Varicella-zoster virus and herpes simplex virus types 1 and 2 are neurotropic viruses that can be reactivated after a surgical or stressful intervention. Although such cases are uncommon, consequences can be debilitating, and variable treatment responses merit consideration. We describe a 41-year-old male with a history of varicella-mediated skin eruptions, who presented with continuing right arm pain, burning, and numbness in a C6 dermatomal distribution following a C5-6 anterior cervical discectomy and fusion and epidural steroid injections. The operative course was uncomplicated and he was discharged home on postoperative day 1. Approximately ten days after surgery, the patient presented to the emergency department complaining of severe pain in his right upper extremity and a vesicular rash from his elbow to his second digit. He was started on Acyclovir and discharged home. On outpatient follow-up, his rash had resolved though his pain continued. The patient was started on a neuromodulating agent for chronic pain. This case adds to the limited literature regarding this rare complication, brings attention to the symptoms for proper diagnosis and treatment, and emphasizes the importance of prompt antiviral therapy. We suggest adding a neuromodulating agent to prevent long-term sequelae and resolve acute symptoms.
Varicella-zoster virus (VZV), herpes simplex virus type 1 (HSV-1), and herpes simplex virus type 2 (HSV-2), members of the Herpes virus family, are a group of neurotropic viruses that infect neurons, remain dormant in dorsal root ganglia, and by axoplasmic transport, can become reactivated during times of stress or immunocompromised states in the axonal terminals causing neuralgia, and a cutaneous rash most often in a segmental or radicular distribution. Although afferent sensory neurons are most often affected, motor neuron involvement has been reported in 0.5–31% cases of Herpes Zoster [
Patients with herpes radiculitis—study, demographics, and presenting symptoms.
Author | Age/sex | Indication for initial intervention | Location | Presenting symptom | Time to outbreak, if applicable |
---|---|---|---|---|---|
Conliffe et al. [ |
75/M | L5 radiculopathy with foot drop | Lumbosacral distribution, L5 | Herpetic rash | No information |
Haverkos et al. [ |
52/M | T9 to L1 laminectomy for excision of arteriovenous malformation | Below umbilicus (T10) in all dermatomes. | Back pain and complete paralysis of both legs | 9 days postoperatively |
Haverkos et al. [ |
50/F | L4 laminectomy, L4-5 discectomy, and bilateral L5 foraminotomies for herniated disc | S2 and S3 | Clusters of vesicular lesions in right S2 and S3 dermatomes | 3 days postoperatively |
Haverkos et al. [ |
55/F | L4-5 discectomy | Right buttock laterally | 3 clusters of vesicles (3 × 4 cm) | 5 days postoperatively |
Makkar et al. [ |
30/F | Bilateral transforaminal fluoroscopy-guided steroid injection at L4 for 1 year of low back pain and radiculopathy | T10 | Burning sensation and eruption of herpes zoster lesions | 5 days after injection |
Makkar et al. [ |
42/F | Serial transforaminal steroid injections for L5 radiculopathy of 6 months duration | T8 | Pruritis and herpes zoster lesions | After third injection |
Grauvogel and Vougioukas [ |
56/M | Foraminotomy for dysesthetic pain in C8 nerve root distribution | C6 and C7 | New motor deficits | 2 days postoperatively |
Godfrey et al. [ |
59/M | 2-stage anterior and posterior spinal fusion for progressive idiopathic adult lumbar scoliosis | T4 and T5 | Severe left-sided chest pain and painful vesicular rash | 29 days postoperatively |
Godfrey et al. [ |
47/F | Anterior left 8th rib thoracotomy and cord decompression for lower extremity hyperreflexia and left T7 and T9 intercostal hyperalgesia | Left 7th, 8th, and 9th rib | Sudden onset severe left thoracogenic pain and vesicular eruptions | 5 days postoperatively |
Parsons and Hawboldt [ |
42/M | Series of 6 epidural blocks for complex regional pain syndrome | Right L2 | Burning sensation followed by shingles lesions 7 days postoperatively | 7 days postoperatively |
Hung et al. [ |
70/M | Hospital admission for multiple fractures and compression of S1 ventral ramus | S1 | Severe tingling pain and allodynia | 30th day of hospital admission |
Szokol and Gilbert [ |
52/F | Epidural steroid injection at L4-L5 interspace | S3 | Pruritus in tailbone and herpes zoster outbreak in S3 distribution with no tenderness | 4 days after injection |
Nabors et al. [ |
57/F | T6-T8 laminectomy for spinal cord meningioma | Both buttocks | Vesicular rash | 7 days postoperatively |
Nabors et al. [ |
61/F | Occiput to C3 fusion because of underlying multiple myeloma | Vertex to base of neck with lesions at the rim of the pinna of the ear | Vesicular rash on the back of the head | 5 months postoperatively |
Nabors at el. [ |
63/F | Right L5 hemilaminectomy for excision of ruptured L5-S1 disc with topical corticosteroid applied to S1 nerve root | Left buttock | Vesicular rash | 2 days postoperatively |
Nabors et al. [ |
61/F | L3-L5 laminectomy for decompression with topical steroids applied to nerve roots | Both buttocks | Vesicular lesions | 7 days postoperatively |
Nabors et al. [ |
77/F | C3-C6 laminectomy for decompression of canal stenosis | Right side of lower back and buttocks | Vesicular rash | 7 days postoperatively |
Nabors et al. [ |
62/F | Right frontal craniotomy for clipping of aneurysm | Right side of chest | Vesicular rash | 7 days postoperatively |
Nabors et al. [ |
60/M | Left craniotomy for Glioblastoma Multiforme resection | Both eyes (V1 distribution) | Progressive right side weakness and, one week after, bilateral periorbital swelling | 10 months postoperatively |
We present the case of a 41-year-old male with a history of herpetic shingles, who had previously undergone a C5-6 foraminotomy two years prior to presentation, which had failed to relieve his right arm pain. Of note, after this surgery he experienced a recurrence of his shingles, which subsequently resolved. He presented to our clinic with continued pain and numbness in a C6 dermatomal distribution, as well as a burning sensation in this distribution, despite the previousely mentioned intervention. Conservative management including epidural steroid injections had failed to improve his symptoms.
On physical examination, he demonstrated full strength in all muscle groups bilaterally. He had no evidence of myelopathic signs. MRI of the cervical spine upon initial presentation to our clinic showed degenerative disk disease at C5-6, with bilateral foraminal stenosis.
Given that he had already undergone attempted foraminal decompression posteriorly, it was decided to proceed with C5-6 anterior cervical discectomy and fusion. The operative course was uncomplicated, the patient tolerated the procedure well, and he was discharged home on postoperative day 1.
Approximately ten days after the procedure, the patient presented to the emergency department with complaints of severe pain in his right upper extremity and a vesicular rash from his elbow to his second digit (Figure
Postoperative photograph of the patient’s index finger (a) and forearm (b) demonstrating a vesicular rash.
At the follow-up visit, his vesicular rash had completely resolved. However, the upper extremity pain, which he had preoperatively, continued. Therefore, the possibility of neuropathic rather than radiculopathy was raised. He was started on neuromodulating agents including Lyrica and nortriptyline for chronic neuropathic pain.
In the cases we reviewed, patients manifested VZV or HSV outbreaks from 2 days to 10 months after the inciting incident, which ranged from an epidural steroid injection to surgical manipulation. However, after surgical intervention, we noted that outbreaks or its resulting deficits occurred most often (9/13 cases) at 2–7 days postoperatively [
In many cases, surgical manipulation of nerve roots led to the development of shingles or herpes radiculitis in dermatomal distribution of the same manipulated nerve roots or those in adjacent levels [
A recent case report demonstrated the successful usage of epidural corticosteroid injections in the vicinity of the affected spinal cord root in a patient with VZV-mediated radiculitis [
We encountered several cases of herpetic outbreaks following craniospinal interventions that utilized different treatments with variable success (Table
Treatments and outcome of patients with herpes radiculitis.
Author | Treatment | Follow-up and outcome, if applicable |
---|---|---|
Conliffe et al. [ |
Fluoroscopically guided R L5 transforaminal epidural injection with Depo-Medrol and lidocaine | 6 weeks: pain decreased and improvement in right foot weakness with ability to ambulate |
Haverkos et al. [ |
Vidarabine | Several days; skin lesions and CSF pleocytosis resolved but neurologic status unchanged |
Haverkos et al. [ |
No treatment mentioned | Not mentioned |
Haverkos et al. [ |
No treatment mentioned | Not mentioned |
Makkar et al. [ |
Acyclovir | Lesion resolved and postherpetic neuralgia did not occur |
Makkar et al. [ |
Acyclovir and amytryptyline | Few days; resolution of skin lesions postherpetic neuralgia did not occur |
Grauvogel and Vougioukas [ |
Acyclovir | 3 months: neurologic deficits improved |
Godfrey et al. [ |
Acyclovir (then switched to famciclovir) and gabapentin | 1 year: pain resolution with mild rib pain (3/10) and no new skin lesions |
Godfrey et al. [ |
Valacyclovir and gabapentin (GBN later discontinued due to adverse effects) | 1 year: no pain or skin eruptions |
Parsons and Hawboldt [ |
Valacyclovir | 1 year: resolution of complex region pain syndrome after 12-month period |
Hung et al. [ |
Valacyclovir | 7 days: skin lesions and tingling pain resolved |
Szokol and Gilbert [ |
Acyclovir | Several weeks; skin lesions resolved and patient had 50% reduction of radicular symptoms |
Nabors et al. [ |
Acyclovir | Complete resolution of rash and skin lesions |
Nabors et al. [ |
Antibiotics and Acylovir; tricyclic antidepressant and analgesics administered for postherpectic neuralgia | 9 days: resolution of skin lesions but patient developed tenderness at site of former lesions with relief provided by TCA and analgesics |
Nabors at el. [ |
Acyclovir | Resolution of skin lesions |
Nabors et al. [ |
Acyclovir | Resolution of skin lesions |
Nabors et al. [ |
Acyclovir | Resolution of skin lesions |
Nabors et al. [ |
No treatment mentioned | Patient transferred to another hospital |
Nabors et al. [ |
Virotropic ophthalmic solution | Resolution of Herpes dendritic keratitis but patient became comatose and eventually died |
In a case series of postoperative neurosurgical patients who developed VZV or HSV reactivation, oral or IV Acyclovir was used successfully in the resolution of symptoms and lesions [
In the reviewed cases, although the herpetic outbreaks were treated with an appropriate antiviral agent either topically, orally, or intravenously, only a few tried to prevent postherpetic neuralgia with a neuromodulator, that is, amitriptyline and/or gabapentin [
VZV- and HSV-mediated radiculitis and associated lesions are rare events which occasionally occur after surgical manipulation or steroid injections in the spinal canal. In cases with successful resolution, oral or intravenous antiviral agents, most commonly Acyclovir, have been used. Neuromodulating agents such as gabapentin and/or amitriptyline were used in some cases to prevent or decrease the severity of postherpetic neuralgia.
This case report adds to the limited literature regarding this rare complication, brings attention to the symptoms for proper diagnosis and treatment, and emphasizes the importance of prompt antiviral therapy. We suggest the addition of a neuromodulating agent to prevent long-term sequelae and resolve acute symptoms.
The authors declare that they have no conflict of interests.