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Transnasal Sphenopalatine Ganglion Block for Postdural Puncture Headache in an Adolescent: A Case Report

Stalls, Caleb MD*; Zatochill, Mary MD; Petersen, Timothy R. PhD; Falcon, Ricardo J. MD; Al Haddadin, Caroline MD; Southwell, Bronwyn MD§; Soneru, Codruta N. MD

doi: 10.1213/XAA.0000000000001029
Case Reports
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We present a pediatric patient with postdural puncture headache after a lumbar puncture, who was successfully treated with a sphenopalatine ganglion block. An uneventful autologous epidural blood patch had been placed 2 days before, but the patient reported a recurrence of symptoms after about 5 hours. Sphenopalatine ganglion block is well described in the treatment of postdural puncture headache for the obstetric population, but examples of its use in the pediatric population are not described. To our knowledge, this is the first pediatric case of sphenopalatine ganglion block for postdural puncture headache reported in the literature.

From the *Department of Anesthesiology and Critical Care, Yale University, New Haven, Connecticut

Department of Anesthesiology and Critical Care, University of New Mexico, Albuquerque, New Mexico

Department of Anesthesiology, Yale University, New Haven, Connecticut

§Department of Anesthesiology and Critical Care, University of Minnesota, Minneapolis, Minnesota.

Accepted for publication March 18, 2019.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Caleb Stalls, MD, Department of Anesthesiology and Critical Care, Yale University, 360 State St, Apt 2515, New Haven, CT 06510. Address e-mail to calebStalls@gmail.com.

Postdural puncture headache is a potentially incapacitating and relatively frequent complication of neuraxial anesthesia procedures.1 Initially thought of as a benign, eventually self-resolving pain, recent data suggest that it may develop into chronic headache in a subset of patients.1

An epidural blood patch is a well-described treatment of postdural puncture headache, typically after a trial of conservative therapy has failed.1 While efficacious, an epidural blood patch is not without risk of complications, including bleeding, infection, repeat dural puncture, arachnoiditis, malignant seeding, and vasovagal syncope.1–3 Sphenopalatine ganglion block is an established therapy for acute and chronic facial and head pain. More recently, there have been small case series in the adult literature showing sphenopalatine ganglion block to have similar efficacy to an epidural blood patch for postdural puncture headache.4–6 There is also a promising but unpublished report of sphenopalatine ganglion block in pediatric migraine.7 However, there are no published reports of sphenopalatine ganglion block for postdural puncture headache in children. We present a successful transnasal sphenopalatine ganglion blockade to treat postdural puncture headache for a pediatric patient. Written consent for publication was obtained from the patient’s parents.

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CASE

The pediatric acute pain service was consulted for a repeat epidural blood patch for a 45-kg, 12-year-old boy who was experiencing refractory postdural puncture headache after a diagnostic surveillance lumbar puncture in the setting of acute lymphocytic leukemia. A 22-gauge Quincke needle was used for the lumbar puncture with easy return of clear cerebrospinal fluid. The subsequent epidural blood patch was performed with sterile, loss-of-resistance technique under sedation (midazolam 2 mg and fentanyl 50 μg) and 9 mL (0.2 mL/kg) of fresh, autologous blood administered without complication, although it failed to relieve his headache. At the time of assessment, the patient was lying in bed complaining of intense, bilateral parietotemporal, aching, positional pain that was worse when upright. The mother asked about alternative treatment modalities because the epidural blood patch did not provide long-term relief. After assessment of the patient and discussion of the adult literature regarding sphenopalatine ganglion block with the mother, it was decided to perform a transnasal sphenopalatine ganglion block for rescue analgesia.

Per the mother’s report that the patient was previously unable to tolerate nasal swab screening for bacterial colonization, we agreed on sedation. The sphenopalatine ganglion block was performed in the operating room. The patient continued to lie supine, under sedation, breathing spontaneously on 2 L/min of supplemental oxygen via blow-by delivery. Both nasal passages were topicalized with atomized 4% lidocaine, then 2% lidocaine gel (Figure 1). Cotton-tipped applicators were prepared and soaked in 4% lidocaine; the submaximum dose administered totaled 170 mg. An applicator stick was inserted parallel to the floor of each nasal cavity until resistance was met at the posterior wall of the nasopharynx (Figure 2). The patient required multiple 20 mg boluses of propofol and 0.4 μg/kg/h infusion of dexmedetomidine to tolerate the block. Once the applicators were in place, additional 4% lidocaine was dripped through their hollow shafts, and they were left in place for 40 minutes. The applicators were removed and sedation discontinued. The patient reported immediate resolution of his positional headache. In the postoperative recovery room, he was able to stand up and walk. He remained symptom free at 5 days and again at 4 weeks. When contacted for follow-up discussions, the patient’s mother spontaneously requested that this technique be shared, so it can be used to help other children.

Figure 1.

Figure 1.

Figure 2.

Figure 2.

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DISCUSSION

Postdural puncture headache occurs due to a violation of the dural barrier, causing loss of cerebrospinal fluid. Symptoms are classically positional and thought to be related to nerve traction from downward displacement of the cranial contents as well as to the compensatory parasympathetic-mediated intracranial venodilation that restores the intracranial volume.8

Sphenopalatine ganglion block has been used to treat acute and chronic facial and head pain for over 100 years.9 The sphenopalatine ganglion lies superficially in the pterygopalatine fossa, covered by only a thin layer of tissue, making it an ideal target for topical drug application (Figure 2).

The sphenopalatine ganglion is an important target for blockade because it has sympathetic, parasympathetic, and sensory innervation overlapping in a small area. The junction of these various components of the nervous system may explain the efficacy of this block to treat pain related to various etiologies, including postdural puncture headache. Blocks applied to it may mitigate transmission of sensory pain signals, as well as nociception mediated by the sympathetic or parasympathetic nervous systems.

As noted above, there are case series in the adult literature suggesting that an sphenopalatine ganglion block’s efficacy for postdural puncture headache relief is comparable to that of epidural blood patch.4 Its side effects are generally mild, such as transient nausea and vomiting, but rare cases of worsened migraine have also been reported.10 Sphenopalatine ganglion block could provide an analgesic bridge for the patient, possibly preventing symptoms during the window of time required for dural injuries to heal.

Sphenopalatine ganglion block has shown promise in the adult and obstetric populations as a minimally invasive procedure to treat postdural puncture headache.4–6 Given the clinical value of this technique, the sphenopalatine ganglion block may represent an underutilized, effective, and less-invasive alternative to epidural blood patch that we can offer our pediatric patients with postdural puncture headache.

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DISCLOSURES

Name: Caleb Stalls, MD.

Contribution: This author helped compose and revise the manuscript.

Name: Mary Zatochill, MD.

Contribution: This author helped perform the sphenopalatine ganglion block and draw Figure 2.

Name: Timothy R. Petersen, PhD.

Contribution: This author helped proofread and edit the manuscript.

Name: Ricardo J. Falcon, MD.

Contribution: This author helped proofread and edit the manuscript.

Name: Caroline Al Haddadin, MD.

Contribution: This author helped proofread and edit the manuscript.

Name: Bronwyn Southwell, MD.

Contribution: This author helped proofread and edit the manuscript.

Name: Codruta N. Soneru, MD.

Contribution: This author helped compose and revise the manuscript, and draw Figure 2. She was the attending anesthesiologist supervising the sphenopalatine ganglion block.

This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.

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REFERENCES

1. Gaiser RR. Postdural puncture headache: an evidence-based approach. Anesthesiol Clin. 2017;35:157–167.
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3. Demaree CJ, Soliz JM, Gebhardt R. Cancer seeding risk from an epidural blood patch in patients with leukemia or lymphoma. Pain Med. 2017;18:786–790.
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8. Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91:718–729.
9. Sluder G. The anatomical and clinical relations of the sphenopalatine ganglion to the nose. NY State J Med. 1909;90:293–298.
10. Binfalah M, Alghawi E, Shosha E, Alhilly A, Bakhiet M. Sphenopalatine ganglion block for the treatment of acute migraine headache. Pain Res Treat. 2018;2018:2516953.
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