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Background: Intense, refractory neuropathic pain is an unfortunate complication following a Herpes Zoster (HZ) infection/rash and is regarded as post-herpetic neuralgia (PHN). The risk of PHN increases with age. The erector spinae plane (ESP) block has been demonstrated to block transmission through the thoracic and lumbar spinal nerves. This report describes two patients that were able to significantly reduce their chronic pain medications following a series of ESP blocks. Methods: ESP blocks were performed in two patients at the transverse process level correlating with their clinical presentation. All the blocks were performed with ultrasound guidance using a previously described technique using 30 ml of 0.25% bupivacaine and 80 mg methylprednisolone in a fascial plane deep to erector spinae muscle. Standard monitoring was applied to both patients. A baseline pain score was taken and following the procedure, the patients were given a pain diary to document their pain severity for two weeks. A clinic visit with the completed pain diary was scheduled approximately 2-4 weeks later for block assessment in terms of pain relief, with further clinic follow-up as indicated. Case reports: Both patients had a flare of their PHN following major surgery. The referral to the Transitional Pain Service (TPS) at Toronto General Hospital (TGH) was primarily for help with management of PHN pain and optimization of the patients’ pain regimen. Pain medications were being escalated without analgesic benefit and daily activities were becoming negatively impacted. The two patients were scheduled for series of three ESP blocks at intervals of not less than 4 weeks. After every block their pain severity reduced and their medications were able to be tapered gradually. Conclusions: The results from the above interventions indicate that a series of ESP blocks with local anesthetic and steroid may be considered as a viable therapeutic option in the management of refractory PHN. Concurrent benefits of interventional blocks may include improvements in patients’ pain scores and functional status, along with the ability for patients to reduce their opioid and other neuropathic pain medication doses and help to reduce the associated side effects.

A Series of Erector Spinae Plane Blocks Reduced Pain and Opioid Consumption in Patients with Post Herpetic Neuralgia: Two Patient Cases