Article Review, Clinical Anaesthesia

A single case of a successful sphenopalatine block in a patient with a post dural puncture headache

Posted on by Majic Sites

Case Report

Corresponding Author: S. Muthu

S. Muthu,1 L. Amaratunge,2

1. Intensive Care Registrar, Western Health, Melbourne, Australia

2. Anaesthetist, Western Health, Melbourne, Australia

MeSH terms: Post Dural Puncture Headache (D051299), Sphenopalatine Ganglion Block (D059387), Pain Management (D059408).

Acknowledgements

Published with the written consent of the patient with appropriate deidentification. No external funding or competing interests declared.

Summary

This article examines the case of a 35-year-old woman with a history of herpes simplex virus (HSV) meningitis, who experienced a post dural puncture headache (PDPH). Conventional simple analgesic treatments were ineffective in providing relief. The implementation of a sphenopalatine ganglion block (SPGB), via both topical and drip methods, resulted in significant pain reduction and was favourably received by the patient. The article underscores the efficacy and improved patient comfort associated with SPGB in the management of PDPH, advocating for its consideration as a potential standard for enhancing patient experiences in PDPH treatment. Furthermore, the discussion delineates the benefits of SPGB alongside the traditional approach involving an epidural blood patch and oral analgesics, as demonstrated by a local successful case.

Introduction

PDPH presents a notable challenge within anaesthesia, often disrupting the recovery trajectory for patients who have undergone such procedures. Traditional management, ranging from pharmacologic interventions to hydration, remains the first line of defence but does not consistently deliver adequate relief. Consequently, the epidural blood patch (EBP) has become a gold standard, despite its invasiveness, associated patient discomfort and often similarities with the culprit procedure itself. Within this context, less invasive yet effective treatments would be a necessary addition to clinical practice.

This case report examines the implementation of the SPGB, an alternative treatment modality, in a patient suffering from PDPH. The patient, a 35-year-old female with a medical history of recurrent HSV meningitis, presented with PDPH for which conventional analgesics proved insufficient. A SPGB was successfully administered through both topical and drip methods, offering a noteworthy case study on the efficacy of this approach.

The sphenopalatine ganglion (SPG) is an extracranial parasympathetic ganglion with sensory, sympathetic, and parasympathetic fibres, situated in the pterygopalatine fossa (Fig 1a). It is accessible trans-nasally, allowing for a minimally invasive approach to block its associated neural pathways. The SPGB aims to anesthetise the SPG through the application of local anaesthetics, thereby diminishing pain signals from various craniofacial regions. Its application in PDPH leverages the ganglion’s role in the cranial autonomic system, hypothesising that blocking the SPG can reduce the vasodilation thought to contribute to the headache’s pathophysiology10.

Previous randomized control trials have acknowledged the potential of SPGB in PDPH management, advocating for its therapeutic promise7. Likewise in the Middle East and USA, there also has been further investigation regarding the local anaesthetics used as well as the timing of the block, suggesting a more widespread use in these areas5,8. This report seeks to build upon such research, exploring how SPGB might offer an optimal balance between efficacy and patient comfort. The details of the patient’s case contribute to an evolving conversation about improving pain management strategies and enhancing patient experiences following dural punctures.

Report

The patient, a thirty-five-year-old female, presented to the emergency department with meningitis symptoms persisting for five days. The patient’s medical history includes recurrent HSV meningitis (Mollaret’s Syndrome), diagnosed through lumbar punctures, the most recent being five years prior. She has not experienced post-puncture headaches in the past. Although she occasionally suffers from migraines, no current medication is prescribed following ineffectiveness of triptans. Apart from this, her medical and hospitalisation history is unremarkable.

The patient maintains full independence in daily activities while employed as an administrator. She reports infrequent alcohol use and denies ever having smoked or used other illicit substances. Significantly, she is not on regular analgesics and does not suffer from chronic pain.

Upon arrival, the patient reported progressive headaches, neck stiffness, and photophobia, associated with some nausea and diaphoresis. She however did not report any fevers, rigors, vomiting, or loss of consciousness. She was also menstruating at the time of presentation. Assessment revealed orientation to time and place, though her responses to questions were notably sluggish. Her vital signs remained within normal ranges, and she was normothermic. A comprehensive neurological examination, including assessments of cranial, upper, and lower limb functions, yielded no positive findings. Similarly, no signs were elicited on Kernig’s or Brudzinski’s tests, and a systemic review revealed no other significant findings. Initial bloodwork, including CRP, and a CT scan of the brain were unremarkable.

An attempted lumbar puncture in the Emergency Department was unsuccessful and subsequently abandoned. The documentation regarding the specifics of the equipment utilised such as the gauge and type of needle, was not available. There was however clear documentation of consent, outlining potential risks, including post-puncture headache. There was only a single puncture attempted in the emergency department prior to the procedure being abandoned.

Despite administration of broad-spectrum antibiotics, antiviral therapy, and a pain management regimen of regular paracetamol, ibuprofen, tapentadol, and oxycodone, her pain persisted. Following this, a CT-guided lumbar puncture on the second day of admission was successful; however, she continually had a fronto-occipital, positional headache. This was despite escalation of opioid analgesics post-review by the remote pain service team. With infectious aetiologies ruled out, antibiotics and antiviral therapy was ceased, and given the symptoms the working diagnosis was presumed to be a post-dural puncture headache.

On day five, a sphenopalatine ganglion block (SPGB) was proposed. The patient consented to the SPGB after a detailed explanation. The block was first performed with the topical method which involved 2.5ml of 1% lignocaine soaked swabs being inserted into the nasal passage and positioned appropriately abutting the ganglion (Fig 1b). This promptly yielded significant pain relief, substantiated by the patient’s decreased need for breakthrough opioids for the following eight hours.

Given the transient nature of the block, a repeat SPGB was performed the following day. However, this time the drip method was used in which a small catheter attached to a syringe was advanced just past the nasal passage. Once positioned appropriately (Fig 1.2b), a mixture of 3mls of 2.5% bupivacaine and 2.5mls of 2% lignocaine was slowly dropped directly onto the ganglion. Despite the positive outcome immediately post block, an EBP was also performed, with the aim of sustained analgesia despite the time interval since the initial puncture. Her symptoms resolved entirely by that evening and was discharged home the same day.

Follow-up was conducted four weeks later via a phone interview. At this time the patient reflected very positively on the SPGB, emphasising its immediate relief and non-invasive approach. She favoured this over the EPB citing that she felt that it was far more intrusive and uncomfortable a procedure that didn’t provide the same immediacy in pain relief. Furthermore, the patient advised that she found the drip method more comfortable than the topical method and that the relief she felt post both blocks were not discernible from each other. She expressed a preference for SPGB for future analgesic needs should she sustain any further dural puncture headaches, valuing its efficacy and minimal side effects over oral medication and more invasive procedures.

Discussion

Severe headaches are a widely recognised complication post dural puncture, with incidence rates reaching up to 9% following spinal anaesthesia, 11% after lumbar punctures, and approximately 6% in unintentional epidural placements10. A plethora of independent risk factors contribute to this phenomenon, including but not limited to the female sex, needle gauge, the volume of cerebrospinal fluid extracted, patient age, and lower body mass index (BMI).

Historically, the benchmark for therapeutic intervention has been the administration of an EBP, which has demonstrated a notable success rate ranging from 65-98%10, often providing swift and effective relief. Despite these figures, the invasiveness of EBPs, coupled with an extensive list of potential contraindications and adverse effects such as back pain, bleeding, haematoma, and neuropathies, prompt the consideration of alternative treatment modalities.

The SPGB presents a promising and less invasive technique that offers rapid analgesia by delivering local anaesthetic directly to the sphenopalatine ganglion via a trans-nasal route. Randomized controlled trials (RCTs) underscore the SPGB as a procedure with immediate impact, significantly reducing the requirement for adjunctive analgesics as well as EBPs1. Presently, there are three recognised methods for administering the local anaesthetic in SPBs: the drip method, first mentioned in the Indian Journal of Anaesthesia in 2020, the more traditional topical method and finally the spray method, which is essentially a modification of the drip method2. In the case presented, the drip method was better tolerated however there have been other studies showing that while overall the drip method may be more comfortable there may be increased efficacy with the applicator method. The drip method employs a syringe coupled with a small catheter, positioned to traverse beyond the nasal passage, thereby allowing the anaesthetic to be incrementally administered to the target site (Fig1c). Alternatively, the topical method entails the application of an anaesthetic-coated soft applicator, inserted nasally to reach the site of effect.

Furthermore, RCTs have been completed comparing choice of local anaesthetics bupivacaine vs lignocaine5, which so far have indicated to significant clinical difference between the choice of local anaesthetic. In the case presented the patient received lignocaine the first time and a combination of both the second time. During the follow up interview there was no indication that either had any noticeable difference. Finally, a RCT completed in 2023 comparing late vs early blocks showed quite demonstrably that an early block resulted in fewer days in hospital8.

Although utilisation of the SPGB is predominantly observed in the Middle East, with a substantial body of evidence originating from the region, its adoption in different locales is gradually increasing. Overall, patient preference trends towards the drip method, attributed to its enhanced tolerability and the absence of discernible disparity in efficacy between the two approaches. This case report details a successful local implementation of the drip method, reinforcing the viability and potential for broader application of SPBs in the management of post-dural puncture headaches.

References

  1. Nazir N, Saxena A, Asthana U. Efficacy and Safety of Trans-nasal Sphenoid Ganglion Block in Obstetric Patients With Post-dural Puncture Headache: A Randomized Study. Cureus. 2021;13(12):e20387. doi:10.7759/cureus.20387
  2. Levin D, Cohen S. Images in anesthesiology: three safe, simple, and inexpensive methods to administer the sphenopalatine ganglion block. Reg Anesth Pain Med. 2020;45(11):880-882. doi:10.1136/rapm-2020-101765
  3. 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(1):143-145. doi:10.4103/aer.aer_67_21
  4. Marques A, Morais I, Costa V, Romao H. Sphenopalatine Ganglion Block for Headache Treatment After an Incidental Durotomy: A Case Report. Turk Anestezi Ve Reanim. 2023;51(1):72-74. doi:10.5152/TJAR.2023.21634
  5. Kirkpatrick DL, Townsend T, Walter C, et al. Lidocaine Versus Bupivacaine in the Treatment of Headache with Intranasal Sphenopalatine Nerve Block. Pain Physician. 2020;23(4):423-428.
  6. Cohen S, Levin D, Mellender S, Zhao R, Patel P, Grubb W, Kiss G. Topical Sphenopalatine Ganglion Block Compared With Epidural Blood Patch for Postdural Puncture Headache Management in Postpartum Patients: A Retrospective Review. Reg Anesth Pain Med. 2018;43(8):880-884. doi:10.1097/AAP.0000000000000840
  7. Gayathri GA, Karthik K, Saravanan R, Meshach MD, Pushparani A. A randomized control study to assess the efficacy of the sphenopalatine ganglion block in patients with post dural puncture headache. Saudi J Anaesth. 2022;16(4):401-405. doi:10.4103/sja.sja_780_21
  8. Santos NS, Nunes JM, Font ML, Carmona C, Castro MM. Early versus late sphenopalatine ganglion block with ropivacaine in postdural puncture headache: an observational study. Braz J Anesthesiol. 2023;73(1):42-45. doi:10.1016/j.bjane.2021.01.007
  9. Takmaz SA, Karaoglan M, Baltaci B, Bektas M, Basar H. Transnasal Sphenopalatine Ganglion Block for Management of Postdural Puncture Headache in Non-Obstetric Patients. J Nippon Med Sch. 2021;88(4):291-295. doi:10.1272/jnms.JNMS.2021_88-406
  10. Post-Dural Puncture Headache. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc., Wolters Kluwer; [14/02/2024]. Accessed [20/03/2024]. Available at: https://www.uptodate.com/contents/post-dural-puncture-headache?search=rates+of+post+dural+puncture+headaches&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1.
Majic Sites