Anesthesia: Essays and Researches

CASE SERIES
Year
: 2021  |  Volume : 15  |  Issue : 1  |  Page : 143--145

A simple modification of sphenopalatine ganglion block for treatment of postdural puncture headache: A case series


Tanvi Bhargava1, Abhishek Kumar2, Amit Rastogi1, Divya Srivastava1, Tapas Kumar Singh1,  
1 Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Onco-Anaesthesiology, Intensive Care, Pain and Palliative Medicine, DRBRAIRCH, AIIMS, New Delhi, India

Correspondence Address:
Dr. Amit Rastogi
Associate Professor, Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
India

Abstract

To evaluate the efficacy of modified sphenopalatine ganglion block (MSPGB) to reduce the severity of post-dural puncture headache (PDPH). Five adult patients of both genders with age >18 years having PDPH intractable to conservative management were given modified sphenopalatine block in the postoperative period, and numeric rating scale (NRS) was recorded at regular intervals till the hospital discharge. MSPGB is a simple, noninvasive technique that provides instantaneous symptomatic relief in PDPH.



How to cite this article:
Bhargava T, Kumar A, Rastogi A, Srivastava D, Singh TK. A simple modification of sphenopalatine ganglion block for treatment of postdural puncture headache: A case series.Anesth Essays Res 2021;15:143-145


How to cite this URL:
Bhargava T, Kumar A, Rastogi A, Srivastava D, Singh TK. A simple modification of sphenopalatine ganglion block for treatment of postdural puncture headache: A case series. Anesth Essays Res [serial online] 2021 [cited 2021 Nov 30 ];15:143-145
Available from: https://www.aeronline.org/text.asp?2021/15/1/143/325024


Full Text

 Introduction



Postdural puncture headache (PDPH) may occur as a result of a dural puncture during spinal anesthesia or after inadvertent dural puncture during epidural placement. Conservative management of PDPH, including bed rest, hydration, caffeine, and analgesics, is seldom effective.[1] Consensus guidelines for the management of persisting PDPH involve epidural blood patch which is effective in approximately 75% of cases;[2] however, it is invasive and painful and may lead to rare complications such as meningitis, cauda equine syndrome, permanent paraparesis, and epidural infection.[3],[4]

Sphenopalatine ganglion block (SPGB) is a simple and noninvasive treatment of PDPH. The conventional method of SPGB includes nasal probing with a long applicator that may lead to discomfort and nasal bleeding.[5] Bhargava et al. have proposed a noninvasive and simple technique of SPGB by instillation of a local anesthetic agent like nasal drops.[6]

We hereby present a series of five cases wherein MSPGB was seen to be an effective noninvasive treatment for patients suffering from incapacitating PDPH.

 Materials and Methods



Five consenting adults of both genders with PDPH postoperatively were included. PDPH was defined as a moderate-to-severe fronto-occipital headache with a numeric rating scale (NRS) pain score >4 in an upright position that developed within 3 days after an intended or accidental dural puncture. Adequate hydration, caffeine, and paracetamol tablets were tried, but to no avail. Informed consent was taken from all the patients. For Modified sphenopalatine ganglion block (MSPGB) the patients were made to lie supine position with the neck extended and their nostrils pointed in an upward direction. 2 mL of 2% lignocaine was slowly instilled along the superior edge of the middle concha to the posterior wall of the nasopharynx in each nostril alternatively; the nostrils were gently pinched to ensure the drug does not spill out [Figure 1].{Figure 1}

After 5 min, the patients were asked to gradually lift their head, and the headache was assessed usingNRS, (0 – no pain to 10 – worst pain imaginable). Pain was assessed before the procedure. Subsequently, NRS was assessed at 5 min after installation and then at 2, 4, 6, 8, 12, 24, 36, 48, and 72 h after the procedure. The MSGPB was repeated if the patient reported an NRS > 4 between 1 h and discharge from the hospital. All the conservative measures for PDPH were continued throughout the postoperative period for all the patients.

 Case Report



Case 1

A 35-year-old male patient with end-stage renal disease planned for live donor renal transplantation under general anesthesia. The epidural was placed at T11-12 level, with an 18G Touhy needle.

On postoperative day 2, the patient developed PDPH. NRS remained 9 despite all conservative measures. MSPGB was discussed as the patient had deranged coagulation parameters (with INR of 1.76; epidural blood patch was out of the question). The sphenopalatine ganglion block (SPGB) was performed by the modified technique and the patient described significant relief of headache instantaneously. The NRS reduced to 2. The block was repeated twice in the next 48 h, and the patient remained asymptomatic thereafter.

Case 2

A 33-year-old pregnant female G2P1L1A0 with a history of previous cesarean delivery with gestational hypothyroidism and preeclampsia on tablet labetalol. The patient was planned for a cesarean section under spinal anesthesia. On postoperative day 2, patients complained of PDPH. The MSPGB was performed, and the block was repeated at an interval of 6 h. The patient remained asymptomatic until discharge.

Case 3

A 28-year-old female was posted for emergency lower segment cesarian section for a nonreassuring fetal heart rate under spinal anesthesia. On postoperative day 2, she developed PDPH after ambulation. Despite conservative management, the headache was not relieved so MSPGB was given and the patient had immediate relief with an NRS score of 2, the block was repeated at 6 and 36 h after the initial block with all conservative measures for PDPH being continued. The patient remained pain-free for the next 3 days in the hospital stay.

Case 4

A 36-year-old female for ureteroscopic stone removal from the lower ureter. Spinal anesthesia was given. The patient complained of headache in the evening of surgery which was characteristic of PDPH. MSPGB was given. The NRS score dropped from 8 to 2 after the block. The procedure was repeated 8 h after the first block, and the patient remained asymptomatic thereafter.

Case 5

A 62-year-old male posted for transurethral resection of the prostate under subarachnoid block. The patient complained of headache in the evening. NRS was reduced from 8 to 1 after MSPGB. MSPGB was repeated 8 h after the first block and the patient henceforth remained asymptomatic.

 Discussion



The sphenopalatine ganglion (SPG) is an inverted four-sided pyramid-shaped space just posterior to the maxillary sinus. It is located in the pterygopalatine fossa posterior to the middle nasal turbinate and anterior to the pterygoid canal.[7] There is a 1–1.5 mm thick layer of connective tissue and mucous membrane surrounding the ganglion, so the local anesthetic can easily penetrate the ganglion by simple topical application or by injection, as shown in [Figure 1]. The SPG is a junction that has sympathetic, parasympathetic, and sensory innervations overlapping in a minute area. This could be the reason behind the fact that the block diffuses the process of conduction of pain due to several etiologies.

Dural puncture decreases cerebrospinal fluid volume, resulting in compensatory intracranial vasodilation and increased blood volume to ensure a constant volume of brain tissue. Regulation is mediated by parasympathetic activity in the SPG. Presumably, PDPH develops when uncontrolled vasodilation persists after the decrease in cerebro-spinal fluid volume has been countered. The SPG block may attenuate parasympathetic-mediated cerebral vasodilation and provide simple and rapid symptomatic relief.[8] Previous studies highlighting the efficacy of the SPG block in PDPH are available.[9],[10] The conventional method of SPGB includes a long applicator with a cotton swab tip soaked with local anesthetic inserted to the posterior pharyngeal wall which is retained there for 5–10 min.[10] The procedure has the risk of nasal bleeding.

We found that the instillation of local anesthetic with syringe or even by a dropper is a simpler and quicker method to block sphenopalatine ganglion effectively without nasal probing. It is comfortable for the patient who is already in pain and especially useful in patients with deranged coagulation profile.

In our experience, MSPGB is an effective treatment of PDPH, we observed immediate relief in headache, the median NRS reduced from 9 to 1 immediately after the procedure. The median NRS score remained <4 up to 6 h after which the patient again complained of headache and the SPG block was repeated through the same route. The block was repeated twice for all the patients within 72 h after the onset of symptoms after which the patients had a median NRS score <4 until discharge from the hospital. None of the patients experienced any side effects during blockade of SPG [Table 1] and [Figure 2].{Figure 2}{Table 1}

MSPGB is a simple, noninvasive method of treating PDPH that can be easily performed by nursing staff on training. The total amount of local anesthetic agents never exceeds the toxic dose even on repeated blocks.

The MSPGB has shown promise to treat PDPH in our chosen sample along with minimal side-effects in the postoperative care settings, we strongly feel that there is a scope for further research in the above-mentioned area with blinded randomized controlled trials.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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