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8 Articles in this Series
Introduction
Interview with AAPM President Daniel B. Carr, MD
Sphenopalatine Ganglion Block Effective and Safe for Postdural Puncture Headache
Women Have More Neck Pain Than Men
Intradiscal Biacuplasty Effectively Treats Discogenic Low Back Pain
Cooled Radiofrequency Ablation Provides Pain Relief for Knee Osteoarthritis
Link Between Atherosclerosis and Degenerative Disc Disease
Bleeding Complications Rare in Interventional Pain Procedures
Spinal Cord Compression Following Spinal Cord Stimulation: A Case Report

Sphenopalatine Ganglion Block Effective and Safe for Postdural Puncture Headache

Post-dural puncture headache often affects women after delivery.For women who suffer from post-dural puncture headache, there is a fast and easy solution—sphenopalatine ganglion block (SPGB). The non-invasive block relieves the disabling headache faster than an epidural blood patch (EBP), without the trauma of another epidural procedure, according to results from a retrospective analysis.1

At 24 to 48 hours, both treatments were similarly effective; however, SPGB was associated with greater headache relief at 30- and 60- minutes post-treatment, said lead author Preet Patel, MD, a research fellow at Rutgers—Robert Wood Johnson (RWJ) Medical School in New Brunswick, NJ. He said advantages of SPGB include its relative ease of administration and lower complication rates.

“One of the advantages of SPGB is that you will know relatively quickly if it is providing headache relief for your patient,” Dr. Patel said. “If the block is not effective within the first 3 hours, you can switch to the more invasive EBP.” And if it does work, he said, the new mothers can avoid the complications that can appear days or weeks later with EBP and enjoy a quicker recovery, “which is absolutely critical in this population.”

Disabling headache from dural puncture can follow the administration of spinal anesthesia. According to the International Headache Society, PDPH worsens with sitting upright, improves with reclining and is accompanied by neck stiffness, tinnitus, photophobia or nausea. When conservative measures such as oral medications or caffeine fail to relieve the often-severe headache pain, EBP is the usual treatment choice. Unfortunately, EBP can lead to significant complications on rare occasions, including motor and sensory deficits, meningitis, hearing loss, Horner’s Syndrome and subdural hematoma.2-4

Dr. Patel described the history of SPGB use for headache relief, including migraine and cluster headache, going back for over 100 years but said it had not been previously adequately studied for PDPH treatment.

The investigators reviewed 72 records over 17 years of women without a previous history of primary headaches who had experienced PDPH during childbirth. Thirty-three women received SPGB (with EBP available upon request), and 39 women received routine EBP. The women were similar in age, height, body mass index, and potential risk for suffering complications from general anesthesia.

The block is performed with the patient in either supine or trendelenburg position. The physician then places two, 6-inch, cotton tipped plastic hollow applicators transnasally. "We inject 1.5 cc of 4% lidocaine through each applicator," Dr. Patel said. "The cotton-tipped end of the applicator does not make physical contact with the ganglion. Rather, we position the applicator so that the cotton-tipped end is just superior to the middle turbinate. Then we inject the 4% lidocaine and the local anesthetic drips down to the ganglion via gravity."

The superior pain relief with SPGB was observed at the earliest time points: 55% of those receiving SPGB had recovered from headache at 30 minutes compared with 21% in the EBP treatment group. At 1 hour post-treatment, 64% of SPGB recipients had recovered compared with 31% in the EBP treatment group. At 24 hours, 48 hours, and one week after treatment, no differences were seen in pain relief.

However, EBP recipients experienced higher complication rates, including 9 emergency-room visits, 3 complaints of backache radiating to the leg, 1 vasovagal reaction, and 1 complaint of temporary hearing loss.

Dr. Patel said that although the study is small and retrospective, the results are ample evidence to ask anesthesiologists to consider using the non-invasive SPGB for the treatment of PDPH in obstetric patients before they consider using the more invasive EBP.  The research team in the Department of Anesthesiology at Rutgers–RWJ is planning a prospective study and hopes to report data within 3 years.

References                                       

1.      Patel P, Zhao R, Cohen S, Mellender S, Shah S, Grubb W. Sphenopalatine Ganglion Block (SPGB) Versus Epidural Blood Patch (EBP) for Accidental Postdural Puncture Headache (PDPH) in Obstetric Patients: A Retrospective Observation. Poster presentation at: 32nd Annual Meeting of the American Academy of Pain Medicine; February 18-21, 2016; Palm Springs, CA. Poster #145.

2.      Snidvongs S, Shah S. Horner's syndrome following an epidural blood patch. JRSM Short Reports 2012;3(10):68.

3.      Beilin Y, Spitzer Y. Presumed Group B Streptococcal Meningitis After Epidural Blood Patch. A A Case Rep. 2015;4(12):163-165.

4.      Kardash K, Morrow F, Béïque F. Seizures after epidural blood patch with undiagnosed subdural hematoma. Reg Anesth Pain Med. 2002;27(4):433-436.

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