American Journal of Emergency Medicine 33 (2015) 1714.e1–1714.e2
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Transnasal sphenopalatine ganglion block for the treatment of postdural puncture headache in the ED☆,☆☆ Abstract Postdural puncture headache (PDPH), also known as spinal headache, is a common complication associated with neuraxial anesthesia and diagnostic lumbar puncture. Autologous epidural blood patch is considered the definitive treatment for PDPH with efficacy greater than 75%; but it is an invasive procedure that carries the same risks as other epidural procedures, including dural puncture, infection, and neurologic complications [1–3]. Transnasal sphenopalatine ganglion block (SPGB) has been traditionally used to treat chronic conditions such as migraine, cluster headache, trigeminal neuralgia, and atypical facial pain [4], and has also been used with good results in a recent case series to treat acute PDPH headache in obstetric patients [5]. This low-risk, noninvasive technique was performed using 2% viscous lidocaine for the treatment of 3 PDPH cases in the emergency department, with promising results. In all 3 cases presented, the patients had significant improvement in pain following SPGB. By becoming familiar with this technique, emergency physicians could use the SPGB as a first-line therapy for PDPH. They could potentially decrease visit time and improve patient satisfaction without the need of an autologous epidural blood patch. However, this technique needs to be further studied in a larger population and versus placebo. Postdural puncture headache (PDPH) is a common complication associated with neuraxial anesthesia and diagnostic lumbar puncture (LP). The incidence of PDPH is inversely proportional to the gauge of the needle, ranging from less than 2% with a 29-gauge Quincke to 70% with a 16-gauge Tuohy [1]. Postdural puncture headache is thought to be due to a cerebrospinal fluid (CSF) leak that exceeds the rate of CSF production, thereby causing a downward traction of the meninges and reflex vasodilatation of the meningeal vessels that is mediated by the parasympathetic nervous system [1]. Autologous epidural blood patch (AEBP) is considered the definitive treatment for PDPH, with efficacy of up to 75% [1,2]. However, AEBP is an invasive procedure with risks of difficulty identifying the epidural space, inadvertent dural puncture, patient discomfort during the procedure, infection, and neurologic complications [3]. The sphenopalatine ganglion is an extracranial neural structure located in the pterygopalatine fossa that has both sympathetic and parasympathetic components as well as somatic sensory roots. It can be accessed through either a transcutaneous or transnasal approach. Sphenopalatine ganglion block (SPGB) has been used historically to
☆ Conflicts of interest: none ☆☆ Funding: none
0735-6757/© 2015 Elsevier Inc. All rights reserved.
treat migraine and cluster headache, trigeminal neuralgia, and atypical facial pain [4]. The transnasal approach is a low-risk, noninvasive technique that is easily performed and could potentially be beneficial in the treatment of PDPH through a supposed mechanism of blocking the parasympathetic flow to the cerebral vasculature through the sphenopalatine ganglion which would allow the cerebral vessels to return to normal diameter and thus relieve the headache [6]. The goal was to offer SPGB to PDPH patients in the emergency department (ED) who had presented following diagnostic LP. All patients were also offered AEBP and informed that it was the current definitive therapy. Patients who chose SPGB gave consent to be published in this report. The visual analog scale (VAS) was used to quantify pain level. While in the sitting position, VAS scores (0-10) were recorded preprocedure, immediately postprocedure, 24 hours postprocedure, and 48 hours postprocedure. If a patient received an AEBP, follow-up VAS assessments were terminated. All SPGBs were performed without any other treatement including, but not limited to, caffeine, intravenous fluid bolus, and narcotics. The SPGBs were performed with the patient supine with the shoulders slightly elevated to flex the neck and extend the head. Long cotton-tipped applicators were saturated with 2% viscous lidocaine and inserted into each nare until properly seated in the posterior nasopharynx. These were left in place for 10 minutes. The applicators were then removed, saturated with 2% viscous lidocaine, and placed in the same position for 20 more minutes. The patients were then positioned sitting, and VAS pain assessments were recorded. Upon completion of the SPGB, the patients were discharged with a short prescription of oral analgesics for any breakthrough pain. They were instructed to stay hydrated and to drink caffeinated beverages. They were told to go to the ED for AEBP or repeat SPGB if the headache were to return and were not tolerable. The patient was an 18-year-old woan with a history of migraine who had presented to the ED with headache of VAS 9/10. She was 4’11”, was 54 kg, and had no other significant medical history. She initially presented to an outside ED with a fever and worsening headache, and so an LP was performed to rule out meningitis. The results of the CSF studies were normal, and she was discharged. She returned to the ED 5 days later with a postural headache that she described as much different from her original headache, and her VAS score was 8/10 while sitting at that time. She consented for SPGB. Her immediate post-SPGB VAS score was 1/10 while sitting. On the 24-hour phone call follow-up, we learned that her headache had returned approximately 12 hours after the SPGB was completed. Her 24-hour VAS score was 4/10, although she denied any postural component to the headache at this point. Her 48-hour VAS score was 0/10. She did not require an AEBP. The patient was a 28-year-old woman who was 5’9”, 81 kg, with no significant medical history, who initially presented to the ED with
S. Kent, G. Mehaffey / American Journal of Emergency Medicine 33 (2015) 1714.e1–1714.e2
headache, neck pain, nausea, and vomiting. Lumbar puncture was performed to rule out meningitis; and the results of the CSF studies were normal, so she was discharged. She returned to the ED the next day with a postural headache and blurry vision. She was given intravenous caffeine, promethazine, and ondansetron and was discharged again. She then later returned to the ED with the same symptoms post-LP day 2, and anesthesiology was consulted. Her initial VAS score was 9/10 while sitting. She consented for SPGB. Her immediate post-SPGB VAS score was 4/10 while sitting. She was satisfied with the amount of relief and discharged home. On the 24-hour phone call follow-up, we learned that her headache had returned to 8/10 approximately 14 hours after the SPGB was performed. She then presented to an outside ED and elected to receive an AEBP. The patient had complete resolution of her headache following the AEBP. The patient was a 33-year-old woman with a history of pseudotumor cerebri. She was 5’3”, was 85 kg, and had no other significant medical history. She previously underwent LP for worsening of her baseline chronic headache to measure her opening pressure. Three days later, she presented to the our ED with a postural headache, different from her typical headaches. Initial VAS score was 9/10 while sitting. She consented for SPGB. Her immediate post-SPGB VAS score was 1/10 while sitting. She was discharged from the ED but returned the following morning complaining that her pain had returned after 11 hours of complete relief. Her VAS score was 5/10. She elected to receive an AEBP. The patient had complete resolution of her headache following the AEBP. This is the first case series that we are aware of in which SPGB has been offered for patients who have received diagnostic LPs and then presented to the ED with PDPH. Patient 1 had complete resolution of the postural component of her headache and did not require an AEBP. And although the other 2 patients in this small case series did return to the ED for AEBP, the fact that they experienced 11 to 14 hours of relief from their presenting headache is encouraging. This technique needs to be studied in a larger patient population and against a control to determine its true efficacy. One option to potentially increase the duration of headache relief would be to increase the lidocaine dose by using 4% or 5%, which has been used to perform SPGBs for PDPH in obstetric patients with success [5]. Another option would be to use a longer-acting local anesthetic, such as bupivacaine. When these blocks are used to treat chronic conditions such as migraine, cluster headache, trigeminal neuralgia, and atypical facial pain, patients are educated by their pain physician on how to perform this block at home [7]. That system could be used here, and the time to educate patients could be minimized by teaching the patient or their family members how to perform the block while the ED physician is performing the initial block. The patients could then receive an educational brochure with a description of how to perform the procedure and what to do if they experience a complication such as bleeding.
1714.e2
When comparing the risks of a transnasal SPGB, which include bleeding and temporary discomfort [4], against those of an AEBP, which are documented as dural puncture, neurologic complications, bleeding, and infection [8–10], it seems reasonable to offer the SPGB before AEBP. If emergency physicians were familiar with this technique, it could potentially be used as a first-line therapy. Once the diagnosis of PDPH is made, the SPGB could be performed immediately. The patient would not even need intravenous access placed. They could then be discharged with instructions to follow conservative therapy at home (hydration, caffeine intake) and given a prescription for nonsteroidal anti-inflammatory drugs (ketorolac, etc). These data would need to be studied in a larger population, but it seems logical to assume that using SPGB as first-line therapy could shorten ED visit time and therefore lower the cost to the health care system incurred from PDPH, as well as improve patient satisfaction by offering a less invasive procedure for treatment. Sheffield Kent, MD⁎ Greg Mehaffey, MD Department of Anesthesiology, University of Arkansas for Medical Sciences, UAMS Medical Center, 4301 West Markham St Little Rock, AR 72205 ⁎Corresponding author. Tel.: +1 870 759 1471 E-mail addresses: [email protected] (S. Kent) [email protected] (G. Mehaffey)
http://dx.doi.org/10.1016/j.ajem.2015.03.024 References [1] Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth 2003;91(5):718–29. [2] Safa-Tisseront, Valérie M.D.; Thormann, Françoise M.D.; Malassiné, Patrick M.D.; Henry, Michel M.D.; Riou, Bruno M.D., Ph.D.; Coriat, Pierre M.D.; Seebacher, Jeanne M.D. Effectiveness of epidural blood patch in the management of post-dural puncture headache. Anesthesiology 2001; 95 (2): 334–339 [3] Paech M. Epidural blood patch-myths and legends. Can J Anaesth 2005;52:R1–5. [4] Day M. Sphenopalatine ganglion analgesia. Curr Rev Pain 1999;3(5):342–7. [5] Cohen S, Sakr A, Katyal S, Chopra D. Sphenopalatine ganglion block for postdural puncture headache. Anaesthesia 2009;64:570–9. [6] Edvinsson L. Innervations and effects of dilatory neruopeptides on cerebral vessels. Blood Vessels 1991;28:35–45. [7] Peterson JN, Schames J, Schames M, King E. Sphenopalatine ganglion block: a safe and easy method for the management of orofacial pain. Cranio 1995;13(3):177–81. [8] Davies JM, Murphy A, Smith M, O’Sullivan G. Subdural hematoma after dural puncture headache treated by epidural blood patch. Br J Anaesth 2001;86:720–3. [9] Mehta SP, Keogh BP, Lam AM. An epidural blood patch causing acute neurologic dysfunction necessitating a decompressive laminectomy. Reg Anesth Pain Med 2014; 39:78–80. [10] Tekkok IH, Carter DA, Brinker R. Spinal subdural haematoma as a complication of immediate epidural blood patch. Can J Anaesth 1996;43:306–9.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Transnasal sphenopalatine ganglion block for the treatment of postdural puncture headache in the ED☆,☆☆ Abstract Postdural puncture headache (PDPH), also known as spinal headache, is a common complication associated with neuraxial anesthesia and diagnostic lumbar puncture. Autologous epidural blood patch is considered the definitive treatment for PDPH with efficacy greater than 75%; but it is an invasive procedure that carries the same risks as other epidural procedures, including dural puncture, infection, and neurologic complications [1–3]. Transnasal sphenopalatine ganglion block (SPGB) has been traditionally used to treat chronic conditions such as migraine, cluster headache, trigeminal neuralgia, and atypical facial pain [4], and has also been used with good results in a recent case series to treat acute PDPH headache in obstetric patients [5]. This low-risk, noninvasive technique was performed using 2% viscous lidocaine for the treatment of 3 PDPH cases in the emergency department, with promising results. In all 3 cases presented, the patients had significant improvement in pain following SPGB. By becoming familiar with this technique, emergency physicians could use the SPGB as a first-line therapy for PDPH. They could potentially decrease visit time and improve patient satisfaction without the need of an autologous epidural blood patch. However, this technique needs to be further studied in a larger population and versus placebo. Postdural puncture headache (PDPH) is a common complication associated with neuraxial anesthesia and diagnostic lumbar puncture (LP). The incidence of PDPH is inversely proportional to the gauge of the needle, ranging from less than 2% with a 29-gauge Quincke to 70% with a 16-gauge Tuohy [1]. Postdural puncture headache is thought to be due to a cerebrospinal fluid (CSF) leak that exceeds the rate of CSF production, thereby causing a downward traction of the meninges and reflex vasodilatation of the meningeal vessels that is mediated by the parasympathetic nervous system [1]. Autologous epidural blood patch (AEBP) is considered the definitive treatment for PDPH, with efficacy of up to 75% [1,2]. However, AEBP is an invasive procedure with risks of difficulty identifying the epidural space, inadvertent dural puncture, patient discomfort during the procedure, infection, and neurologic complications [3]. The sphenopalatine ganglion is an extracranial neural structure located in the pterygopalatine fossa that has both sympathetic and parasympathetic components as well as somatic sensory roots. It can be accessed through either a transcutaneous or transnasal approach. Sphenopalatine ganglion block (SPGB) has been used historically to
☆ Conflicts of interest: none ☆☆ Funding: none
0735-6757/© 2015 Elsevier Inc. All rights reserved.
treat migraine and cluster headache, trigeminal neuralgia, and atypical facial pain [4]. The transnasal approach is a low-risk, noninvasive technique that is easily performed and could potentially be beneficial in the treatment of PDPH through a supposed mechanism of blocking the parasympathetic flow to the cerebral vasculature through the sphenopalatine ganglion which would allow the cerebral vessels to return to normal diameter and thus relieve the headache [6]. The goal was to offer SPGB to PDPH patients in the emergency department (ED) who had presented following diagnostic LP. All patients were also offered AEBP and informed that it was the current definitive therapy. Patients who chose SPGB gave consent to be published in this report. The visual analog scale (VAS) was used to quantify pain level. While in the sitting position, VAS scores (0-10) were recorded preprocedure, immediately postprocedure, 24 hours postprocedure, and 48 hours postprocedure. If a patient received an AEBP, follow-up VAS assessments were terminated. All SPGBs were performed without any other treatement including, but not limited to, caffeine, intravenous fluid bolus, and narcotics. The SPGBs were performed with the patient supine with the shoulders slightly elevated to flex the neck and extend the head. Long cotton-tipped applicators were saturated with 2% viscous lidocaine and inserted into each nare until properly seated in the posterior nasopharynx. These were left in place for 10 minutes. The applicators were then removed, saturated with 2% viscous lidocaine, and placed in the same position for 20 more minutes. The patients were then positioned sitting, and VAS pain assessments were recorded. Upon completion of the SPGB, the patients were discharged with a short prescription of oral analgesics for any breakthrough pain. They were instructed to stay hydrated and to drink caffeinated beverages. They were told to go to the ED for AEBP or repeat SPGB if the headache were to return and were not tolerable. The patient was an 18-year-old woan with a history of migraine who had presented to the ED with headache of VAS 9/10. She was 4’11”, was 54 kg, and had no other significant medical history. She initially presented to an outside ED with a fever and worsening headache, and so an LP was performed to rule out meningitis. The results of the CSF studies were normal, and she was discharged. She returned to the ED 5 days later with a postural headache that she described as much different from her original headache, and her VAS score was 8/10 while sitting at that time. She consented for SPGB. Her immediate post-SPGB VAS score was 1/10 while sitting. On the 24-hour phone call follow-up, we learned that her headache had returned approximately 12 hours after the SPGB was completed. Her 24-hour VAS score was 4/10, although she denied any postural component to the headache at this point. Her 48-hour VAS score was 0/10. She did not require an AEBP. The patient was a 28-year-old woman who was 5’9”, 81 kg, with no significant medical history, who initially presented to the ED with
S. Kent, G. Mehaffey / American Journal of Emergency Medicine 33 (2015) 1714.e1–1714.e2
headache, neck pain, nausea, and vomiting. Lumbar puncture was performed to rule out meningitis; and the results of the CSF studies were normal, so she was discharged. She returned to the ED the next day with a postural headache and blurry vision. She was given intravenous caffeine, promethazine, and ondansetron and was discharged again. She then later returned to the ED with the same symptoms post-LP day 2, and anesthesiology was consulted. Her initial VAS score was 9/10 while sitting. She consented for SPGB. Her immediate post-SPGB VAS score was 4/10 while sitting. She was satisfied with the amount of relief and discharged home. On the 24-hour phone call follow-up, we learned that her headache had returned to 8/10 approximately 14 hours after the SPGB was performed. She then presented to an outside ED and elected to receive an AEBP. The patient had complete resolution of her headache following the AEBP. The patient was a 33-year-old woman with a history of pseudotumor cerebri. She was 5’3”, was 85 kg, and had no other significant medical history. She previously underwent LP for worsening of her baseline chronic headache to measure her opening pressure. Three days later, she presented to the our ED with a postural headache, different from her typical headaches. Initial VAS score was 9/10 while sitting. She consented for SPGB. Her immediate post-SPGB VAS score was 1/10 while sitting. She was discharged from the ED but returned the following morning complaining that her pain had returned after 11 hours of complete relief. Her VAS score was 5/10. She elected to receive an AEBP. The patient had complete resolution of her headache following the AEBP. This is the first case series that we are aware of in which SPGB has been offered for patients who have received diagnostic LPs and then presented to the ED with PDPH. Patient 1 had complete resolution of the postural component of her headache and did not require an AEBP. And although the other 2 patients in this small case series did return to the ED for AEBP, the fact that they experienced 11 to 14 hours of relief from their presenting headache is encouraging. This technique needs to be studied in a larger patient population and against a control to determine its true efficacy. One option to potentially increase the duration of headache relief would be to increase the lidocaine dose by using 4% or 5%, which has been used to perform SPGBs for PDPH in obstetric patients with success [5]. Another option would be to use a longer-acting local anesthetic, such as bupivacaine. When these blocks are used to treat chronic conditions such as migraine, cluster headache, trigeminal neuralgia, and atypical facial pain, patients are educated by their pain physician on how to perform this block at home [7]. That system could be used here, and the time to educate patients could be minimized by teaching the patient or their family members how to perform the block while the ED physician is performing the initial block. The patients could then receive an educational brochure with a description of how to perform the procedure and what to do if they experience a complication such as bleeding.
1714.e2
When comparing the risks of a transnasal SPGB, which include bleeding and temporary discomfort [4], against those of an AEBP, which are documented as dural puncture, neurologic complications, bleeding, and infection [8–10], it seems reasonable to offer the SPGB before AEBP. If emergency physicians were familiar with this technique, it could potentially be used as a first-line therapy. Once the diagnosis of PDPH is made, the SPGB could be performed immediately. The patient would not even need intravenous access placed. They could then be discharged with instructions to follow conservative therapy at home (hydration, caffeine intake) and given a prescription for nonsteroidal anti-inflammatory drugs (ketorolac, etc). These data would need to be studied in a larger population, but it seems logical to assume that using SPGB as first-line therapy could shorten ED visit time and therefore lower the cost to the health care system incurred from PDPH, as well as improve patient satisfaction by offering a less invasive procedure for treatment. Sheffield Kent, MD⁎ Greg Mehaffey, MD Department of Anesthesiology, University of Arkansas for Medical Sciences, UAMS Medical Center, 4301 West Markham St Little Rock, AR 72205 ⁎Corresponding author. Tel.: +1 870 759 1471 E-mail addresses: [email protected] (S. Kent) [email protected] (G. Mehaffey)
http://dx.doi.org/10.1016/j.ajem.2015.03.024 References [1] Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth 2003;91(5):718–29. [2] Safa-Tisseront, Valérie M.D.; Thormann, Françoise M.D.; Malassiné, Patrick M.D.; Henry, Michel M.D.; Riou, Bruno M.D., Ph.D.; Coriat, Pierre M.D.; Seebacher, Jeanne M.D. Effectiveness of epidural blood patch in the management of post-dural puncture headache. Anesthesiology 2001; 95 (2): 334–339 [3] Paech M. Epidural blood patch-myths and legends. Can J Anaesth 2005;52:R1–5. [4] Day M. Sphenopalatine ganglion analgesia. Curr Rev Pain 1999;3(5):342–7. [5] Cohen S, Sakr A, Katyal S, Chopra D. Sphenopalatine ganglion block for postdural puncture headache. Anaesthesia 2009;64:570–9. [6] Edvinsson L. Innervations and effects of dilatory neruopeptides on cerebral vessels. Blood Vessels 1991;28:35–45. [7] Peterson JN, Schames J, Schames M, King E. Sphenopalatine ganglion block: a safe and easy method for the management of orofacial pain. Cranio 1995;13(3):177–81. [8] Davies JM, Murphy A, Smith M, O’Sullivan G. Subdural hematoma after dural puncture headache treated by epidural blood patch. Br J Anaesth 2001;86:720–3. [9] Mehta SP, Keogh BP, Lam AM. An epidural blood patch causing acute neurologic dysfunction necessitating a decompressive laminectomy. Reg Anesth Pain Med 2014; 39:78–80. [10] Tekkok IH, Carter DA, Brinker R. Spinal subdural haematoma as a complication of immediate epidural blood patch. Can J Anaesth 1996;43:306–9.
