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(*Fictitious case)
You are called to the postnatal ward by the midwife to review a woman who unfortunately had an accidental dural puncture the day before during her labour. When you see her today she has a classic postural headache – and has been unable to mobilise for more than 10-15 min and has basically confined to bed in a dark room. You take a detailed history and perform a neurological exam and are relatively confident that it is unlikely that she has any other serious pathology and that the headache is secondary to the CSF leak. You explain to her the natural history of the condition, discuss epidural blood patch, or conservative management. The patient tells you she is not very keen on the idea of anyone putting another big needle in her back – “isn’t there anything else we can try?”
This week on the podcast we are joined again by Gareth Ansell to discuss the role of sphenopalatine ganglion block (SPGB) in the management of postdural puncture headache (PDPH).
SPGB is useful in reducing post dural puncture headache. It can be used as an alternative or as interim management of PDPH.
So far there has been no randomised controlled trials looking at SPGB specifically for PDPH but there have been case series. Cohen et al (1) published in 2009 showed that in their case series of 32 patients, 69% avoided epidural blood patch and another case series by Kent (2) had a 100% success rate in resolution of headache. There is also a systematic review of SPGB for treatment of headaches published in 2017 by Ho (3) and there are RCTs underway. Some patients get permanent resolution of the headache with the a single SPGB, other patients may need repeat SPGB. Remembering that the natural time course of PDPH is that the majority of patients gets better 7-14 days after the dural puncture.
Sphenopalatine ganglion lies in the pterygopalatine fossa which lies posterior to the the middle concha. The sphenopalatine ganglion is the largest of the four parasympathetic ganglions associated with the trigeminal nerve. It is postulated to work by blocking the parasympathetic nerve fibres and improving cerebral vasculature reducing the headache.
Advantages of the SPGB is that it is less invasive, easier and quicker to perform and has lower risks than and epidural blood patch. As well as an useful alternative to patients who do not want an epidural blood patch or who have contraindications such as bacteraemia or spina bifida
The contraindications for performing a SPGB are previous nasal trauma, deviated septum or local anaesthetic allergy.
For further information on how to perform a SPGB watch our video tutorial on youtube below. Remember you have to perform the block on both sides.
References
- Cohen S, Sakr A, Katyal S, Chopra D. Sphenopalatine ganglion block for postdural puncture headache. Anaesthesia. 2009 May 1;64(5):574-5
- Kent S, Mehaffey Transnasal sphenopalatine ganglion block for the treatment of postdural puncture headache in the ED. The American journal of emergency medicine. 2015 Nov 1;33(11):1714-e1
- Ho KW, Przkora R, Kumar S. Sphenopalatine ganglion: block, radiofrequency ablation and neurostimulation-a systematic review. The journal of headache and pain. 2017 Dec;18(1):118
- Láinez MJ, Puche M, Garcia A, Gascón Sphenopalatine ganglion stimulation for the treatment of cluster headache. Therapeutic advances in neurological disorders. 2014 May;7(3):162-8