Notalgia Paresthetica Relieved by Cervical Traction

Discussion

Notalgia paresthetica has been speculated to be a sensory nerve entrapment syndrome caused by damage to the cutaneous branches of the posterior division of spinal nerves.^1,2 The nerves, especially at the T2–T6 region, emerge through the multifidus spinae muscle at right angles en route to the epidermis, rendering them exposed and more susceptible to injury.⁴ The nerves can also become entrapped as they exit the vertebral foramina. Studies have shown that over 60% of patients with notalgia paresthetica have degenerative vertebral changes or herniated discs that correspond with the dermatomal distribution of their symptoms.¹ Savk et al³ reported a striking correlation of localization of notalgia paresthetica with degenerative changes in the spines of 10 patients, suggesting that spinal nerve impingement may be important to its pathogenesis. Notalgia paresthetica has also been reported with radiologic evidence of low cervical spinal compression.⁵

Traditional first-line antipruritic agents, such as antihistamines and topical corticosteroids, are ineffective for treating notalgia paresthetica.¹ Case reports have shown variable improvement of itch with topical capsaicin⁶, lidocaine, and prilocaine topical cream (Emla cream)⁷, tacrolimus ointment⁸, cutaneous botulinum toxin type A injection⁹, local paravertebral nerve block¹⁰, transcutaneous electric nerve stimulation^11,12, surgical nerve decompression¹³, epidural steroid injections, and UVB light treatments¹⁴; and with the drugs gabapentin¹⁵, oxycarbazepine⁷, amitriptyline¹⁶, and phenytoin.¹ However, these treatments are typically temporary, invasive, or expensive, or have potential side effects.

Physical therapeutic measures have also been reported to relieve the pruritus of notalgia paresthetica. In 2 women, exercises to strengthen postural muscles¹⁷ and extend the spine were effective in reducing the angle that the cutaneous nerves passed through the rhomboid and trapezius muscles, thereby relieving itch.⁴ Deep, intramuscular-stimulation acupuncture was temporarily effective in 16 patients, with recurrence of symptoms between 1 and 12 months.¹⁸ Osteopathic manipulative treatment successfully treated 1 woman with notalgia paresthetica.¹⁹

In busy primary-care settings, providers may overlook possible biomechanical and neurologic causes of notalgia paresthetica. A comprehensive history and examination for cervical spondylosis, disk disease, radiculopathy, or prior trauma are important in the assessment of notalgia paresthetica. In addition, alternative diagnoses should be considered, including primary skin diseases, such as contact or atopic dermatitis, or other neuropathic disorders, such as postherpetic neuralgia or multiple sclerosis. Our patient did not have any evidence of a primary skin or other neurologic disease as the source of her symptoms, and a skin biopsy showed no features characteristic of dermatitis. Although she said that she had clothing intolerance, the intolerance was probably a consequence of the hyperesthesia from her nerve compression.

This is the first report, to our knowledge, of the use of cervical traction for notalgia paresthetica. Our patient’s condition responded with permanent remission after a limited therapeutic course of cervical traction, physical therapy, and posture education. We believe the cervical traction was the more important component of the therapy. A trial of cervical traction seems a reasonable therapeutic option for patients, considering the current understanding of pathophysiology of notalgia paresthetica, and it has the advantage of being safe and relatively inexpensive. This is especially true if diagnostic imaging supports nerve impingement as the cause. Ultimately, more investigative work needs to be done to prove efficacy.