The sphenopalatine ganglion block as a treatment for post-dural puncture headache in the post-partum patient: a case report
Abstract Number: S2D-1
Abstract Type: Case Report/Case Series
Introduction: Post-dural puncture headache (PDPH) is a major cause of morbidity in postpartum patients who received neuraxial anesthesia for labor analgesia. The headache is thought to be due to loss of cerebrospinal fluid causing downward traction on the meninges with parasympathetically mediated reflex vasodilation of the meningeal vessels. (1) While the epidural blood patch (EBP) is the gold-standard treatment for PDPH, it is not without risk and the time from diagnosis to procedure may be prolonged due to scheduling or staffing issues.
The sphenopalatine ganglion (SPG) is a parasympathetic ganglion located in the pterygopalatine fossa which can be topically accessed trans-nasally. The proposed mechanism of the SPG block is parasympathetic blockade preventing the profound vasodilation associated with PDPH, providing symptomatic relief. (2) We describe the case of a patient with a severe PDPH unresponsive to conservative management and our use of the SPG block as a pain relieving measure until definitive treatment with and EBP could be scheduled.
Case: A 29 y/o G1P0 at 38/5 weeks gestation presented for an induction of labor due to gestational hypertension. A labor epidural was placed, which was complicated by a dural puncture. On post-partum day (PPD) 1, the patient reported symptoms consistent with a PDPH, which were severe despite conservative management with fluids, an abdominal binder, and acetaminophen, butalbital and caffeine tablets. At approximately 23:15 on PPD1, anesthesia was called to evaluate the patient for an EBP. Due to anesthesia staff and nursing availability on a busy overnight shift, it was not possible to schedule the EBP until the morning. In order to treat her headache, an SPG block was performed using cotton tipped applicators soaked in 4% viscous lidocaine. Prior to the SPG block she rated her headache as a 10/10. Immediately following the SBG block, she rated her headache as a 0/10 and was able to sleep. On nursing evaluation four hours after the block, she rated her headache as a 3/10 but did not require any medication and was able to sleep for the rest of the night. Her headache returned the following morning at which point she received an EBP with complete resolution of her headache.
Discussion: The SPG block is a relatively noninvasive procedure that has been used as a treatment for migraines and cluster headaches. Little is known about the utility of the SPG block as a treatment for PDPH. This case demonstrates that while the SPG block may not replace the EBP as the gold standard treatment for PDPH, it may play a role as a temporizing measure for patients prior to getting an EBP. The SPG block may also be an appropriate treatment for patients who do not wish to take oral medications, or who want to try a less invasive option prior to an EBP.
1. Kent et. al. J Clin Anesth 2016;34:194-6.
2. Nair et. al. The Korean J Pain, vol. 30, no. 2, 2017, 93.