Efficacy of local anaesthetic and steroid combination in prevention of post-herpetic neuralgia: A meta-analysis

Objective: The objective was to provide synthesized evidence on the efficacy of local anaesthetics and steroid injections for prevention and management of PHN, compared to the standard treatment using anti-viral and analgesic medications. The primary outcomes of interest were incidence of PHN and duration of neuralgic pain. Methods: Comprehensive searches were done systematically through PubMed, Scopus, Cochrane Central Register of Controlled Trials and Google scholar databases. Randomized controlled trials that compared the efficacy of local anaesthetics and steroid injections for preventing and managing PHN were included for this meta-analysis. A comprehensive search was done for papers published until 15th July 2021. Results: A total of 10 RCTs were included in the meta-analysis. In the overall pooled analyses, compared to standard care/placebo, those receiving a combination of local anaesthetic and steroid injection had 55% lower risk of PHN at 3 months from onset of rash (RR 0.45; 95% CI, 0.29; 0.70). Out of the different modes of intervention delivery i.e., intravenous, subcutaneous and nerve block, maximum beneficial effect in reducing the incidence of PHN was noted in nerve block (RR 0.55; 95% CI, 0.34, 0.89). Conclusions: The meta-analysis provides some evidence to support the use of combined local anaesthetic and steroids in reducing risk of post-herpetic neuralgia and duration of neuralgic pain in patients with herpes zoster rash. doi: https://doi.org/10.12669/pjms.38.3.5140 How to cite this:Zhang X, Wang Z, Xian Y. Efficacy of local anaesthetic and steroid combination in prevention of post-herpetic neuralgia: A meta-analysis. Pak J Med Sci. 2022;38(3):---------. doi: https://doi.org/10.12669/pjms.38.3.5140 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Delayed-Onset Neuropathic Pain after Septoplasty

Postoperative pain following a septoplasty is expected to be mild and limited to a few days after the operation. Chronic pain following the procedure is rare. No cases of delayed-onset neuropathic pain or allodynia have been described in the literature. This paper presents a case of delayed-onset neuropathic pain after septoplasty in a previously pain-free asthmatic patient that was successfully managed by administration of intranasal local anaesthesia. Physical examination and imaging excluded any other cause of neuralgia. A literature review revealed reports of chronic pain in patients following septoplasty if there were nasal contact or compression points or nasal tumours. Separately, acute postseptoplasty allodynia is documented in iatrogenic maxillary nerve damage. However, delayed-onset neuralgic pain, exacerbated by certain environmental triggers, has not been previously described. Facial pain can be debilitating; successfully managing this neuralgic pain with administration of intranasal local anaesthetic had a substantial effect on the patient’s quality of life.

Endoscopic Keyhole Approach for Intracranial Epidermoid

Objective In contemporary neurosurgical practice, keyhole endoscopic approach has established its role in various neurosurgical pathologies. Intracranial epidermoid is an ideal pathology for endoscopic keyhole approach as epidermoid is well encapsulated, extra-axial, avascular, and easily suckable. The objective of this study is to share our experience of endoscopic keyhole approach for intracranial epidermoids at various locations as a new minimally invasive neurosurgical approach to deal with these lesions. Materials and Methods We conducted a retrospective study on 26 patients who underwent keyhole pure endoscopic excision of intracranial epidermoid between July 2015 and December 2019. Patient's demographics, clinical features, radiological imaging, and postoperative complications were noted. Follow-up outcome of preoperative symptoms and postoperative complications were also analyzed. Results The mean age of the study population was 30.5 years with a mean follow-up of 30 months. The common presenting features were headache, hearing loss, and trigeminal neuralgic pain. Gross total resection was achieved in 73.1% cases, while near total resection and subtotal resection were achieved in 19.2 and 7.7% cases, respectively. In the follow-up, maximal improvement was seen in trigeminal neuralgic pain (83%) and headache (66.7%). Major postoperative complications were facial nerve paresis, lower cranial nerve paresis, and transient facial hypoesthesia, most of which improved over time. None of the patients required resurgery till date. Statistical Analysis Patients' data were analyzed using SPSS software version 23 (Statistical Package for Social Sciences, IBM, Chicago, United States). Conclusion This study demonstrates that with careful patient selection, endoscopic keyhole excision of epidermoid is a good alternative to conventional microsurgical excision with comparable surgical and functional outcomes.

A Case Report of Chondrosarcoma of Temporomandibular Joint

In this case report we describe a rare case of chondrosarcoma of the Temporomandibular joint in a 70 years old female who presented with a right preauricular swelling, trismus and neuralgic pain. On examination, firm and tender swelling was noted in the right preauricular region. CT Scan revealed 3.48 × 3.0 cm size mass lesion in the region of mandibular condyle and extending into the right temporomandibular joint space. The cytopathological report was suggestive of chondroid malignancy. The tumor was excised and histopathological examination showed large sheets of atypical tumor cells with cartilaginous matrix and diagnosis of a well differentiated Chondrosarcoma was confirmed. Post-surgical resection, patient remains disease free at 15 months follow up.

Referred Trigeminal Facial Pain from Occipital Neuralgia Occurring Much Earlier than Occipital Neuralgia

We report a very rare case in which a patient believed to have auriculotemporal neuralgia due to the repeated recurrence of paroxysmal stabbing pain in the preauricular temporal region for four years developed occipital neuralgia, which finally improved with decompression of the greater occipital nerve (GON). The pain of occipital neuralgia has been suggested to be referred to the frontoorbital (V1) region through trigeminocervical interneuronal connections in the trigeminal spinal nucleus. However, the reports of such cases are very rare. In occipital neuralgia, the pain referred to the ipsilateral facial trigeminal region reportedly also occurs in the V2 and V3 distributions in addition to that in the V1 region. In the existing cases of referred trigeminal pain from occipital neuralgia, continuous aching pain is usually induced, but in the present case, typical neuralgic pain was induced and diagnosed as idiopathic auriculotemporal neuralgia. In addition, recurrent trigeminal pain occurred for four years before the onset of occipital neuralgia. If the typical occipital neuralgia did not develop in four years, it would be impossible to infer an association with the GON. This case shows that the clinical manifestations of referred trigeminal pain caused by the sensitization of the trigeminocervical complex by chronic entrapment of the GON can be very diverse.

Stabbing facial pain reminiscent of primary stabbing headache

Primary stabbing headache (PSH) is a transient and localized headache disorder. Facial variants of this rare pain syndrome have not been previously described. Four patients (n = 2 female, 2 male) presented themselves to our headache and facial pain outpatient clinic. They suffered daily from several dozen to several hundred short-lasting stabbing pain paroxysms primarily in the second and third trigeminal branches (V2 and V3) without lateral predominance. These non-neuralgic pain paroxysms did not strictly follow dermatomes, were not accompanied by trigeminal autonomic features and could not be triggered but occurred exclusively spontaneously. They did not fulfill any existing ICHD-3 criteria but appeared clinically to have similarities to primary stabbing headache syndromes. Indomethacin showed no efficacy. Exclusive facial variants of stabbing pain paroxysms should be classified as separate entities and tentatively be called stabbing facial pain.

Post-total knee arthroplasty herpes zoster activation

Herpes zoster is a clinical manifestation of reactivation of varicella-zoster virus (VZV) that lies dormant in the dorsal root ganglia after a past primary infection. It can be associated with severe pain, a crop of vesicles in typical dermatomal distribution but the neuralgic pain persists long, making the patient uncomfortable and often disturbing patient’s sleep. There are cases reported after trauma or post surgeries that are mainly related to organ transplant or malignancy. In the literature, there is a solitary report of VZV infection along the sciatic nerve post ipsilateral hip and contralateral knee joint replacement. Here, we report a VZV infection in post knee replacement setting along the L2-3 dermatomal distribution.

Effects of a sensory branch to the posterior external ear canal: coughing, pain, Ramsay Hunt's syndrome and Hitselberger's sign

Background:A distinct nerve innervating the external auditory canal can often be identified in close relation to the facial nerve when gradually thinning the posterior canal wall. This nerve has been attributed to coughing during cerumen removal, neuralgic pain, Hitselberger's sign and vesicular eruptions described in Ramsay Hunt's syndrome. This study aimed to demonstrate the origin and clinical impact of this nerve.Methods and results:In patients with intractable otalgia or severe coughing whilst inserting a hearing aid, who responded temporarily to local anaesthesia, the symptoms could be resolved by sectioning a sensory branch to the posterior canal. In a temporal bone specimen, it was revealed that this nerve is predominantly a continuation of Arnold's nerve, also receiving fibres from the glossopharyngeal nerve and facial nerve. Histologically, the communicating branch from the facial nerve was confirmed.Conclusion:Surgeons should be aware of the posterior auricular sensory branch and its clinical implications.