Chronic pain perspectives: Treating herpes zoster and postherpetic neuralgia: an evidence-based approach.

When are corticosteroids appropriate for patients with herpes zoster? Which tricyclics are best for frail and elderly patients with PHN pain? And when should you consider opioids?

Post herpetic neuralgia.

BACKGROUND: During the past decade, important advances have been made in understanding the epidemiology, pathogenesis, prevention and treatment of post herpetic neuralgia pain as well as treatment of other neuropathic pain conditions. PHN is accepted as a model for management and clinical trials of neuropathic pain of less clear etiologies. In palliative medicine, where the etiology of pain may be nociceptive, neuropathic, or mixed, it is frequently to the research on PHN that we turn in order to extrapolate the data to the patients at hand. OBJECTIVE: To review and summarize what is known about epidemiology, pathogenesis, clinical features and prevention strategies for post herpetic neuralgia. Discuss the available including the most recent therapeutic options as regards to their mechanism of action, efficacy, safety and tolerability in an attempt to explain the rationale for their use. CONCLUSION: A multidisciplinary and integrative approach has the best chance of success in the management of patients with PHN pain, a problem that can be often frustrating to the patient and challenging to the clinician. Prevention strategies for PHN include administration of zoster vaccine, treatment with antiviral therapy within 72 hours of rash onset and aggressive pain control. First and second line pharmacotherapy include anticonvulsants, antidepressants, topical lidocaine, high dose capsaicin, and opioids either used individually or in combination. Interventional techniques play a limited role in the management of PHN although some data indicate that Intrathecal methylprednisolone and spinal cord stimulation may be effective.

Interventional approaches to pain management.

This article reviews the evidence for several common interventional techniques for the treatment of chronic pain, including: intraspinal delivery of analgesics, reversible blockade with local anesthetics, augmentation with spinal cord stimulation, and ablation with radiofrequency energy or neurolytic agents. The role of these techniques is defined within the framework of a multidisciplinary approach to the neurobehavioral syndrome of chronic pain. Challenges to the study of the analgesic efficacy of procedural interventions are explored, as are the practical issues raised by their clinical implementation, with the aim of helping nonspecialist physicians identify the patients most likely to benefit from these approaches.

Interventional approaches to pain management.

This article reviews the evidence for several common interventional techniques for the treatment of chronic pain, including: intraspinal delivery of analgesics, reversible blockade with local anesthetics, augmentation with spinal cord stimulation, and ablation with radiofrequency energy or neurolytic agents. The role of these techniques is defined within the framework of a multidisciplinary approach to the neurobehavioral syndrome of chronic pain. Challenges to the study of the analgesic efficacy of procedural interventions are explored, as are the practical issues raised by their clinical implementation, with the aim of helping nonspecialist physicians identify the patients most likely to benefit from these approaches.