Magnified view of “A” - Contrast opacifies Meckel’s cave. Horizontal linear lucency coursing through midaspect of contrast collection likely represents V2 branch of trigeminal nerve (arrow). Left petrous tip (*).

ConclusionsIntroduction

• This is the first case report of Gasserian ganglion injection for recalcitrant pain due to HSV-1 infection of the trigeminal nerve under CT-guidance. • We believe that Gasserian ganglion injection of dexamethasone with lidocaine may be useful in the treatment of HSV-1 infections of the trigeminal nerve in select individuals suffering from recurrent severe pain, who have failed to demonstrate a response to non-interventional therapies.

• 17 yo boy with dermatologic HSV-1 outbreaks with incapacitating facial pain requiring multiple hospitalizations• Diagnosed with HSV-1, and treated with acyclovir and valacyclovir• Pain was unresponsive to interventional therapies including stellate ganglion, supra-orbital and supra-trochlear nerve blocks • Pain regimens included acetaminophen, Naproxen, Tramadol, Pregabalin, hydromorphone IV, amitriptyline, topiramate, topical lidocaine 5% patch and Capsaicin cream

• Gasserian ganglion block for trigeminal neuralgia was described by Harris in 19121

• These blocks have been performed for managing facial pain associated with herpes zoster (HZV)• Literature search performed on PubMed and Medline found no references for using Gasserian ganglion block in the treatment of HSV-1 infection.• This is the first reported use of Gasserian ganglion block for treatment of HSV-1 infection of the trigeminal nerve.

• Presented to our Pain Clinic for persistent, unremitting pain, desperately seeking a long-term strategy to manage the pain• Habituated to hydromorphone (8mg tablets every 3-4 hours), with minimal benefits• Placed into the CT scanner in the supine position with the head and neck extended. • Skin wheal approximately 3cm lateral to the angle of the mouth with 3mL of 0.5% ropivacaine, using a 27-G 1.5inch needle • 25-G Whitacre-type subarachnoid needle with a curve at its distal tip• Once the needle tip was located in the foramen ovale on the left side (Figures 1a, 2a and 3a), 0.5mL of Iopamidol-200 contrast was injected (Figures 1b, 2b and 3b).• Contrast outlined Meckel’s cave, depicting all three branches of the trigeminal nerve (Figure 2b). • Noting the absence of CSF and w/out paresthesias, a total of 2mg of dexamethasone and 1mL of 1% lidocaine was subsequently slowly injected (total volume 1.5mL). • The needle was flushed with 0.5mL normal saline, was re-styletted, and was withdrawn. • The patient tolerated the procedure well with no immediate side effects or complications. • It was the first time in almost two years that he had absolutely no pain. • Opioid medications were completely discontinued on the day of the procedure and were not reinstated.

• The patient followed up in our Pain Clinic for 6 months and he remained pain free, on no opioids whatsoever. • He was able to complete his high school senior year and earn a diploma.

1. Harris W. Proc R Soc Med 1912; 5: 115-1192. Kikuchi A, et al. RAPM 1999; 24: 287-933. Kotani N, et al. NEJM 2000; 343: 1514-9