Journal of Neuro-Ophthalmology, March 1981, Volume 1, Issue 1

Stellate block for trigeminal zoster.

Stellate ganglion block for relief of pain and prevention of ophthalmic complications in trigeminal herpes zoster has been advised for many years. In a series of 27 patients, control of pain was dramatic after local anesthetic block of the stellate ganglion. This report is presented to stimulate renewed interest in this old form of therapy. Because of the retrospective nature of this investigation, the lack of adequate numbers and the absence of controls, no conclusions on efficacy of treatment can be made. However, enough hope of success is presented to justify a controlled series in a large metropolitan area where adequate numbers of patients can be accumulated for a double-blind protocol.

}. Clio. Neuro-ophthalmol. 1: 53-55, 1981. Stellate Block For Trigeminal Zoster E. RULE OLSON, M.D. H. BERRY IVY, M.D. Springfield, Missouri Abstract Stellate ganglion block for relief of pain and preven­tion of ophthalmic complications in trigeminal herpes zoster has been advised for many years. In a series of 27 patients, control of pain was dramatic after local anesthetic block of the stellate ganglion. This report is presented to stimulate renewed interest in this old fonn of therapy. Because of the retrospective nature of this investigation. the lack of adequate numbers and the absence of controls, no conclusions on efficacy of treatment can be made. However, enough hope of success is presented to justify a controlled series in a large metropolitan area where adequate numbers of patients can be accumulated for a double-blind proto­col. Herpes zoster has two forms as classified by Walsh and Hoytl: idiopathic and symptomatic. Symptomatic herpes zoster is triggered by inflam­mation, trauma, and neoplastic involvement of the nerve. The idiopathic form may be identical in pain and eruptions, but tends to clear much more slowly, and the eruptions tend to scarring with characteristic pigmentation. The viral cause of var­icella and herpes zoster are identical.2 Richard T. ]ohnson/ Sir Duke-Elder,4 and C. F. Borgoon5provide general statistics on herpes zoster and its natural course. The incidence of herpes zoster, 3-5/1000 per year, increases with age, being rare in children, and usually seen in persons over 50 years. The ophthalmic division of the trigeminal is the most common cranial nerve involvement, accounting for 10-15% of all cases of herpes zoster. Ocular complications are seen in 50% of trigeminal zoster. The classic clinical course is 1-4 days of malaise and 4-5 days of dysesthesia preceding the rash. The vesicular rash dries in 5-10 days to crusted lesions. The vesicules may become con­fluent and appear as crusted patches. Sensory dis­turbances present in 66% usually persist for 1-4 weeks. Thirty percent over 40 have postherpetic neuralgia lasting months or years. Prolonged pain is more common with the elderly and in trigeminal involvement. Treatment of the acute disease using vitamins,5, 6 roentgenotherapy,5 Protamide,6 hyperimmune se- March 1981 rum,7 5-iodo-2-dioxuridine,H. 9 cytarabine,1II auto­hemotherapy, 11.12 steroids and/or ACTHI3- 16 diphtheria antitoxin l7 and smallpox vaccineIII are but a few of those attempted. Interferon may hold some therapeutic promise. 19 Ocular complications are treated by steroids, cycloplegics and antiglau­comatous drugs. Traub reported postherpetic neuralgia relief with psychotropic drugs.to Nerve root destruction has proved disappointing.5The use of intravenous Pro­caine21 and sensory nerve block with Bupivacaine22 have also been reported. Procaine injection of the pre- and paravertebral ganglion and of the gasse­rian ganglion was advocated by Rosenak23 in 1938. He concluded that "It is absolutely necessary to infiltrate the gasserian ganglion in all cases of herpes zoster ophthalmicus not only for the accom­panying pain, but also to prevent serious damage to the eye." Alon P. Winnie of the Abraham Lin­coln School of Medicine, Department of Anesthe­siology, Chicago, Illinois, presented his experience in the management of postherpetic neuralgia by the use of sympathetic block at the annual meeting of the American Society of Anesthesiologists in 1976. The intraocular findings of herpes zoster ophthalmicus are similar to known ischemic necro­sis of the anterior segment as reported by Knox/4 Crock/5 and Naumanm et al. 26 It is tempting to suggest a common pathophysiology. The iritis, iris atrophy, disrupted intraocular pressure, optic neu­ritis and scleritis all could be explained by is­chemia. An ischemic process might be relieved by sympathetic block. This theory was published by Findley and Patzer27 in 1945. The potent placebo effect of a long needle pushed deeply into the neck also appears an attractive explanation. Methods The observations of 18 of 27 patients with tri­geminal herpes zoster are presented. The initial stimulus to recommend stellate ganglion block in therapy is credited wholly to Alon Winnie, M.D. Flushed by the dramatically successful resolution of symptoms in the author (HBI) and two family members of physicians, 24 additional patients were accumulated. 53 Stellate Block for Trigeminal Zoster Procedure All 27 of the patients were seen at least briefly by an ophthalmologist and referred for therapy to the Department of Anesthesiology. Eighteen of these patients were adequately followed and re­ported by ophthalmologists for precise comment. All therapeutic blocks utilized Bupivacaine (Mar­caine) at times in conjunction with Lidocaine (Xy­locaine). The patients had one to four stellate gan­glion injections, averaging 2.5 per patient. The ages ranged from 36 to 82, averaging 63 years. Unless hospitalized at the time of the initial contact, or for geographic reasons, treatments were done on an outpatient basis. Stellate blocks were initiated as early as 2 days after the prodrome and 2 days before eruptions to as late as 15 days after the onset of pain and 8 days after the eruption. The average duration of pain at initial block was 8 days. Side Effects The side effects of the stellate ganglion block were transient and caused variable alarm in the patients observed. An effective blockade was syn­onymous with a Horner's defect. Hoarseness was common. Pain or paresis of the ipsilateral arm was frequently noted. One patient had transient paresis of the hemidiaphragm. Another patient apparently experienced some intravascular injection of the local anesthetic, became confused, and required 1.5 hours observation in the recovery room before release. No evidence of trauma to any of the great vessels or to the pulmonary apex was observed. Results It may be significant that the most subjective aspect of this disease, pain, was the most consist­ently and rapidly alleviated. Nine of the 27 patients were referred by outlying general physicians, and were seen on only one occasion by an ophthal­mologist for diagnosis. In these patients, the anes­thesia department reports that all experienced pain relief by the time of the third injection. However, in these nine patients, no ophthalmologic follow­up is available. Of those patients with follow-up, where the relief of pain was recorded, 11 of 15 received dramatic comfort after the first or second stellate ganglion block. One patient reported relief of severe pain, but some persistent pain after two injections. Another required three blocks to obtain relief of severe pain and had persistent aching for weeks. The other two patients had "good" pain relief 1 and 2 days after the third injection. Pain recurred in four of the 13 patients with initial dramatic relief: 7, 14, 25, and 242 days poststellate ganglion block. Two of these recurrent pain pa­tients received an additional injection with imme­diate and lasting pain relief. The other two were not treated at the time of recurrence. In one of 54 these the pain cleared in 62 days and in the other pain persists 480 days later. This last patient also has continuing iritis, corneal opacity, and second­ary glaucoma. Five of 11 with pain relief described mild or occasional tingling and itching of the af­fected area, which persisted for weeks. Nine of 18 patients developed iritis, all but two having nasal vesicles observed. Two with nasal vesicles healed without evidence of ocular involve­ment. Three patients developed iritis subsequent to the first block. One eye has iris atrophy. Secondary glaucoma was recorded in four pa­tients and appeared to parallel the response of the iritis to treatment. Corneal involvement was recorded in seven of 18 patients. Four of these patients had persistent corneal change. In the two with prezoster vision records, one lost four lines and one lost two lines on the Snellen chart. One patient showed rapid progression of a preexisting cataract. No patients were observed with optic neuritis, posterior uveitis or scleritis. Vesicular skin lesions were present in all patients during the course of the disease. Two patients were treated (1 and 2 days) before vesiculation, but developed typical skin lesions after the stellate block. It was the clinical impression of the observ­ers that drying of the vesicles and healing of the skin occurred more rapidly than would be expected in the natural course of the disease. Comment A total of 27 patients with trigeminal herpes zoster were treated by a block of the ipsilateral stellate ganglion. Eighteen of these patients were adequately followed and reported by ophthalmol­ogists for precise comment. All patients received pain relief which ranged from dramatic and lasting relief of all dysesthesia to some pain and paresthe­sia of the affected area persisting for several weeks. Four patients had recurrence of pain after initial relief. Two patients were retreated and received lasting pain relief. Of the nine patients with ob­served iritis, four cleared within 6 days of the first treatment. Secondary glaucoma followed the course of the iritis. Corneal opacities appeared to be relatively unaffected by treatment. Vesicular skin lesions appeared to dry more rapidly than the natural course of the disease. Addendum The Editor has asked the pertinent question, "Does stellate block control the postherpetic pain syndrome?" The authors have observed only two previously untreated patients with postherpetic pain in whom a ganglion block was attempted. Both patients noted pain relief while the anesthetic was in effect, but had return of pain thereafter. Journal of Clinical Neuro-ophthalmology In the group of 27 reported above, four patients did have recurrence of significant pain after the initial relief apparently produced by the sympa­thetic block. The first developed severe pain 7 days after the first block. The patient was treated one more time with no additional pain reported. An­other had pain recurrence after 242 days. The pain was both in the eye and in the distribution of the first division of the trigeminal nerve. The relapse was associated with a flare-up of the chronic iritis and responded with lasting pain relief to topical ophthalmic steroids and cyclopll'gia, plus one ad­ditional stellate block. The relief of pain correlatl'd dramatically with the stellatl' injl'ction. Of thl' re­maining two patients, one refuSl'd rl'peat block (at 14 days) and c1earl'd the pain 62 days latl'r. The last patient was trl'ated early in the sl'ries and received immediatl' and complete rl'lief of discom­fort for 25 days. Shl' was lost to follow-up after 480 days with persistl'nt forehead and scalp pain, glaucoma, chronic iritis and corneal opacity. No treatment had been advised. References 1. Walsh. F.A., and Hoyt, W.F.: Clinical Neuro-Oph­thalmology. Vol. /I (3rd ed.). Williams & Wilkins, Baltimore, 1979, pp. 1351-1361. 2. Tavlor-Robinson, D.: Chickenpox and herpes zoster: 1II.·Tissue culture studies. Br. l Exp. Pathol. 40: 521­532, 1959. 3. Johnson, R.T.: Viral infections of the nervous system. In Textbook of Medicine (14th ed.), P.B. Beeson and W. McDennott, Eds. W. B. Saunders, Philadelphia, 1975, pp. 684-687. 4. Duke-Elder, S.: System ofOphthalmology, Vol. VI//. C. V. Mosby, St. Louis, 1965, pp. 340-348. 5. Borgoon, C.F., Borgoon, J.S. and Baldridge, G.D.: The natural history of herpes zoster. lAM.A 164(3): 265-269, 1957. 6. Vorhaus, M.G.: The present evaluation of vitamin BI therapy. Am. l Dig. Dis. Nutr. 3: 915, 1937. 7. Gunderson, T: Convalescent blood for treatment of herpes zoster ophthalmicus. Arch. Ophthalmol. 24: 132-141,1940. 8. Juel-Jensen, B.L, MacCallum, F.O., MacKenzie, A.R. and Pike, M.C.: Treatment of zoster with idoxuridine in dimethyl sulphoxide Br. Med. l 4: 776, 1970. 9. Marsh, R.}.: Idoxuridine in dimethyl sulfoxide in the treatment of ophthalmic zoster. Ophthalmol. Dig. 39: 17-19,1977. 10. Pierce, L.E., and Jenkins, R.B.: Herpes zoster ophthalmicus treated with cytarabine. Arch. Oph­thalmol. 89: 21-24, 1973. 11. Beesom, B.B.: Autohemotherapy in the treatment of March 1981 Olson,Ivy herpex zoster. Arch. Dermatal. Syphil. 18: 573, 1928. 12. Barksdale, LE.: The use of autohemotherapy in the treatment of psoriasis and herpes zoster-Prelimi­nary report. Va. Med. Mon. 64: 378, 1937. 13. Elliot, F.A.: Treatment of herpes zoster with high doses of prednisone. Lancet 2: 610, 1964. 14. Scheie, H.G., and McLellan, TG.: Treatment of herpes zoster ophthalmicus with corticotropin and corticosteroids. Arch. Ophthalmol. 52: 579-587, 1959. 15. Epstein, E.: Intralesional triaminolone therapy in herpes zoster and postzoster neuralgia. Eye Ear Nose Throat Mon. 52: 416-417,1973. 16. Eaglstein, W.H., Katz, R., and Brown, J.A.: The effects of early corticosteroid therapy on the skin eruption and pain of herpes zoster. j.AM.A. 211(10): 1681-1683,1970. 17. Wdlker, J.R., and Wdlker, B.F.: A specific treatment for herpes zoster. Arch. Ophthalmol. 20: 304-306, 1938. 18. Lillie, W.I.: Treatment of herpes zoster ophthalmicus with small pox vdccine. N. Y. State j. Med. 43: 857­859,1943. 19. Groth, K.E., McCollough, J., rv.arker, S.c., Howard, R.J., Simmons, R.L., Najarian, J.s., and Balfour, H.H., Jr.: Human leukocyte interferon for the treatment of herpes zoster in patients with cancer. N. Engl. j. Med. 298(18): 981-987, 1978. 20. Taub, A.: Relief of postherpetic neuralgia with psy­chotrophic drugs. j. Neurosurg. 39: 235, 1973. 21. Shanbrom, E.: Treatment of herpetic pain and post­herpetic neuralgia with intervenous Procaine. j.AM.A 176(12): 151-153, 1961. 22. Hannington-Kiff, J.G.: Treatment of intractable pain by Bupivacaine nerve block. Lancet 1392-1394,1971. 23. Rosenak, S.: Procaine injection treatment of herpes zoster. Lancet 2: 1056-1050, 1938. 24. Knox, D.L.: Ischemic ocular inflammation. Am. j. Ophthalmol. 60: 995-1002, 1965. 25. Crock, G.: Clinical syndromes of anterior segment ischemia. Trans. Ophthalmol. Soc. u.K. 87: 513-533, 1967. 26. Naumanm, G., Gass, JD.M., and Font, R.L.: Histo­pathology of herpes zoster ophthalmicus. Am. j. Ophthalmol. 65(4): 533-541, 1968. 27. Findley, T, and Patzer, R.: Treatment of herpes zoster by paravetebral Procaine block. j.A.M.A. 128: 1217-1219,1945. Acknowledgments The authors are grateful to Drs. Thomas E. Atkinson, Robert H. Michaels, Wayne R. Shelton, and David L. Spalding, who contributed patients to this series. Write for reprints to: E. Rule Olson, MD., 1900 S. Nationdl, Springfield, Missouri 65804. 55