Intrathecal Methylprednisolone for PHN

[dhcofc]

I have an 88yo patient with severe PHN. Has failed the usual suspects: Lyrica, TCA, gabapentin, capsaicin, opioids, Lidoderm. He is losing weight, has become inactive and is in severe pain. I've come across research about intrathecal Methylprednisolone injection and some studies look to be quite effective. Have any of you done this? I have never injected IT steroids and know about concerns with additives causing arachnoiditis, etc.

Can anyone comment on whether IT steroids should be considered for this refractory severe PHN pain?

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[callmeanesthesia]

Sorry, no experience with IT steroids but have you already tried just a paramedian ESI at that level?

 

[lobelsteve]

Haven’t done it and would not do it. Would try QUTENZA first. From an interventional Steve point I would recommend an intercostal nerve block a transfer aminal epidural to get the medicine on the DRG and then I would consider neuromodulation.

 

[chibadriver]

A colleague of mine has tried the ITN steroid thing with no luck... Epidurals never seem to work for this either. I second Qutenza patch. I like ESP block, faster than intercostals, I do it under fluoro. Agree with DCS if failing to derive benefit.

 

[Ducttape]

you did say that you tried opioids. did you try Cymbalta or nucynta? there is some risk in an 88 year old, but you said he tried TCAs already, so...

intercostal nerve block would be my next step though with possible RFA. and failing that, SCS.



if you are going to use intrathecal steroids - stick to dex.

 

[swamprat]

Ive done a few thoracic DRGs that have really helped these patients - off label I think as DRG is only approved to T12

 

[chibadriver]

intercostal nerve block would be my next step though with possible RFA. and failing that, SCS.

I've not done intercostal RF although, I've thought about it for a few patients lately... are you placing these under US? Ever try pulsed or just go straight to thermal? Multiple lesions along the nerve? Time and dose recs?

 

[lobelsteve]

I've not done intercostal RF although, I've thought about it for a few patients lately... are you placing these under US? Ever try pulsed or just go straight to thermal? Multiple lesions along the nerve? Time and dose recs?

Cervical settings on machine. I do pulsed RF for non cancer pain first. If not 6mo or more , then thermal.
Under fluoroscopy.

 

[Ferrismonk]

Problem is insurance. Pulsed not usually covered, so pulse and do homeopathic thermal for billing.

How did you get the DRG approved? I'm getting trained on DRG next month and have a few PHN patients that I think it could help with.

 

[Aether2000]

I did a few of these IT injections but the results were only marginal.

 

[painfree23]

Problem is insurance. Pulsed not usually covered, so pulse and do homeopathic thermal for billing.

How did you get the DRG approved? I'm getting trained on DRG next month and have a few PHN patients that I think it could help with.

Why not just stim em?

 

[10KHertz]

This is the study we were exposed to in training . I’d consider it with decadron only . For a couple cases, I have had mixed results ...

https://www.nejm.org/doi/full/10.1056/nejm200011233432102