Comparative evaluation of conservative management and sphenopalatine ganglion block for postdural puncture headache: A randomized controlled trial

Raman Kumar; Vinod Kumar Verma; Swati; Chandrakant Prasad

doi:10.4103/BJOA.BJOA_127_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 4 | Issue : 4 | Page : 183-187

Comparative evaluation of conservative management and sphenopalatine ganglion block for postdural puncture headache: A randomized controlled trial

Raman Kumar¹, Vinod Kumar Verma², Swati², Chandrakant Prasad³
¹ Department of Anesthesia and Critical Care, All India Institute of Medical Sciences, New Delhi, India
² Department of Anesthesia and Critical Care, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
³ Department of Neuro-Anesthesia and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Submission	02-Jul-2020
Date of Decision	16-Aug-2020
Date of Acceptance	19-Aug-2020
Date of Web Publication	16-Sep-2020

Correspondence Address:
Dr. Chandrakant Prasad
Department of Neuro-Anaesthesia and Critical Care, All India Institute of Medical Sciences, 33/7, Gautam Nagar, New Delhi - 110 049
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/BJOA.BJOA_127_20

Abstract

Background: Postdural puncture headache (PDPH) is a well-known iatrogenic and distressing complication of a subarachnoid block. In this study, we aimed to see if the sphenopalatine ganglion block (SPGB) is beneficial for the treatment of PDPH in comparison to conservative management or not. Patients and Methods: This prospective, randomized, observational study registered in the Clinical Trials Registry of India (CTRI/2018/02/011883). We included 60 patients, divided into three groups of 20 each. Group C patients were managed conservatively. Group L4 patients were given SPGB with 4% lignocaine per SPGB. Group L10 patients were given SPGB with lignocaine 10% puffs. The patients were assessed at predefined durations for Visual Analog Scale (VAS) score, readiness to discharge, and feel-good index. SPSS 20.0 software was used for data analysis. Results: There was a statistically significant reduction in VAS score and mean treatment duration in group L4 and group L10 in comparison to group C. At 72 h of treatment, 5.26% of Group C patients, 88.89% of Group L4, and 95% of Group L10 patients were found ready to discharge. The feel-good index was assessed after 15 min of treatment was found best in Group L10, followed by L4 and C groups. Conclusion: SPGB increases the proportion of patients ready to discharge at 72 h of treatment. Lignocaine 10% is more effective than lignocaine 4% solution for SPGB. SPGB decreases the hospital stay, hence cost-effective.

Keywords: Conservative management, pain, postdural puncture headache, sphenopalatine ganglion block

How to cite this article:
Kumar R, Verma VK, Swati, Prasad C. Comparative evaluation of conservative management and sphenopalatine ganglion block for postdural puncture headache: A randomized controlled trial. Bali J Anaesthesiol 2020;4:183-7

How to cite this URL:
Kumar R, Verma VK, Swati, Prasad C. Comparative evaluation of conservative management and sphenopalatine ganglion block for postdural puncture headache: A randomized controlled trial. Bali J Anaesthesiol [serial online] 2020 [cited 2023 Mar 23];4:183-7. Available from: https://www.bjoaonline.com/text.asp?2020/4/4/183/299872

Introduction

Subarachnoid block (SAB) is one of the most typical techniques used in anesthetic practice for obstetric patients, patients undergoing lower abdominal or lower limb surgery. Postdural puncture headache (PDPH) is a well-known iatrogenic and distressing complication of SAB.^[1] The International Classification of Headache Disorders defines PDPH as headache occurring within 5 days after SAB and being aggravated when standing or sitting and relieved when lying flat.^[2]

The incidence and severity of PDPH are influenced by types and bores of the needle, number of attempts, and increasing in obstetric patients.^[3] The incidence of PDPH performed with Quincke is 36% with 22G needle, 25% with 25G needle, 2%–12% with 26G needle, and <2% for smaller than 26G needle.^{[4],[5],[6],[7],[8]} Spinal needles generally used today are 22–27G, but sizes ranging from 19G to 30G are available.^[9] The incidence of PDPH ranges from 0.16% to 1.3% in experienced hands.^[10]

PDPH increases not only the misery of patients but also the length of stay and overall cost of treatment in the hospital. It is thought to be due to a cerebrospinal fluid (CSF) leak that exceeds the rate of CSF production, decreasing intracranial pressure. This causes downward traction of meninges and reflex vasodilatation of the meningeal vessels, which is mediated by the parasympathetic nervous system.^{[9],[10],[11]} In the majority of cases, treatment is symptomatic (conservative), but relief may take up to 7–10 days.

Autologous epidural blood patch (AEBP) is considered the definitive treatment for PDPH, but it is invasive and has risks such as inadvertent dural puncture, difficulty in identifying epidural space, infection, and neurological complications.^[12],[13] The sphenopalatine ganglion has both sympathetic and parasympathetic components as well as somatic sensory roots.^[14] Sphenopalatine ganglion block (SPGB) has been used earlier to treat migraine, cluster headache, and atypical facial pain.^[15] This study compared two different techniques of SPGB (transnasal application of lignocaine 4% 1.5 ml through a cotton-tipped applicator and lignocaine 10% spray in both nostrils) for PDPH with its conservative management.

Patients and Methods

This prospective, randomized, observational study was conducted at Indira Gandhi Institute of Medical Sciences, India, after approval from the Institutional Ethics Committee and registration with the Clinical Trials Registry of India (CTRI/2018/02/011883 dated February 13, 2018). Written informed consent was obtained from all patients. We included 60 patients of American Society of Anesthesiologists Grades I and II, aged between 18 and 60 years, undergoing SAB for various surgeries who developed postoperative PDPH. They were divided into three groups, consisting of 20 in each by computer-generated randomization method [Figure 1].

Figure 1: CONSORT flow diagram

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Group C (control) was managed conservatively. They were given oral paracetamol 325 mg and tramadol 37.5 mg twice daily, caffeine 300–500 mg/day, and advised to increase fluid intake and bed rest.

Participants in Group L4 were given xylometazoline nasal drops, and after that, a cotton-tipped plastic hollow applicator was inserted in the nose with the swab soaked in 1.5 ml 4% lignocaine. The applicator was inserted parallel to the floor of the nose until resistance encountered. The swab rested in the pterygopalatine fossa superior to the middle turbinate and was removed after 10 min. This procedure was repeated in another nostril too.

For participants in Group L10, after optimization with xylometazoline nasal drops, they were asked to take a deep breath, hold it, and exhale when signaled to do so. As the participant took a full breath, at the height of inspiration, two puffs of lignocaine 10% were administered into one nostril aimed slightly medially and inferiorly. They were advised to keep their eyes closed during spray administration. The patient was signaled to exhale after a few seconds. After the patient conditions settled down, the same process was repeated in another nostril too.

The patients in treatment groups L4 and L10 were asked to remain supine, keeping head extended facilitated with a pillow below shoulders for 30 min, after which they were allowed to sit up gradually.

To maintain uniformity and to decrease the risk of PDPH, all patients were given SAB with a 26G Quincke type spinal needle, and the SAB procedure was carried out by a senior anesthesiologist to avoid multiple attempts.

PDPH was diagnosed on clinical grounds associated with bilateral frontal or occipital headache that was typically postural, aggravated on sitting or upright posture, and relieved on lying down. Anterior rhinoscopy was performed to rule out any nasal pathology such as ulcer, sore, and polyp. The pain score was noted based on the Visual Analog Scale (VAS). Then, the treatment was given according to the allocated group.

Patients of all groups were assessed after 15 min, 30 min, 1 h, 2 h, and then, every 24 h until discharge. Any patient who complained of not being relieved of pain (i.e., VAS score not improving) at 1 h after the treatment received had the respective treatment repeated. If the pain was still not relieved, the participant was marked as a failure, and we continued the treatment as per standard institute protocol. When the VAS score reached ≤3, the intervention was discontinued. They were discharged when having minimal symptoms and were followed up by telephone to 7 days to report the pain score.

After 15 min of the first intervention in all treatment groups, the patient was asked: “How do you feel?” They had to reply in either very good, good, poor, or very poor. This was termed as the “feel-good index.” After 72 h, the patients were assessed for the VAS score. Patients with VAS score ≤3 were considered ready to be discharged, which was termed as “readiness to discharge.” Observers and analysts were blinded to the study group in this study. Treatment to the patients as per the allocation group was given by a consultant anesthesiologist who was not involved in data collection and analysis.

For quantitative data, percentage, mean, and standard deviations were computed. For the significance of the difference of means, a t-test for independent samples was used after performing Levene's test for equality of variance. A Chi-square test was performed for qualitative data to judge the independence of attributes. P < 0.05 was considered to indicate statistical significance. The data were compiled and subjected to statistical analysis using the Statistical Package for the Social Sciences (SPSS Inc., version 20.0. Chicago, IL, USA).

Results

The demographic profile was comparable for all three groups [Table 1]. The VAS score after the intervention was significantly lower than that before intervention up to day 6 in Group C, day 4 in Group L4, and day 4 in Group L10 [Table 2]. The time trend of the same is shown in [Figure 2]. There was a statistically significant reduction in VAS score after intervention in Group L4 and Group L10 in comparison to Group C, and the mean treatment duration was statistically less in Group L4 and Group L10 [Table 3]. At 72 h of treatment, 5.26% of Group C, 88.89% of Group L4, and 95% of Group L10 patients were found ready to discharge, and patient feel-good index after 15 min of treatment was found best in Group L10, followed by patients in Group L4 and worst in Group C patients [Table 4].

Table 1: Demographic profile of the participants (presented in mean±standard deviation)

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Table 2: Mean Visual Analog Scale score before and after respective interventions

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Figure 2: Line graph showing the mean Visual Analog Score before and after interventions for all treatment groups

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Table 3: Mean Visual Analog Scale score before and after intervention in all three groups

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Table 4: Patient readiness to discharge and feel-good index

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Discussion

PDPH is a well-known iatrogenic and distressing complication of SAB.^[1] AEBP is considered the definitive treatment for PDPH,^[13] but it is invasive. Less invasive procedures reported earlier to treat PDPH are SPGB and occipital nerve block.SPGB was first described by Sluder (1913) for the treatment of sphenopalatine neuralgia.^[16] Later (1911), he used a transnasal needle for the injection of phenol for SPGB. Ruskin then introduced the transoral and lateral injection approaches.^[17]

Cohen et al.^[18] performed SPGB in 22 parturients and found this effective for the management of tension headaches, migraines, low backaches, and neck pain, and it was found to be effective. Another study reported the use of SPGB in 13 parturients and found this useful for the treatment of moderate-to-severe PDPH.^[19] Patelet al.^[20] conducted a retrospective study on 72 patients who received either SPGB or EBP for the treatment of PDPH. They described comparatively better pain relief after an hour of intervention in the SPGB group and more complications associated with EBP procedure. Kent and Mehaffey^[21] performed SPG blocks in three patients with confirmed PDPH in the emergency room using 2% viscous lignocaine, where all three patients had good pain relief after the intervention.

Krasukiet al.^[22] used sterile cotton sticks soaked in 4% lignocaine, inserted through the patient's nose to the back of the nasopharynx for SPGB in patients complaining severe headache, and claimed good pain relief in 12 out of 15 patients. Yarrnitskyet al.^[23] found satisfactory pain relief in migraine patients with SPGB using lignocaine intranasally. Maizels^[24] studied SPGB in recurrent headaches using intranasal lignocaine 4% during the aura phase and found it to prevent headaches. Costaet al.^[25] found SPGB to be effective for the treatment of episodic and chronic cluster headache. Sprigge and Harper^[26] reported that bed rest and mild analgesics do not provide pain relief for more than 14% of patients suffering from PDPH.

Mechanism of PDPH is thought to be through loss of CSF pressure and volume and causes downward traction on the pain-sensitive intracranial veins, meninges, and intracranial nerves. Traction on the upper cervical nerves, C₁, C₂, and C₃, causes pain in neck and shoulders and that on the sixth cranial nerve causes visual symptoms. The bimodal theory also suggests resultant vasodilation of the meningeal vessels due to the lowered CSF pressure. Treatment strategies should target the parasympathetic-mediated vasodilatation by postganglionic parasympathetic fibers and block of somatic sensory supply.^{[27],[28],[29],[30]}

Sphenopalatine ganglion is located in the pterygopalatine fossa, posterior to the middle nasal turbinate and anterior to the pterygoid canal. It poses sympathetic, parasympathetic, and somatic sensory roots. The preganglionic parasympathetic fibers and postganglionic sympathetic neurons, along with somatic sensory fibers from the maxillary division of trigeminal nerve, synapse within the ganglion.^[31] SPGB blocks all these mainly by blocking parasympathetic flow to cerebral vasculature through this ganglion, which allows cerebral vessels to return to a normal diameter.^[27]

We opted for a transnasal approach of SPGB as this is the most comfortable, least invasive, and safest approach, which can be done at the bedside, however, allergy to local anesthetics can be a contraindication. Another report described alternative approaches for SPGB, such as transoral, subzygomatic, and lateral infratemporal.^[32] These methods can be executed precisely with the help of fluoroscopy or using landmark technique but are quite invasive so inherit associated complications such as pain, hematoma formation, infections, and local anesthetic toxicity due to inadvertent intravascular injection.

Conclusion

SPGB increases the proportion of patients ready to discharge at 72 h of treatment. Lignocaine 10% is more effective than lignocaine 4% solution for SPGB. SPGB decreases the hospital stay, hence cost-effective.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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