Nonpharmacologic treatments

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Two studies appear to have been published on the use of neurostimulation in PHN. In 62 patients weekly acupuncture was compared to mock TENS over eight sessions [96]. No difference in pain relief was found between the two groups: in both, approximately one-fifth reported improvement irrespective of the treatment. Genuine TENS was inferior to combined clomipramine and carbamazepine in a moderate-quality study involving 29 patients (odds ratio 0.15; 95% CI 0.03-0.7) [97]. There is currently insufficient evidence to support the use of either acupuncture or TENS in PHN.

Although controlled studies demonstrate that spinal cord stimulation (SCS) is effective in some neuropathic conditions, none have been published on PHN. In one case series of 28 patients good results were reported from SCS in 82% of patients with PHN [98]. Patients were those responding to a sympathetic block and did not have sensory deficits. The effect of SCS was tested at times by switching off the stimulator. There were 10 patients who recovered, five who developed progressive dementia and one who only reported pain at 2/10 during 60 hours of nonstimulation. Unequivocal long-term benefit was therefore seen in 12/28 (40%) in this carefully chosen patient population. A properly controlled trial seems warranted in view of these results.

For neuroablative surgical interventions, several small case series have been published. These range from neurectomy to dorsal root entry zone ablation, spinal trigeminal nucleotractotomy and stereotactic radiosurgery of the trigeminal root [99]. The reported outcomes suggest satisfactory pain relief lasting 2 or 3 years. These results are highly contentious and almost certainly represent a small number of surgical interventions attempted with a strong publication bias. The data are far too limited and methodologic flaws too significant in the reports to allow any recommendation on the use of neurodestructive procedures.

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