Combining Botulinum Toxin (A) Injection With Peripheral Nerve Stimulation in a Patient for Intractable Ophthalmic Postherpetic Neuralgia.

BACKGROUND: Postherpetic neuralgia (PHN) is a particularly challenging neuropathic pain condition, especially when it involves the trigeminal nerve. Peripheral nerve stimulation (PNS) can provide 50-70% improvement in pain to many who fail medical management. However, this pain relief can be incomplete, and residual pain may persist for many years. Here we report a case that was successfully managed by a novel technique of combining supraorbital nerve stimulation with botulinum toxin type A (BTA) for intractable ophthalmic PHN. CASE: A 73-year-old man presented with burning, stabbing, constant, severe pain in the ophthalmic branch of left trigeminal nerve dermatome, which had been present for a year. A permanent PNS provided 50% pain relief, but there was residual pain in the left orbital area that has remained, which was refractory to pharmaceutical treatment. Because of the restricted location of the residual pain, this patient was an appropriate candidate for BTA injection. RESULTS: Following the BTA injection, the patient had a significant improvement in pain relief and this continued for six months without any oral medication. CONCLUSIONS: In a patient with trigeminal PHN, local injection of BTA effectively reduced pain remaining after treatment with PNS.