ultrasound-guided pulsed radiofrequency treatment for

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


















































for developing PHN

REFERENCES




Pain 2009 22 167-70




2004 17 239-42











Sci 2007 12 154-60







136 57-66












2011 66 1057-8


















































for developing PHN

REFERENCES




Pain 2009 22 167-70




2004 17 239-42











Sci 2007 12 154-60







136 57-66












2011 66 1057-8

ultrasound-guided pulsed radiofrequency treatment for

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