PR2-168
Transnasal Sphenopalatine Ganglion Block as an Alternative Treatment for Post-dural Puncture Headache in an Adolescent
Zatochill M, Soneru C, Falcon R, Petersen T
University of New Mexico, Albuquerque, NM, USA
INTRODUCTION: An epidural blood patch (EBP) is typically considered the gold standard for treatment of post-dural puncture headache (PDPH) after a trial of conservative therapy has failed. Sphenopalatine ganglion (SPG) block has been known as a therapy for acute and chronic facial/head pain for over 100 years. More recently, there have been small case series in the adult literature that have shown similar efficacy comparing SPG block to an EBP for PDPH. However, there are no published reports of SPG block for PDPH in children. We present a successful transnasal SPG nerve block to treat PDPH with procedure modifications for a pediatric patient.
CASE REPORT: The Pediatric Acute Pain Service was consulted to do a repeat epidural blood patch for a 45kg 12-year-old boy who was experiencing refractory PDPH after a diagnostic and therapeutic lumbar puncture. An epidural blood patch two days prior had relieved the pain for about five hours. After assessment of the patient and discussion of the adult literature regarding SPG block, it was decided to attempt a transnasal sphenopalatine ganglion block instead of EBP.
The transnasal SPG block was performed in the operating room under sedation with a native airway. Both nasal passages were topicalized with lidocaine 2% gel, then cotton-tipped applicators soaked in 4% lidocaine were inserted parallel to the floor of each nasal cavity until resistance was met at the posterior wall of the nasopharynx. The patient required 10-20mg boluses of propofol to tolerate insertion of the applicator sticks without significant movement. Additional 4% lidocaine was dripped down the shaft of each applicator stick and they were left in place for 40 minutes. They were then removed and the sedation discontinued. The patient reported resolution of his headache symptoms with no recurrence throughout follow-up five days later.
DISCUSSION: While EBP is considered the gold standard for treatment of PDPH, it is an invasive procedure with associated side effects including possibility of repeat dural puncture, infection, neurologic complications, and neuraxial seeding of malignancy. SPG block has shown promise in the adult and obstetric populations as a minimally invasive procedure to treat PDPH. With further research, SPG block may be something we can offer to treat PDPH in pediatric patients as well.
REFERNCES:
Gaiser R, Postdural Puncture Headache: An Evidence-Based Approach. Anesthesiology clinics 2017 Mar; 35(1): 157-167
Sakr A, Rah K, Cohen S, et al Can we offer sphenopalatine ganglion block for our obstetric patients following accidental dural puncture? Paper presented at American Society of Regional Anesthesia and Pain Medicine 12th Annual Pain Medicine Meeting, November 21–24, 2013
Sluder G. The anatomical and clinical relations of the sphenopalatine ganglion block to the nose. New York State Journal of Medicine 1909; 90: 293–8
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