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Medicine (Baltimore). 2024 Apr 1; 103(14): e36823.
Published online 2024 Apr 1. doi:10.1097/MD.0000000000036823
PMCID: PMC10994496
PMID: 38579055
Xiang Wei, MD,a Chi Zhang, MD,a Wei Wei, MD,b Caiqi Yang, MD,c Junyi Zheng, MD,a and Kejia Wang, MD
a,*
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Abstract
Background:
Postherpetic neuralgia (PHN) is the most common complication of varicella-zoster infection and tends to occur in older people. All patients treated with a single regimen have not achieved consistent success across all current study protocols, and multimodal combination regimens still need to be explored.
Methods:
A total of 111 patients with PHN were randomly divided into drug group (group A), thoracic paravertebral nerve block group (group B), thoracic paravertebral nerve block combined with acupuncture group (group C), with 37 cases in each group. Group A: received oral gabapentin capsules and external lidocaine gel plaster; group B: combined with thoracic paravertebral nerve block based on group A; group C: combined with acupuncture based on group B. The primary outcome was effective rate, and secondary outcomes included pain sensation score (numerical rating scale), SF-36 quality of life score, and sleep quality.
Results:
Before treatment, there were no significant differences in numerical rating scale value, SF-36 quality of life score, and sleep quality level among the 3 groups (P > .05). After 12 weeks of treatment, the total effective rate of treatment of patients in group C (91.43%) was higher than that in group B (77.14%), and significantly higher than that in group A (51.43%) (P < .05).
Conclusion:
Based on drug treatment combined with thoracic paravertebral nerve block and acupuncture, the treatment of PHN in the elderly can quickly and effectively relieve pain, improve the quality of life of patients, and improve the quality of sleep.
Keywords: acupuncture and moxibustion, gabapentin, postherpetic neuralgia, thoracic paravertebral nerve block
1. Introduction
Herpes zoster is a dermatological condition stemming from the reactivation and replication of the latent varicella-zoster virus. Postherpetic neuralgia (PHN), a neuropathic pain condition, is the most prevalent complication and frequently manifests in the elderly.[1] The primary clinical symptoms of PHN encompass severe, enduring pain at the initial site of outbreak, often leading to sleep disturbances, anxiety, depression, and other issues that significantly impact patients’ quality of life.[2] Research indicates that shingles’ global annual incidence is approximately 3% to 5%, with an associated PHN incidence of about 9% to 34% among shingles patients. For HZ patients over 50 years old, the PHN incidence ranges from 25% to 50%, increasing with age.[3,4]
Given the elusive pathogenesis and the lack of specific treatments, existing studies have demonstrated that no single therapeutic approach consistently and effectively alleviates pain for all patients. Thus, combination therapy remains essential.[5] Presently, the principal treatment methods include medication, minimally invasive interventions (such as nerve blocks, neuromodulation, and spinal cord electrical stimulation), acupuncture, and psychotherapy. However, drug treatment has shown limited effectiveness and a high recurrence rate upon discontinuation.[6] Most pulsed radio frequency procedures are performed under CT guidance, incurring high costs, stringent equipment requirements, and substantial radiation exposure, which hinder widespread adoption.[7] Spinal cord electrical stimulation and intrathecal administration pose challenges, with physical trauma, high costs, limited tolerance among elderly patients with compromised physical function, and potential complications like cerebrospinal fluid leakage and infection.[8] Selective nerve destruction entails surgical, chemical, or physical impairment of the affected nerve, leading to irreversible damage.[9]
Thoracic paravertebral nerve block (TPVB) involves the local administration of anesthetic into the spinal nerve outlet area through the intervertebral foramen. This method can effectively block the ipsilateral spinal nerve, including the dorsal branch of the spine, communication branches, and the sympathetic nerve chain. By doing so, it disrupts the cycle of pain and promotes the expansion of blood vessels within the nerve distribution area. This, in turn, enhances local blood circulation and reduces the accumulation of inflammatory substances. In recent years, the advent of point-of-care ultrasound visualization has improved the precision of TPVB positioning. Studies have substantiated the substantial advantages and safety of TPVBs in treating PHN.[10]
Currently, research has confirmed that acupuncture has a positive impact on the treatment of PHN.[11] Nevertheless, there are still certain inadequacies in the exploration of acupuncture for PHN treatment, primarily due to the following reasons:
(1)
Many studies are limited to small-scale clinical observations and lack standardized randomized controlled trials.
(2)
Diagnosis, efficacy assessment, and evaluation criteria for PHN are predominantly subjective and lack universally quantifiable standards.
(3)
The absence of extended follow-up data on treatment effectiveness.[12]
In this study, we conducted a prospective, randomized controlled trial to assess the effectiveness and safety of combining TPVBs with acupuncture for the treatment of PHN in elderly patients with thoracic and abdominal HZ. Our aim was to investigate a holistic treatment approach that offers consistent efficacy and widespread accessibility.
2. Materials and methods
2.1. Patients and study design
This study was a prospective, randomized, parallel-group, controlled trial conducted in compliance with the Declaration of Helsinki and received approval from the Ethics Committee of the First Affiliated Hospital of Guangzhou University of Chinese Medicine (Approval No. ZYYECY2019-195-JT). It was also registered in advance with the China Clinical Trials Registry on July 14, 2020 (ChiCTR2000034673). Prior to treatment, all patients were duly informed about the potential risks and complications associated with the trial and provided written informed consent.
2.2. Inclusion and exclusion criteria
The inclusion criteria were as follows:
Meeting the diagnostic criteria for PHN as per the 2016 edition of the Diagnosis and Treatment Guidelines for Postherpetic Neuralgia in China.[13]
Aged between 50 and 75 years.
Patients who were newly diagnosed with PHN within the past 6 months and had not undergone any previous treatments.
Pain localized in the chest and abdomen.
Patients capable of clearly expressing their pain perception score (NRS score) and cooperating with the SF-36 quality of life score assessment.
Patients who voluntarily participated in this trial and provided their informed consent.
The exclusion criteria were as follows:
Patients experiencing other forms of neuropathic pain.
Those with severe systemic diseases leading to decompensatory insufficiency.
Diabetic individuals with poorly controlled blood sugar levels (fasting blood glucose > 8 mmol/L, blood glucose > 10 mmol/L 2 hours after meals).
Presence of local or systemic infections at the puncture site.
Abnormal coagulation function.
Patients with known allergies or sensitivities to the ingredients in the drug used in this study.
Individuals with liver and kidney insufficiency.
2.3. Grouping and sample size
We initially conducted a pilot study with 10 patients in each group to estimate the required sample size. These participants were not included in the main study. The efficacy rates observed at 12 weeks after treatment were as follows: 40% in the drug group, 70% in the TPVB group, and 90% in the TPVB combined with acupuncture group. Based on a differential study design,[14] we recruited a total of 102 patients and eventually enrolled 120 patients to account for a possible 15% dropout rate.
Out of the initial 120 patients with PHN, 7 did not meet the inclusion criteria, and 2 declined to participate in the study. The remaining 111 patients were then randomly divided into 3 parallel groups, each consisting of 37 patients, using the sealed envelope method. A random allocation sequence was generated by a doctor not involved in the study to prevent performance bias. All nerve blocks and acupuncture procedures were performed by experienced physicians who were well-versed in these techniques. Both patients and surgeons were aware of the groupings, but the individuals responsible for follow-up and the statisticians were kept blinded to the specific group assignments. Furthermore, follow-up procedures did not involve any group-specific information. Six patients were lost during the follow-up period, resulting in a final sample of 105 patients for subsequent follow-up and statistical analysis.
2.4. Surgical procedures
Group A.
Treatment with oral gabapentin capsules (Jiangsu Hengrui Pharmaceutical Co., Ltd., Lianyungang, Jiangsu, China) and an external lidocaine gel patch (Beijing Tide Pharmaceutical Co., Ltd., Beijing, China). Patients are advised to take 0.2 g of gabapentin capsules at noon and in the evening on the first and second days, followed by 0.3 g each time on the third day, unless there are specific circ*mstances. Subsequent adjustments, up to 3 times a day at 0.3 g, may be made during follow-up consultations, depending on the patient’s condition. Drug treatment is to be continued until the patient experiences significant pain relief or complete alleviation, following which the dosage should be gradually reduced until discontinuation. In cases of abnormal liver and kidney function or if patients find the oral medication intolerable due to side effects, appropriate dosage reductions are permitted. In severe cases, oral drug treatment may be ceased, and the patient will be closely monitored with corresponding treatment. The lidocaine gel patch is applied to the painful area and should be used continuously for no <12 hours each day, with a replacement every 24 hours. This regimen is to be continued for 14 days.
Group B.
Treatment involving TPVB in addition to the regimen from group A. The nerve block method comprises the extraction of 1% ropivacaine injection (Guangdong China Resources Shunfeng Pharmaceutical Co. Ltd., Foshan, Guangdong, China) and combining it with TPVB treatment based on group A. The mixture includes 40 mg of prednisolone acetate injection (Zhejiang Xianju Pharmaceutical Co. Ltd., Taizhou, Zhejiang, China), 37.5 mg of vitamin B12 injection (Anhui Fengyang Keyuan Pharmaceutical Co. Ltd., Chuzhou, Anhui, China), all diluted to 20 mL with 0.9% sodium chloride solution. Before the treatment, patients undergo routine monitoring of blood pressure, heart rate, electrocardiogram (ECG), and blood oxygen saturation (SpO2). Patients assume a prone position, and the responsible thoracic nerve is determined based on the location of the herpes scar and pain. After disinfection and the placement of a sterile drape, bedside ultrasound (Sonosite M-Turbo, Jiangsu Dongxing Smart Medical Technology Co. Ltd., Changzhou, China) is utilized. A low-frequency ultrasound probe is used to scan the spine’s short axis, providing visualizations of facet joints, pleura, and the paravertebral space. Following local anesthesia, a peripheral nerve stimulation needle (B. Braun, Sonosite M-turbo, SonoSite, Inc. Bothell, WA) is employed to perform paravertebral space puncture using an in-plane technique. After ensuring no abnormalities, 15 mL of the mixture is injected into this space. Following the injection, patients are advised to lie down and rest, with continued monitoring of BP, heart rate, ECG, and SpO2. They are discharged from the hospital after 30 minutes if no special features are observed. This treatment is administered once a week for 3 consecutive sessions.
Group C.
This treatment combines acupuncture with the approach used in group B. Patients commenced acupuncture treatment on the day following the nerve block procedure, with “Ah” as the acupoint and spinal points as the primary acupoints. Individuals exhibiting Qi stasis and blood stasis were matched with men, inner guan, and 3 yin intercourse acupoints. Those with blood stasis received treatment at internal passes, 3 yin sex, and qi seas acupoints. For individuals experiencing anxiety and depression, Baihui, Shenting, and Shenmen acupoints were utilized. All of these acupuncture points were disinfected as part of routine preparation. A 30-gauge million needles were selected, and the treatment duration was set at 30 minutes per session after achieving a Qi gain. The treatment was administered once daily for 7 consecutive sessions.
In this study, patients initially attended the clinic once a week for the first 5 weeks. They underwent a follow-up evaluation in the 12th week, which included efficacy assessment and data recording. Subsequently, for the remaining duration of the study, follow-up and data recording were conducted via telephone.
2.5. Primary outcome
The primary outcomes were assessed based on the patient’s NRS weighted value (NRS-WV) score after 12 weeks of treatment, calculated as follows: NRS-WV = (NRS score before treatment − NRS score at follow-up)/NRS score before treatment. Efficacy, as measured by NRS, was categorized into 4 types: “cure,” “effective,” “significant,” and “ineffective.” “Cure” was defined as NRS-WV ≥ 75%, “effective” for 50% ≤ NRS-WV < 75%, “significant” for 25% ≤ NRS-WV < 50%, and “ineffective” for NRS-WV < 25%. The total effective rate was calculated as (number of cured cases + number of effective cases)/total number of cases × 100%.
2.6. Secondary outcomes
Secondary outcomes encompassed NRS scores, SF-36 quality of life scores, and sleep quality assessment. NRS scores were employed to gauge the level of pain, utilizing a scale from 0 to 10, with the following pain grading criteria: 0 points for pain-free, 1–3 points for mild pain, 4–6 points for moderate pain, and 7–10 points for severe pain. Pain levels were evaluated using a numerical rating scale (NRS) before treatment and at weeks 1, 4, and 12 following treatment. The SF-36 quality of life score was determined through questionnaires administered before treatment and 12 weeks after treatment. The SF-36 assesses eight dimensions, each scoring from 0 to 100, with higher scores indicating better health status. In this study, the dimensions most pertinent to pain, physical pain, and physical role, were evaluated. To monitor sleep quality, we utilized the Huawei Band 4 to record the actual sleep duration and deep sleep duration of patients. Sleep efficiency was calculated as follows: sleep efficiency = (total actual sleep time)/(total time in bed at night)%. Enhanced sleep quality is reflected in longer actual sleep duration, increased deep sleep duration, and higher sleep efficiency. Sleep quality was monitored before treatment and at the 4-week posttreatment mark.
2.7. Adverse events
Throughout the follow-up period, all adverse events, including medication-related adverse effects and complications arising from parathoracic block and acupuncture, were diligently documented.
2.8. Statistical analysis
We employed SPSS 24.0 statistical software for data analysis. Categorical data were presented as relative composition ratios (%) or percentages (%), and the chi-squared (χ²) test was utilized. Normally distributed metric data were expressed as mean ± standard deviation (), and comparisons among the 3 groups were conducted using a 1-way analysis of variance (ANOVA), followed by pairwise comparisons with the Student–Newman–Keuls (SNK-q) test. To assess the changes in NRS scores before treatment and at 1, 4, and 12 weeks posttreatment in the 3 groups, repeated measures of ANOVA were applied. Furthermore, a rank sum test was employed to compare the clinical efficacy among the 3 groups. Statistical significance was considered with a threshold of P < .05.
3. Result
3.1. Patient demographics
In this study, 120 patients were initially assessed for eligibility. Out of these, 7 patients did not meet the inclusion criteria, 2 patients declined to participate in the study, and 6 patients were lost during the follow-up period. Consequently, the final number of participants in this study was 105 (Fig. (Fig.11).
Figure 1.
Study flowchart. The 111 patients were randomly assigned to groups A, B, and C. (A) drug, (B) thoracic paravertebral nerve block, (C) thoracic paravertebral nerve block combined with acupuncture.
Demographic information encompassed age, gender, body mass index, duration of PHN onset, and pretreatment pain perception score. No statistically significant differences were observed in these characteristics among the 3 groups (P > .05), as indicated in Table Table11.
Table 1
Preoperative characteristics of the patients ().
| Baseline data | Group A (n = 35) | Group B (n = 35) | Group C (n = 35) | P value |
|---|---|---|---|---|
| Gender (male/female) | 19/16 | 17/18 | 15/20 | .15 |
| Age (yr) | 65.06 ± 5.09 | 64.54 ± 5.16 | 64.23 ± 5.23 | .76 |
| BMI (kg/m2) | 23.10 ± 1.56 | 23.15 ± 1.54 | 23.12 ± 1.69 | .93 |
| Disease course (wk) | 8.66 ± 2.48 | 8.85 ± 2.88 | 8.69 ± 2.93 | .92 |
| Pretherapy NRS grade | 8.10 ± 1.01 | 7.90 ± 0.94 | 8.07 ± 1.03 | .74 |
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Group A: drug group; group B: thoracic paravertebral nerve block group; group C: thoracic paravertebral nerve block combined with acupuncture group.
3.2. Primary outcome
After 12 weeks of treatment, in group A, out of 35 patients, 6 were considered cured, and 12 showed effectiveness, resulting in a total effective rate of 51.42%. In group B, among the 35 patients, 12 were cured, 15 showed effectiveness, and the total effective rate reached 77.14%. Group C had 35 patients, with 20 cured and 12 showing effectiveness, leading to an impressive total effective rate of 91.43%. The total effective rates in both group C and group B were significantly higher than that of group A, with group C achieving the highest total effective rate, and this difference was statistically significant (P = .001 < .05), as indicated in Table Table22.
Table 2
Comparison of clinical efficacy among the 3 groups.
| Group | Number | Cure | Effective | Total effective rate |
|---|---|---|---|---|
| Group A | 35 | 6 | 12 | 51.43% |
| Group B | 35 | 13 | 14 | 77.14%a |
| Group C | 35 | 20 | 12 | 91.43%a,b |
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aA comparison of P < .05 with group A.
bA comparison of P < .05 with group B.
3.3. Secondary outcomes
The analysis of variance for the repeated measurement design revealed significant differences in NRS scores among the 3 groups (P < .05). Moreover, there were notable differences between different time points (P < .05), and interactions were observed between groups and time points (P < .05). Further examination through separate effect analysis indicated that there were no significant differences in NRS scores between the 3 groups before treatment (P > .05). However, compared to the baseline, the NRS scores in all 3 groups exhibited significant reductions after 1, 4, and 12 weeks of treatment (P < .05). Notably, the NRS scores in group C were significantly lower than those in group B and group A after 1, 4, and 12 weeks of treatment, and the NRS scores in group B were also significantly lower than those in group A (P < .05), as illustrated in Table Table33.
Table 3
Comparison of 3 sets of NRS scores ().
| Group | Pretherapy | Posttreatment | ||
|---|---|---|---|---|
| 1 wk | 4 wk | 12 wk | ||
| Group A (n = 35) | 8.10 ± 1.01 | 6.03 ± 0.91a | 3.88 ± 1.20a | 3.63 ± 1.33a |
| Group B (n = 35) | 7.90 ± 0.94 | 5.30 ± 0.82a,b | 2.50 ± 0.92a,b | 2.40 ± 1.36a,b |
| Group C (n = 35) | 8.07 ± 1.03 | 4.63 ± 0.80a,b,c | 1.73 ± 0.89a,b,c | 1.70 ± 1.2a,b,c |
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aP < .05 compared with pretreatment.
bP < .05 compared with group A at the same time point.
cP < .05 compared with group B at the same time point.
One-way ANOVA analysis revealed no significant differences in actual sleep duration, deep sleep duration, and sleep efficiency among the 3 groups (P > .05). However, after 4 weeks of treatment, statistically significant differences emerged in actual sleep duration, deep sleep duration, and sleep efficiency between the 3 groups, all of which had improved compared to the pretreatment values (P < .05). Notably, group C exhibited higher average actual sleep duration, deep sleep duration, and sleep efficiency than group A and group B, and group B also had greater sleep duration and sleep efficiency compared to group A (P < .05), as summarized in Table Table44.
Table 4
Comparison of sleep quality of the 3 groups ().
| Group | Time | Actual sleep duration (min) | Deep sleep duration (min) | Sleep efficiency (%) |
|---|---|---|---|---|
| Group A (n = 35) | Pretherapy | 272.00 ± 38.79 | 67.49 ± 11.97 | 64.28% ± 4.12% |
| 4 wk | 337.17 ± 32.02a | 80.09 ± 12.78a | 76.69% ± 5.09%a | |
| Group B (n = 35) | Pretherapy | 267.90 ± 40.01 | 68.49 ± 12.75 | 64.50% ± 4.15% |
| 4 wk | 383.20 ± 25.13a,b | 98.71 ± 13.71a,b | 84.45% ± 4.42%a,b | |
| Group C (n = 35) | Pretherapy | 273.90 ± 38.58 | 67.26 ± 12.64 | 64.23% ± 3.77% |
| 4 wk | 401.83 ± 29.86a,b,c | 105.40 ± 13.62a,b,c | 87.08% ± 2.96%a,b,c |
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aP < .05 compared with pretreatment.
bP < .05 compared with group A at the same time point.
cP < .05 compared with group B at the same time point.
One-way ANOVA analysis revealed no significant difference in the SF-36 quality of life scores before treatment among the 3 groups (P > .05). However, after 12 weeks of treatment, the differences in SF-36 quality of life scores between the 3 groups were statistically significant and showed improvement compared to pretreatment values (P < .05). Notably, group C exhibited higher average scores for physiological functions and somatic pain compared to groups B and A, and group B also had higher scores than group A (P < .05), as presented in Table Table55.
Table 5
Comparison of the SF-36 quality of life in the 3 groups ().
| Group | Time | Physical role | Physical pain |
|---|---|---|---|
| Group A (n = 35) | Pretherapy | 27.14 ± 18.29 | 29.97 ± 6.37 |
| 12 wk | 56.43 ± 26.95a | 47.17 ± 13.29a | |
| Group B (n = 35) | Pretherapy | 27.86 ± 20.50 | 30.54 ± 7.88 |
| 12 wk | 69.29 ± 23.97a,b | 62.34 ± 12.66a,b | |
| Group C (n = 35) | Pretherapy | 28.57 ± 19.03 | 30.17 ± 6.25 |
| 12 wk | 80.00 ± 18.71a,b,c | 70.1 ± 10.11a,b,c |
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aP < .05 compared with pretreatment.
bP < .05 compared with group A at the same time point.
cP < .05 compared with group B at the same time point.
3.4. Adverse events
A total of 16 patients experienced varying degrees of vertigo following oral administration, and none of them were able to tolerate it even after careful dosage adjustments. In both group B and group C, 2 patients each reported local skin itching as a result of the lidocaine patch. This discomfort was alleviated by modifying the application time and using topical calamine, enabling them to continue their participation in the trial. Importantly, none of the patients in this study encountered complications such as pneumothorax, puncture site infection, hematoma, nerve injury, or local anesthetic poisoning.
4. Discussion
PHN is defined as pain that persists for 1 month or longer following the healing of the HZ rash. The current understanding of its pathogenesis is primarily associated with peripheral sensitization and central sensitization. Reduced immune function can trigger the reactivation and replication of the latent varicella-zoster virus along peripheral sensory nerves, causing neural damage within the skin’s distribution. This neural damage prompts neurochemical, physiological, and anatomical alterations in primary sensory neurons, leading to sensitization of peripheral nociceptors and the amplification of their afferent nerve signals. Furthermore, varicella-zoster virus expression can result in heightened peripheral nerve excitability and sensitivity due to secondary inflammation. Central sensitization, on the other hand, involves an increase in the excitability and synaptic transmission of pain-related neurons within the spinal cord and beyond, marked by extensive degeneration and necrosis of primary afferent fibers and deafferentation of central neurons. This leads to heightened excitability in secondary central neurons.[13] Building on this pathogenesis, our study employed a combination of TPVB and acupuncture to treat PHN in conjunction with gabapentin and lidocaine gel patches. This approach aimed to target peripheral neurosensitization and central sensitization in PHN patients through multiple mechanisms, enhancing the efficiency of treatment, all while considering the accessibility of these treatment modalities.
The results of this study revealed no significant difference in NRS values among the 3 groups before treatment. However, following treatment, the NRS values in all 3 groups exhibited a decrease compared to the pretreatment levels. Particularly noteworthy was the pronounced reduction in NRS values in groups B and C when compared to group A, notably at the 1-week and 4-week posttreatment marks. This suggests that TPVB and TPBV combined with acupuncture can promptly alleviate the pain experienced by PHN patients in the short term.
This rapid pain relief might be attributed to the TPVB treatment, which incorporates a combination of ropivacaine, prednisolone, and vitamin B12. Ropivacaine primarily acts on the dorsal root ganglion (DRG), obstructing the transmission of peripheral pain signals to the central nervous system. The DRG, situated near each intervertebral foramen, houses the cell bodies of first-level sensory afferent neurons, responsible for transmitting sensory impulses from peripheral nerves to the spinal cord and brain. The DRG is considered a new target for nerve modulation in PHN therapy.[15] Simultaneously, it blocks the sympathetic nerve, disrupting the connection between the sympathetic nerve and pain, and enhances the local blood supply, facilitating the effective restoration of damaged ganglia, thereby reducing peripheral sensitization. Prednisolone effectively mitigates the damage and toxicity caused by inflammatory reactions to nerve fibers and ganglia while also suppressing the aberrant firing of damaged sensory nerves and the movement of inflammatory factors to the inflammation site. B vitamins play a role in the synthesis of neuromyelin lipoprotein, offering nutrients to damaged nerve roots.[16]
In this study, the response rate to treatment in group A after 12 weeks was 51.43%, whereas group B showed a treatment efficiency of 77.14%, surpassing the results of a study conducted by Wei et al involving gabapentin alone and gabapentin combined with TPVB.[16] This favorable outcome may be linked to the lidocaine gel patch used in our study, as lidocaine can bind to a specific region of the sodium channel receptor α subunit, inhibiting sodium channel opening and reducing cell membrane depolarization, thus diminishing peripheral sensitization in PHN patients.[17] The lidocaine gel patch also offers the benefit of stable and long-lasting clinical effects.
Furthermore, in group C, the treatment efficiency reached 90%, exceeding that of both group A and group B. This outcome indicates that TPVB combined with acupuncture proves more effective for PHN. The NRS values in group C exhibited more substantial declines than those in group B at the 1-week and 4-week posttreatment evaluations, suggesting that TPVB combined with acupuncture provides quicker pain relief compared to TPVB alone. At the 12-week posttreatment mark, the NRS values in group C remained lower than those in group A and group B, underscoring the superior long-term efficacy of TPVB combined with acupuncture. This may be attributed to our specific acupoint selection scheme.
Research has indicated that there are posterior branches of spinal nerves located near the spine points, as well as sympathetic nerve trunks in the deeper layers. Acupuncture of the corresponding nerve segments in the distribution area of herpes can block the pain fibers in the nerves and increase the pain threshold of the body. Additionally, stimulation of the spine points can be adjusted by nerves and body fluids to promote the release of chemical mediators from nerve endings, which can help achieve an analgesic effect.[18] Acupuncture, targeting heat, poisonous phlegm, and stasis at acupoint Ah and spinal point, detoxifies, relieves pain, and regulates internal organs, offering an analgesic effect likely associated with peripheral nerves corresponding to the posterior branches of spinal nerves and sympathetic nerve trunks distributed under spinal acupuncture points.[19,20] Given that PHN patients frequently present with systemic symptoms, this study’s approach integrated these symptoms to differentiate internal organs and assess Qi and blood to select acupoints. This promotes a systemic functional balance beneficial for efficacy improvement.[21] Moreover, acupuncture treatments are straightforward, cost-effective, free from toxic side effects, offer a swift onset, and are generally well-received by patients.
PHN patients frequently grapple with sleep disorders, and research has underscored the link between insomnia and pain tolerance. In PHN patients, insomnia can diminish pain tolerance, degrade sleep quality, and heighten sensitivity to pain, all of which can impact patient satisfaction with treatment. The enhancement of sleep quality exhibits a positive correlation with the reduction in pain intensity.[22,23] Recent studies have demonstrated a favorable consistency between sleep data gathered from smart bracelets and polysomnography.[24] Consequently, Huawei Band 4 was employed to monitor the actual sleep duration and deep sleep duration of patients following 4 weeks of treatment. The evaluation of patient sleep quality was based on their sleep efficiency. Before treatment, there were no significant differences in deep sleep duration, actual sleep duration, and sleep efficiency among the 3 groups. Yet, after 4 weeks of treatment, both sleep duration and sleep efficiency increased compared to their pretreatment levels across all 3 treatment methods, indicating their efficacy. However, group C exhibited higher deep sleep duration and sleep efficiency in comparison to group A and group B, suggesting that TPVB combined with acupuncture for PHN could expedite improvements in sleep quality, possibly attributable to pain relief.
In this study, there were no significant differences in the quality of life scores of the SF-36 scale among the first 3 groups of patients. However, after treatment, the quality of life scores for the 12-week group surpassed those of both group A and group C. Moreover, the quality of life scores for group C were superior to those of group B. These results suggest that TPVB combined with acupuncture is more effective in alleviating symptoms and enhancing the quality of life for PHN patients compared to TPVB and drug treatment. The improved quality of life primarily stems from the effective pain control achieved through this treatment approach.
5. Conclusions
In conclusion, when compared to conventional drug treatment, ultrasound-guided TPVB, in combination with acupuncture, provides a comprehensive approach for addressing chest and abdominal PHN in elderly patients. This combined therapy offers a swift reduction in patient pain, shortens the disease course, and enhances overall quality of life. Its accessibility and high level of safety make it a promising option for wider adoption.
Author contributions
Formal analysis: Xiang Wei, Junyi Zheng.
Writing—original draft: Xiang Wei, Kejia Wang.
Data curation: Chi Zhang.
Investigation: Chi Zhang, Wei Wei, Caiqi Yang.
Abbreviations:
- ANOVA
- analysis of variance
- DRG
- dorsal root ganglion
- HZ
- herpes zoster
- NRS
- the pain sensation score
- NRS-WV
- NRS weighted value
- PHN
- postherpetic neuralgia
- SNK-q
- Student–Newman–Keuls
- TPVB
- thoracic paravertebral nerve block.
XW and CZ contributed equally to this work.
This work was supported by Science and Technology Projects in Guangzhou (Grant No. 202102010494), The First Affiliated Hospital of Guangzhou University of Chinese Medicine Innovation and Strong Hospital Project (Grant No. 2019IIT10).
The trial was conducted in compliance with the Declaration of Helsinki and received approval from the Ethics Committee of the First Affiliated Hospital of Guangzhou University of Chinese Medicine (Approval No. ZYYECY2019-195-JT).
It was also registered in advance with the China Clinical Trials Registry on July 14, 2020 (ChiCTR2000034673).
The authors have no conflicts of interest to disclose.
All data generated or analyzed during this study are included in this published article [and its supplementary information files].
How to cite this article: Wei X, Zhang C, Wei W, Yang C, Zheng J, Wang K. Thoracic paravertebral nerve block combined with acupuncture for the treatment of postherpetic neuralgia in the chest and abdomen: A prospective randomized controlled trial. Medicine 2024;103:14(e36823).
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