DOI: https://doi.org/10.21203/rs.2.19826/v1
Background: Herpes zoster is a common disease mainly affect sensory nerves, but in this report sphenopalatine ganglion (SPG), mainly a parasympathetic ganglion was infected by the vesicular-zoster virus, with the performance of cluster headache.
Case presentation: The patient underwent headache on left side orbit, supraorbital and temporal regions after infection of herpes zoster for 8 months, with lacrimation, conjunctival injection and nasal discharge. Pulsed radiofrequency of the SPG under ultrasound guidance was performed, we applied 2 cycles of PRF at 42℃for 120 seconds each time. Partial response lasted 1 month and the pain had recover to its baseline level. Low-temperature plasma radiofrequency ablation (coblation) technology is a relatively new technology that has shown promise in treating neuropathic pain. Then a CT-guided coblation of SPG was performed, used three of intensity for coblation (lasting for 30s, repeat twice) and six of intensity for coagulation (lasting for 30s, once). After coblation, the patient reported completed pain relief and autonomic symptoms disappeared without any side effects. The patient was satisfied with the effect on post-operative telephone follow-up performed on day 7, month 1 and month 3, pain VAS score remained on 0/10.
Conclusions: Our report demonstrates that coblation technology is succeseful treatment for cluster headache in this case, but this finding still needs additional studies for confirmation.
Key words: cluster headache, coblation, herpes zoster
Cluster headache (CH) is a rare but probably the most severe pain known, characterized by ipsilateral headache, lasting 50 to 180 minutes and occurring as many as 8 times per day. with pain localized to the orbit, supraorbital and/or temporal regions and associated autonomic features. Autonomic symptoms, such as lacrimation (tearing), conjunctival injection (redness of the sclera), rhinorrhoea, nasal congestion, hyperhidrosis (excessive sweating) and eyelid oedema, usually occur on the ipsilateral side to the pain[1].
Herpes zoster (HZ) is a common disease results from reactivation of the vesicular-zoster virus(VZV) which persisted asymptomatically in the ganglia of sensory cranial nerves and spinal dorsal root ganglia, and spread along the sensory nerve to the dermatome. With a performance of painful, blistering skin eruption in a dermatomal distribution. Trigeminal nerve is the most frequently involved site for HZ[2]. There was rare report of CH after HZ, in which the VZV would infect the sphenopalatine ganglion (SPG). Here, we report a case of CH after HZ, who treated with pulsed radiofrequency and low-temperature plasma radiofrequency ablation (coblation).
The SPG has traditionally been considered to be involved in the pathophysiology of CH[1, 5], and radiofrequency of the SPG has been described by Salar et al. in 1987[6].Sanders and Zuurmond [7]performed a retrospective analysis of patients with refractory CHs treated by RFA of the SPG. In this study, 60.7% of the episodic CH group experienced complete pain relief, and 30% of the chronic CH group achieved complete pain relief. A prospective analysis of 37 patients with CCH who underwent PRF or RFA of the SPG showed the effectiveness of PRF and RFA was similar[8]. lately, Chen Zheng et al. [9]reported the long-term outcomes of CT-guided PRF of SPG showed effective remission in 95.6% and 64.3% of patients with refractory episodic and chronic CH, respectively. But Bendersky, D.C et al[4] presented 3 patients failed to achieve adequate pain relief after PRF and subsequently successful CRF of SPG. The patient in this case report had pain remission about 1 month after PRF but then returned to its baseline level, because PRF works as reversible neuromodulation rather than tissue damage[10]. SPG is the biggest parasympathetic ganglion in the head without motor fibers, for those refractory to PRF, neurolysis of the ganglion should be consider, complications like hypoesthesia of the palate or face are usually transient,in this case, patient was free of any observable side effects after coblation of SPG.Coblation is a relatively new technology and has been used in the treatment of NP.It uses radiofrequency energy to create energized plasma that subsequently interact with organic tissue and posses sufficient energy to break molecular bonds causing tissue dissolution at a low temperature (approximately 40℃-70℃)[12, 13],which could reduce the risk of postoperative numbness after radiofrequency for TN.
Facial hematoma because of damage to the maxillary artery or pterygoid plexus is relatively common under fluoroscopy and CT guidance, because of vessels are radio transparent[5, 14, 15]. But under Doppler ultrasound we could identify vessels beside the fossa and keep away from them in real time guidance. Ultrasound guidance has many advantages compare to fluoscopy and CT,and maybe the future direction of pain management.
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CH--Cluster headache; HZ--Herpes zoster; VZV--vesicular-zoster virus; SPG-- sphenopalatine ganglion