Notalgia Paraesthetica

Notalgia Paraesthetica: Understanding and Management

What is Notalgia Paraesthetica?

Notalgia Paraesthetica is a condition characterised by abnormal sensations, such as itchiness or altered feeling, in the area of skin on the medial aspect of the shoulder blade, on one or both sides of the back. “Notalgia” refers to pain in the back, while “paraesthetica” signifies burning pain, tingling, or itchiness. It’s also known as thoracic cutaneous nerve entrapment syndrome.

Causes:

The condition is believed to arise due to compression or traction on nerves supplying sensation to the upper back. This compression or injury to the nerves can be caused by various factors including:

  • Back injury
  • Herniated or ‘slipped’ disc
  • Herpes zoster (shingles)
  • Sunburn
  • Myelopathy
  • Small fiber neuropathy

Clinical Features:

  • Notalgia Paraesthetica often begins after intense exercise leading to muscular stiffness or after a period of inactivity, and patients may recall a specific injury.
  • It is characterised by intense itchiness (pruritus) between the shoulder blades, which can be intermittent or continuous.
  • Scratching and rubbing may not relieve the itch but may paradoxically feel pleasurable.
  • Visible changes such as scratch marks, hyperpigmentation (brown marks), hypopigmentation (white marks), lichen simplex (a type of eczema), and scarring may result from rubbing and scratching the affected area.
  • Changed sensation in the affected area of skin may include reduced or absent sweating.

Investigations:

  • Radiological imaging such as X-ray, CT scan, or MRI may reveal degenerative vertebrae or prolapsed discs corresponding to the nerve supply to the affected skin (dermatome). However, in many cases, no abnormalities are detected.
  • A skin biopsy may appear normal unless there is associated dermatitis.

Treatment:

Treatment for Notalgia Paraesthetica may include:

  • Cooling lotions or creams containing camphor and menthol to soothe the skin.
  • Topical steroids to treat associated skin changes such as lichen simplex.
  • Capsaicin cream, which depletes nerve endings of chemical transmitters, although it requires frequent reapplication and may cause local side effects.
  • Local anaesthetic creams for temporary relief.
  • Oral medications such as amitriptyline (a tricyclic antidepressant) at night to alleviate neuropathic symptoms and aid sleep.
  • Anticonvulsants like gabapentin or pregabalin for neuropathic pain.
  • Physical therapy involving repetitive exercises and stretches for the upper back.
  • Surgical decompression of vertebral nerve impingement in severe cases.

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