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ORIGINAL ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 1  |  Page : 45-51

The efficacy of sphenopalatine ganglion block for the treatment of postdural puncture headache among obstetric population


1 Department of Anaesthesia, College of Medicine, Majmaah University, Al Majma'ah 11952, Saudi Arabia
2 Department of Anaesthesia, King Saud University, Riyadh, Saudi Arabia

Correspondence Address:
Faris I Alwarhi
Department of Anaesthesia, King Saud University, P.O Box 145111, Riyadh 4545
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.sja_651_21

Rights and Permissions
Date of Submission07-Sep-2021
Date of Decision13-Sep-2021
Date of Acceptance26-Sep-2021
Date of Web Publication04-Jan-2022
 

  Abstract 


Background: Postdural puncture headache (PDPH) is a common complication among parturients who had undergone obstetric neuraxial block. Epidural blood patch is the current gold standard treatment for PDPH, although it is an invasive procedure. We conducted this systematic review to assess the efficacy of sphenopalatine ganglion block (SPGB) as a noninvasive treatment of PDPH.
Methods: Relevant reports were searched from Google Scholar, PubMed, Science Direct, and Scopus from the inception of the databases to November 30, 2020. A total of 10 reports found to be related to SPGB for the treatment of PDPH in the obstetric population were enrolled. Significant relief of headache with no further intervention and initial relief of headache that requires further interventions were considered as the primary outcomes. The secondary outcome was the complications after SPGB.
Results: A total of 68 patients were identified. We found that 41 of 68 patients (60.3%) had effective management with significant relief of headache with no further interventions needed. Moreover, a total of 27 of 68 patients (39.7%) had initially effective management that needed further interventions. The use of 2% lidocaine was found to be the most effective among all used local anesthetics with 85.7% effective management. Furthermore, parturients who developed PDPH after spinal anesthesia responded to SPGB better than other obstetric neuraxial techniques.
Conclusions: This systematic review showed that SPGB is a promising treatment modality for the management of PDPH with no reported complications. Before recommending this technique for treating PDPH, we are calling for randomized clinical trials to prove its efficacy.

Keywords: Dural puncture, lidocaine, obstetric population, postdural puncture headache, sphenopalatine ganglion block


How to cite this article:
Albaqami MS, Alwarhi FI, Alqarni AA. The efficacy of sphenopalatine ganglion block for the treatment of postdural puncture headache among obstetric population. Saudi J Anaesth 2022;16:45-51

How to cite this URL:
Albaqami MS, Alwarhi FI, Alqarni AA. The efficacy of sphenopalatine ganglion block for the treatment of postdural puncture headache among obstetric population. Saudi J Anaesth [serial online] 2022 [cited 2022 Jan 19];16:45-51. Available from: https://www.saudija.org/text.asp?2022/16/1/45/334770




  Introduction Top


According to the International Headache Society, PDPH is described as headache occurring within 5 days of a lumbar puncture, caused by cerebrospinal fluid leakage through the dural puncture. It is usually accompanied by neck stiffness and/or subjective hearing symptoms. It remits spontaneously within 2 weeks, or after sealing of the leak with autologous epidural lumbar patch.[1] Occasionally, it is accompanied by serious morbidities, such as neuraxial nerve damage, subdural hematoma, or chronic headache and it could lead to death as reported in the literature.[2],[3] It is a major complication especially in the obstetric population as it can affect the mother's care for the baby and increase the length of hospital stay.[4] Accidental dural puncture (ADP) in the obstetrical population who underwent epidural anesthesia ranges from 0.5% to1.5%, nearly half of those from 52% to 61% will develop PDPH in 72 h.[5],[6] The incidence of PDPH among parturient women who had ADP is reported to be reduced by increased BMI. A previous study among 518 parturient women revealed that parturients with BMI ≥31.5 kg/m had a lower incidence of PDPH than parturients with a BMI <31.5 kg/m.[7] Adversely, a retrospective study among 125 parturient women with ADP, reported no evidence that parturients with higher BMI are less likely to develop PDPH.[8]

Supportive measures such as oral analgesics, hydration, and anti-emetics have been shown to control PDPH symptoms in mild cases.[9] Epidural blood patch (EBP) is the standard treatment for PDPH in patients who fail to improve after conservative treatment although it is an invasive procedure.[5] EBP shows a success rate of 95–98% in complete or partial relief of PDPH.[9],[10] However, a high risk of developing long-term low back pain was reported in a large observational study among obstetric population undergone EBP by Martínez et al.[11] Other complications like acute paresthesia, transient temperature elevations, spinal subdural hematoma, intrathecal hematoma, and arachnoiditis were also reported.[12] EBP possesses many contraindications including coagulopathy, local infection in the back, and fever.[13] The transnasal approach for sphenopalatine ganglion block (SPGB) on the other hand, is considered a noninvasive and easy procedure. Trigeminal neuralgia, migraine and cluster headaches, sciatica, angina, arthritis, and atypical facial pain all are cases in which SPGB is used as a treatment in different approaches with varying success rates.[14] SPGB was first described in 1909 by Sluder with the use of cocaine injection in treating what was called Sluder's neuralgia, which mostly resembles cluster headache.[15],[16]

The aim of this systematic review was to assess the efficacy of SPGB in the treatment of PDPH among the obstetric population.


  Methods Top


Information sources and search strategy

Relevant reports were searched from Google Scholar, PubMed, Science Direct, and Scopus from the inception of the databases to November 30, 2020. Search words were as follows: “Sphenopalatine AND “Postdural puncture headache” and “Sphenopalatine AND PDPH” with adding obstetric, postpartum, and cesarean section with each of previous keywords. We also screened all the citing and related articles. Editorials, review articles, and all studies that were related to other types of headaches, pain medicine, or PDPH in the nonobstetric population were excluded.

Eligibility criteria and study selection

We collected 18 results from different study reports were as follows: case reports, case series, original articles, posters, and shared experiences all were screened, identified through different search engines, and found to be related to SPGB for treatment of PDPH in the obstetric population. Eight reports were excluded and those were as follows: one randomized controlled trial (RCT) because of inclusion of mixed population without a clear enrolment of any obstetric patient in their sample, one retrospective study because of mixed management, one article because of the mixed population without detailed information, and two posters and three shared experiences because of more recent enrolment in other included study.[17],[18],[19],[20],[21],[22],[23],[24],[25] We are aware that a systematic review is performed on RCTs. However, we could find only one prospective observational study that was included in this systematic review. Therefore, and because of the importance of this technique to manage PDPH, we included case reports and case series. A total of 10 studies found to be suitable to our objectives were included. Eight case reports and case series.[26],[27],[28],[29],[30],[31],[32],[33] One retrospective observational study with a sample size of 81 patients in which 42 of them (51%) underwent SPGB.[25] One prospective observational study with a sample size of 20 patients in which 10 of them (50%) underwent SPGB and one patient was lost to be followed up.[34] The flow diagram of the study selection is shown in [Figure 1].
Figure 1: Flowchart of the included reports

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Data collection process and items

All data from the included reports were checked to prevent duplication. Study characteristics were as follows: indication of obstetric procedures, PDPH onset time, type of neuraxial block, pain assessment before and after SPGB, initial management of PDPH including conservative management and EBP, and SPGB technique. Significant headache relief with no further intervention and initial headache relief that required further intervention was considered as the primary outcomes. The secondary outcome included complications after SPGB.

Quality assessment in individual studies

The assessment of the severity of pain in the majority of the reports was performed either by numerical rating scale or by visual analog scale (VAS). All enrolled studies clearly defined the used agent and technique to apply SPGB. The complications after SPGB were recorded for all the enrolled reports. In this systematic review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist protocol.


  Results Top


A total of 68 patients were included in this systematic review. Seventeen patients were included from case reports and case series, 42 patients included from a retrospective observational study, and 9 patients included from a prospective observational study.[25],[26],[27],[28],[29],[30],[31],[32],[33],[34] All enrolled patients were diagnosed with PDPH after obstetric neuraxial block. Fifty-two of enrolled patients underwent an epidural insertion for labor analgesia, two of them had an emergency cesarean section (CS). Fourteen of the enrolled patients received spinal anesthesia for either elective or emergency CS. Two of the enrolled patients underwent combined spinal-epidural for urgent CS and labor analgesia. Transnasal SPGB was applied to all patients. Sixty-six patients received a cotton-tipped applicator with different local anesthetics (LAs). These LAs include 2% lidocaine (n = 14), 4% lidocaine (n = 46), 0.75% ropivacaine (N = 5), and mixture of 2% lidocaine and 0.5% ropivacaine (n = 1). Two patients received 10% lidocaine spray, one of them had a nostril pack with gauze soaked with 4% lidocaine after the spray. Characteristics of all studies enrolled are presented in [Table 1]. Detailed data of case reports/series are shown in [Table 2].
Table 1: Characteristics of enrolled case reports, posters, and original articles

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Table 2: Detailed data of case reports/series

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We investigated all enrolled patients to determine the efficacy of SPGB for the treatment of PDPH. In this systematic review, the efficacy of SPGB was assessed based on our determined primary outcomes which they were: significant headache relief with no further intervention and initial relief of headache that required further intervention. Any reported SPGB that provides relief of headache that does not need further EBP or second SPGB is considered as significant relief of headache and will be labeled as effective management. However, some patients initially responded to SPGB and had initial relief of headache after the procedure but they developed PDPH symptoms that needed either EBP or second SPGB, these blocks will be labeled as initially effective management. Taking into consideration that any administered fluids or medications to patients before or after SPGB will not be considered as an intervention, due to missing data about conservative treatment in most of the enrolled patients.

We found that 41 of 68 patients (60.3%) had effective management with significant relief of headache that does not need further interventions. A total of 27 of 68 patients (39.7%) had initially effective management of PDPH that needed further interventions which were as the following: 10 patients received an EBP, 8 patients received second time SPGB, and 9 patients received both second time SPGB and EBP. Different types of LAs were used for SPGB as mentioned before. The use of 2% lidocaine was among 14 of enrolled patients (22%), was found to be the most effective among all used LAs with 85.7% effective management. 4% lidocaine was found to be the most frequently used LAs, it was used in 46 of enrolled patients (67.6%), and showed 54.3% effective management. Other LAs includes 0.75% ropivacaine (n = 5) with 40% effective management, mixture of 2% lidocaine and 0.5% ropivacaine (n = 1) with 100% effective management, and 10% lidocaine spray (n = 2) with 50% effective management.


  Discussion Top


In this study, we demonstrated that transnasal SPGB was an effective and safe procedure for treating PDPH after obstetric neuraxial block with significant relief of headache. Moreover, the use of 2% lidocaine resulted in higher efficacy than other used LAs, although it was mainly used in patients who developed PDPH secondary to spinal anesthesia. Although the use of 4% lidocaine was less effective than 2% lidocaine, that is likely because it was mainly used in patients who developed PDPH secondary to epidural analgesia. No complications were reported in all enrolled patients apart from the failure of the technique. In addition, worth noting that parturients who developed PDPH after spinal anesthesia responded to SPGB better than other obstetric neuraxial techniques.

EBP is the current gold standard treatment of PDPH and has widely been used in obstetric anesthesia, although it is an invasive procedure. However, the use of SPGB as a simple, noninvasive treatment of PDPH is limited and recently tried by Cohen et al.[25] SPGB is a cost-effective treatment and can be done as an outpatient procedure without the need for imaging or a theater room. As reported previously by Cohen et al.,[25] SPGB showed faster relief of headache in 30 and 60 min compared with EBP; however, they were similar in effectiveness after 24, 48 h, and 1-week post-treatment. The current study reported promising results with 60.3% success rate from the first SPGB. Moreover, the success rate has improved following the second SPGB.

The limitations of this study included: (1) small sample size, (2) 17 of 68 patients were from case reports and case series which they are more prone to be biased results than other study designs, and (3) there was no previous RCT on the efficacy of SPGB for the treatment of PDPH specifically among the obstetric population to be included in this study.

In conclusion, SPGB is a promising treatment modality for the management of PDPH among the obstetric population. However, before routine clinical application, well-designed RCTs are required to confirm and validate their efficacy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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