Background & Aims

Post-herpetic neuralgia (PHN) is a chronic neuropathic pain condition following an outbreak of herpes zoster. Recommended treatment for PHN includes neuropathic agents, antidepressants and topical creams and patches. When these treatments fail to control chronic pain, neuromodulation may provide an additional option for patients.

When PHN affects the scalp and periauricular region, this poses a complex and unique clinical scenario. Peripheral nerve stimulation (PNS) has been used to treat a variety of facial and cranial neuralgias.

We present a case of successful PNS to the lesser occipital and greater auricular nerves for PHN.
An 81-year-old male presented with 3 years of right sided posterior scalp and periauricular pain after herpes zoster infection presenting as Ramsay Hunt Syndrome. The patient trialed oral and topical medications as well as botulinum toxin injections without relief. Pain was rated between 6-10 and averaging a 9 on a scale of 10.

Methods

Neuromodulation using the SPR Therapeutics 60-day peripheral nerve stimulator system was offered to the patient in the distribution of the right lesser occipital and right greater auricular nerves.

Ultrasound guidance was used to visualize the right lesser occipital and right greater auricular nerve which helped identify an optimal needle path.

A total of 2 linear array electrodes were advanced under ultrasound guidance near the right lesser occipital and right greater auricular nerves. Stimulation of the lesser occipital nerve?was successful in stimulating the posterior auricular area.?

The greater auricular nerve branch of C2/C3 was stimulated at the posterior border of the upper one third of the sternocleidomastoid muscle resulting in successful?stimulation of the whole ear.

Results

The patient reported reduction of pain to 1-2 out of 10 directly after stimulation and implantation. Patient consent was obtained to use photographs for purposes of medical education. The patient returned for lead removal on post-procedural day 65.

He reported continuous 90% improvement of his symptoms with pain averaging a 0 out of 10. The patient reported no side effects or complications since the time of his procedure. Leads were removed without?complication.

Conclusions

We present a case of severe pain from PHN of the periauricular region refractory to several prior medical interventions that responded to PNS with immediate and continuous resolution of symptoms. In complex cases of PHN of the scalp and periauricular area, PNS of the lesser occipital and greater auricular nerves may be a treatment option for pain relief.

References

Hadley GR, Gayle JA, Ripoll J, Jones MR, Argoff CE, Kaye RJ, Kaye AD. Post-herpetic Neuralgia: a Review. Curr Pain Headache Rep. 2016 Mar;20(3):17. doi: 10.1007/s11916-016-0548-x. Erratum in: Curr Pain Headache Rep. 2016 Apr;20(4):28. PMID: 26879875.

Chung M, Huh R. Neuromodulation for Trigeminal Neuralgia. J Korean Neurosurg Soc. 2022 Sep;65(5):640-651. doi: 10.3340/jkns.2022.0004. Epub 2022 May 16. PMID: 35574582; PMCID: PMC9452392.

Presenting Author

Brooks Johnson

Poster Authors

Brooks Johnson

MD

Mayo Clinic

Lead Author

Topics

  • Treatment/Management: Interventional Therapies – Neuromodulation