Postherpetik Nevralji
Özet
Postherpetik nevralji (PHN), Varicella zoster virüsünün reaktivasyonu sonucu oluşan Herpes zoster (suçiçeği/gece yanığı) enfeksiyonunun en yaygın ve zorlayıcı komplikasyonudur. Genellikle döküntülerin başlamasından sonra 90 günden fazla süren dermatomal ağrı olarak tanımlanır. İleri yaş (60 yaş üstü), şiddetli akut ağrı ve immünsüpresyon PHN gelişimi için temel risk faktörleridir. Hastalığın patogenezi tam olarak anlaşılamamakla birlikte, virüsün neden olduğu sinir hasarı sonucu gelişen inflamasyon ve nöronal duyarlılık artışı ana sorumlu olarak görülmektedir. Tanı, genellikle hastanın öyküsü ve döküntü sonrası devam eden keskin, yanıcı ağrı ile allodini gibi klinik bulgulara dayanarak kolayca konur. Tedavide temel amaç, kronikleşen ağrıyı hafifleterek yaşam kalitesini artırmaktır. Birinci basamak tedavide gabapentinoidler ve trisiklik antidepresanlar yer alırken; lidokain ve kapsaisin yamaları ikinci basamak seçenekleridir. Farmakolojik tedavinin yetersiz kaldığı durumlarda epidural enjeksiyonlar, paravertebral bloklar, radyofrekans uygulamaları ve spinal kord stimülasyonu gibi girişimsel yöntemler devreye girer. Ayrıca ozon terapisi ve bilişsel davranışçı terapi gibi destekleyici yaklaşımlar da multimodal tedavi kapsamında değerlendirilebilir. PHN yönetimi zorlu bir süreç olup, tedavi hastanın ihtiyaçlarına göre bireyselleştirilmelidir.
Postherpetic neuralgia (PHN) is the most common and challenging complication of Herpes zoster (shingles) infection, resulting from the reactivation of the Varicella zoster virus. It is generally defined as dermatomal pain persisting for more than 90 days after the onset of the rash. Advanced age (over 60), severe acute pain, and immunosuppression are the primary risk factors for developing PHN. Although the pathogenesis is not fully understood, inflammation and increased neuronal sensitivity resulting from virus-induced nerve damage are considered the main causes.
Diagnosis is relatively straightforward, based on the patient's history and clinical findings such as sharp, burning pain and allodynia persisting after the rash heals. The primary goal of treatment is to alleviate chronic pain and improve quality of life. First-line treatments include gabapentinoids and tricyclic antidepressants, while lidocaine and capsaicin patches serve as second-line options. In cases where pharmacological treatment is insufficient, interventional methods such as epidural injections, paravertebral blocks, radiofrequency applications, and spinal cord stimulation are employed. Additionally, supportive approaches like ozone therapy and cognitive-behavioral therapy can be considered as part of a multimodal treatment plan. Managing PHN is a complex process, and treatment must be individualized according to the patient's specific needs.
Referanslar
Haanpää M. Neurological Complications of Herpes Zoster. In: Watson C., Gershon A., Oxman M. (eds.) Herpes Zoster: Postherpetic Neuralgia and Other Complications. Springer: Switzerland; 2017. P. 61-75
El-Yahchouchi C., Nader A. Postherpetic Neuralgia. In: Shimoji K., Nader A., Hamann W. (eds) Chronic Pain Management in General and Hospital Practice. Springer:Singapore; 2021. P. 219-224. https://doi.org/10.1007/978-981-15-2933-7_12
Marra F, Parhar K, Huang B, Vadlamudi N. Risk Factors for Herpes Zoster Infection: A Meta-Analysis. Open Forum Infect Dis. 2020;7(1):ofaa005. doi:10.1093/ofid/ofaa005
Dworkin RH, Portenoy RK. Pain and its persistence in herpes zoster. Pain. 1996;67(2-3):241-251. doi:10.1016/0304-3959(96)03122-3
Arani RB, Soong SJ, Weiss HL, et al. Phase specific analysis of herpes zoster associated pain data: a new statistical approach. Stat Med 2001; 20:2429.
Johnson RW, Rice Andrew SC. Postherpetic Neuralgia. N Engl J Med. 2014;371:1526–33. doi:10.1056/NEJMcp1403062
Ekici AG. Herpes zoster ve postherpetik nevralji. In: Rumeli Ş. (ed.) Ağrı Yönetiminde Girişimsel Uygulamalar. Ankara: Akademisyen Kitabevi; 2020. p. 335-348
Werner RN, Nikkels AF, Marinović B, et al. European consensus-based (S2k) Guideline on the Management of Herpes Zoster -guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV), Part 1: Diagnosis. J Eur Acad Dermatol Venereol. 2017;31(1):9-19. doi:10.1111/jdv.13995
Watson PNC, Evans RJ, Watt VR, et al. Post-herpetic neuralgia: 208 cases. Pain. 1988;35(3):289-297. doi:10.1016/0304-3959(88)90139-X
Ortega E. Postherpetic neuralgia. In: UpToDate, Shefner JM (Ed), UpToDate, Waltham, MA. (20/02/2022 tarihinde ulaşılmıştır)
C. Peter, N. Watson. Postherpetic Neuralgia: Difficult to Treat, Easier to Prevent. In: Watson C., Gershon A., Oxman M. (eds.) Herpes Zoster: Postherpetic Neuralgia and Other Complications. Springer: Switzerland; 2017. P. 279- 296
Moore RA, Wiffen PJ, Derry S et al. Gabapentin for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev. 2011;(3):CD007938. doi:10.1002/14651858.CD007938.pub2
Beydoun A, Uthman BM, Sackellares JC. Gabapentin: pharmacokinetics, efficacy, and safety. Clin Neuropharmacol 1995; 18:469.
Ben-Menachem E. Pregabalin pharmacology and its relevance to clinical practice. Epilepsia. 2004;45 Suppl 6:13-18. doi:10.1111/j.0013-9580.2004.455003.x
Travnicek K. D. Sodium Channel Antagonists. In: T. R. Deer et al. (eds.), Deer’s Treatment of Pain An Illustrated Guide for Practitioners. Springer Nature: Switzerland, 2019. P: 171-180
Keskinbora K, Aydınlı I. An atypical opioid analgesic: Tramadol. Ağrı. 2006; 18(1): 5-19
Watson PN. Postherpetic neuralgia. BMJ Clin Evid. 2010;2010:0905. PMID: 21418680
Jain P, Jain M, Jain S. Subcutaneous Injection of Botulinum Toxin in Patients with Post Herpetic Neuralgia. A Preliminary Study. J Assoc Physicians India 2018; 66:48.
Hu Y, Zou L, Qi X, et al. Subcutaneous botulinum toxin-A injection for treating postherpetic neuralgia. Dermatol Ther 2020; 33:e13181.
Chen N, Yang M, He L et al. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2010;(12):CD005582. https://doi. org/10.1002/14651858.CD005582.pub3
Pasqualucci A, Pasqualucci V, Galla F et al. Prevention of Post-Herpetic Neuralgia: Acyclovir and Prednisolone versus Epidural Local Anesthetic and Methylprednisolone. Acta Anaesthesiologica Scandinavica, 2000;44(8), 910-918. https://doi.org/10.1034/j.1399-6576.2000.440803.x
Makharita MY, Amr YM, El-Bayoumy Y. Single paravertebral injection for acute thoracic herpes zoster: a randomized controlled trial. Pain Pract. 2015;15(3):229-235. doi:10.1111/papr.12179
Ji G, Niu J, Shi Y et al. The effectiveness of repetitive paravertebral injections with local anesthetics and steroids for the prevention of postherpetic neuralgia in patients with acute herpes zoster. Anesth Analg. 2009;109(5):1651-1655. doi:10.1213/ANE.0b013e3181b79075
Lin CS, Lin YC, Lao HC et al. Interventional Treatments for Postherpetic Neuralgia: A Systematic Review. Pain Physician. 2019;22(3):209-228.
Makharita MY, Amr YM, El-Bayoumy Y. Effect of early stellate ganglion blockade for facial pain from acute herpes zoster and incidence of postherpetic neuralgia. Pain Physician. 2012;15(6):467-474.
Colding A. Treatment of pain: organization of a pain clinic: treatment of acute herpes zoster. Proc R Soc Med. 1973;66(6):541-543
Wu CL, Marsh A, Dworkin RH. The role of sympathetic nerve blocks in herpes zoster and postherpetic neuralgia. Pain. 2000;87(2):121-129. doi:10.1016/S0304-3959(00)00230-X
Raj PP, Erdine S. Pain-relieving procedures: the illustrated guide. 1st ed. West Sussex: Wiley-Blackwell; 2012. pp. 244–249.
Brogan S.E, Fine P.G. Interventional Approaches to Postherpetic Neuralgia. In: Watson C., Gershon A., Oxman M. (eds.) Herpes Zoster: Postherpetic Neuralgia and Other Complications. Springer: Switzerland; 2017 p:239-251
Kim YH, Lee CJ, Lee SC et al. Effect of pulsed radiofrequency for postherpetic neuralgia. Acta Anaesthesiol Scand 2008; 52:1140-1143
Ke M, Yinghui F, Yi J, et al. Efficacy of pulsed radiofrequency in the treatment of thoracic postherpetic neuralgia from the angulus costae: a randomized, double-blinded, controlled trial. Pain Physician. 2013;16(1):15-25.
Oakley JC, Prager JP. Spinal cord stimulation: mechanisms of action. Spine (Phila Pa 1976). 2002;27(22):2574-2583. doi:10.1097/00007632-200211150-00034
Kurklinsky S, Palmer SC, Arroliga MJ et al. Neuromodulation in postherpetic neuralgia: case reports and review of the literature. Pain Med. 2017;19:1237. https://doi.org/10.1093/ pm/pnx175
Gazioğlu Türkyılmaz G, Rumeli Ş, Bakır M. Effects of Major Ozone Autohemotherapy on Physical Functionality and Quality of Life in Fibromyalgia Syndrome: A Prospective Cross-sectional Study. Altern Ther Health Med. 2021;27(5):8-12.
Hu B, Zheng J, Liu Q et al. The effect and safety of ozone autohemotherapy combined with pharmacological therapy in postherpetic neuralgia. J Pain Res. 2018;11:1637-1643. doi:10.2147/JPR.S154154
Pei W, Zeng J, Lu L, Lin G, Ruan J. Is acupuncture an effective postherpetic neuralgia treatment? A systematic review and meta-analysis. J Pain Res. 2019;12:2155-2165. doi:10.2147/JPR.S199950
Saxena AK, Bhardwaj N, Chilkoti GT, et al. Modulation of mRNA Expression of IL-6 and mTORC1 and Efficacy and Feasibility of an Integrated Approach Encompassing Cognitive Behavioral Therapy Along with Pregabalin for Management of Neuropathic Pain in Postherpetic Neuralgia: A Pilot Study. Pain Med 2021; 22:2276.
Texakalidis P, Tora MS, Boulis NM. Neurosurgeons' Armamentarium for the Management of Refractory Postherpetic Neuralgia: A Systematic Literature Review. Stereotact Funct Neurosurg. 2019;97(1):55-65. doi:10.1159/000499476
Petersen KL, Rowbotham MC. Relief of post-herpetic neuralgia by surgical removal of painful skin: 5 years later. Pain 2007;131:214-8.
