Trans-nasal sphenopalatine ganglion block for post-dural puncture headache management: a meta-analysis of randomized trials

Abstract Objective: To evaluate the efficacy and safety of trans-nasal Sphenopalatine Ganglion (SPG) block over other treatments for Post-Dural Puncture Headache (PDPH) management. Methods: A systematic literature search was conducted on databases for Randomized Controlled Trials (RCTs) comparing trans-nasal SPG blockade for the management of PDPH over other treatment modalities. All outcomes were pooled using the Mantel-Haenszel method and random effect model. Analyses of all outcomes were performed as a subgroup based on the type of control interventions (conservative, intranasal lignocaine puffs, sham, and Greater Occipital Nerve [GON] block). The quality of evidence was assessed using the GRADE approach. Results: After screening 1748 relevant articles, 9 RCTs comparing SPG block with other interventions (6 conservative treatments, 1 sham, 1 GON and 1 intranasal lidocaine puff) were included in this meta-analysis. SPG block demonstrated superiority over conservative treatment in pain reduction at 30 min, 1 h, 2 h, 4 h after interventions and treatment failures with "very low" to "moderate" quality of evidence. The SPG block failed to demonstrate superiority over conservative treatment in pain reduction beyond 6 h, need for rescue treatment, and adverse events. SPG block demonstrated superiority over intranasal lignocaine puff in pain reduction at 30 min, 1 h, 6 h, and 24 h after interventions. SPG block did not show superiority or equivalence in all efficacy and safety outcomes as compared to sham and GON block. Conclusion: Very Low to moderate quality evidence suggests the superiority of SPG block over conservative treatment and lignocaine puff for short-term pain relief from PDPH. PROSPERO Registration: CRD42021291707.

Sphenopalatine ganglion block - a new treatment for burning mouth syndrome?: a case report

Abstract Burning mouth syndrome is a poorly understood entity for which current treatment modalities fail to provide effective relieve. Branches of the maxillary and mandibular nerves are responsible for the innervation of the affected area. These are also the nerves involved in trigeminal neuralgia, an entity where sphenopalatine block has proved to be effective. We present a case of a patient with burning mouth syndrome in whom a bilateral sphenopalatine ganglion block was successfully performed for pain treatment. It is an easy and safe technique that can be a valuable treatment option for these patients, although more studies are needed.

Early versus late sphenopalatine ganglion block with ropivacaine in postdural puncture headache: an observational study

Abstract Background Postdural puncture headache (PDPH) is a common complication of neuraxial techniques which delays patients' discharge. Sphenopalatine ganglion block (SPGB) is a safe bedside technique with comparable efficacy to Epidural Blood Patch, the gold-standard treatment. There is no evidence on the ideal timing for SPGB performance. We aimed to evaluate the difference between early versus late SPGB concerning efficacy, symptom recurrence and hospital length of stay. Methods We present an observational study with 41 patients diagnosed with PDPH who were submitted to SPGB with ropivacaine 0,75%. The study sample (n = 41) was divided in two groups: an early (less than 24 hours after diagnosis) and a late (more than 24 hours after diagnosis) SPGB group. Pain was evaluated 15 minutes after the block and follow up occurred daily until patients were discharged. Patients' demographic characteristics, neuraxial technique, timing of SPGB, qualitative pain relief and post-SPGB length of stay were registered and analyzed with SPSS statistics (v26) software. Results Early SPGB resulted in a significant reduction in length of stay (p = 0,009) and symptom recurrence (p = 0,036), showing equally effective pain relief, compared to late SPGB. Conclusions SPGB was equally effective in both groups. Data showed that early SPGB reduces length of hospital stay and symptom recurrence, which potentially allows early resumption of daily activities and a reduction in total health costs.

Self-applied sphenopalatine ganglion block for postdural puncture headache: four case reports / Bloqueio do gânglio esfenopalatino autoaplicado para cefaleia pós-punção dural: relato de quatro casos

Abstract Background and objectives The Sphenopalatine Ganglion Block (SGB) is an effective, low-risk treatment option for Postdural Puncture Headache (PDPH) refractory to conservative management. Case report This report presents four complex cases of patients with headache related to low cerebrospinal fluid pressure. Three of them were successfully treated with the application of local anesthetic topical drops through the nasal cavity. Conclusion The novel approach described in this report has minimal risks of discomfort or injury to the nasal mucosa. It is quick to apply and can be administered by the patient himself.

Resumo Justificativa e objetivos: O Bloqueio do Gânglio Esfenopalatino (BGEP) é opção de tratamento efetivo associado a baixo risco para Cefaleia Pós-Punção Dural (CPPD) refratária às medidas conservadoras. Relato de caso: Este relato apresenta quatro pacientes com alta complexidade que apresentaram cefaleia relacionada à baixa pressão do líquido cefaloraquidiano. Três pacientes foram tratados com sucesso pela instilação de gotas de anestésico local tópico na cavidade nasal. Conclusões: A nova abordagem descrita neste relato apresenta riscos mínimos de desconforto ou lesão à mucosa nasal. A aplicação é rápida e pode ser administrada pelo próprio paciente.

Bloqueo del ganglio esfenopalatino, una opción para el tratamiento de la cefalea postpunción dural / Sphenopalatine ganglion block, an option for treatment of post dural puncture headache

Post-dural puncture headache is a complication of neuroaxial anesthesia. The initial approach consists of supportive treatment. In case of therapeutic failure, the epidural blood patch (PSE) is the treatment of choice. The case of a sphenopalatine ganglion block is presented for its management with good results.

La cefalea postpunción dural es una complicación de la anestesia neuroaxial. El abordaje inicial consiste en tratamiento de soporte. En caso de falla terapéutica, el parche sanguíneo epidural (PSE) es el tratamiento de elección. Se presenta el caso de un bloqueo de ganglio esfenopalatino para su manejo con buenos resultados.

Bilateral sphenopalatine ganglion block versus intravenous clonidine premedication for surgical field improvement and postoperative pain relief in endoscopic sino-nasal surgery

ackground: Bilateral sphenopalatine ganglion block (SPGB) and IV clonidine premedication could provide better hemodynamic parameters, surgical field, postoperative pain control during endoscopic sino-nasal surgery. Design: prospectiverandomized controlled comparative study. Methods: A total of 69 patients of ASA grade I or II scheduled for endoscopic sino-nasal surgery were equally divided into three groups (23 patients each): control group; block group; and clonidine group. The sphenopalatine ganglion block technique done by lateral infra-zygomatic approach guided by x-ray fluoroscopy. Iv clonidine premedication was given 15 min before general anesthesia induction with dose 2 µg/kg as singe bolus. Surgical field quality assessment done by average category scale (ACS), hemodynamic profile and consumption of anesthetics were recorded. Postoperative pain evaluated by VAS. The time to first request for analgesia, analgesic requirement for 24 h postoperatively and any complications were recorded. Results: MAP and HR readings at most of intra and postoperative times, Average category scale score, intraoperative blood loss, average consumption of fentanyl and propofol and hypotensive agent (labetalol) were significantly high in control group when compared with block and clonidine groups and were significantly low in block group when compared with clonidine group except for postoperative HR.VASscore postoperatively, Time of first request of analgesia, Total pethidine consumption was significantly high in control group C when compared with block and clonidine groups. Conclusion: SPGB is effective for better hemodynamic control, surgical field and postoperative analgesia in endoscopic sino-nasal surgery when compared with IV clonidine premedication

Ropivacaine use in transnasal sphenopalatine ganglion block for post dural puncture headache in obstetric patients - case series / Uso de ropivacaína em bloqueio do gânglio esfenopalatino via transnasal para cefaleia pós-punção dural em pacientes obstétricas - série de casos

Abstract Purpose Sphenopalatine ganglion block is widely accepted in chronic pain; however it has been underestimated in post dural puncture headache treatment. The ganglion block does not restore normal cerebrospinal fluid dynamics but effectively reduces symptoms associated with resultant hypotension. When correctly applied it may avoid performance of epidural blood patch. The transnasal approach is a simple and minimally invasive technique. In the cases presented, we attempted to perform and report the ganglion block effectiveness and duration, using ropivacaine. Clinical features We present four obstetrics patients with post dural puncture headache, after epidural or combined techniques, with Tuohy needle 18G that underwent a safe and successful sphenopalatine ganglion block. We performed the block 24-48 h after dural puncture, with 4 mL of ropivacaine 0.75% in each nostril. In three cases pain recurred within 12-48 h, although less intense. In one patient a second block was performed with complete relief and without further recurrence. In the other two patients a blood patch was performed without success. All patients were asymptomatic within 7 days. Conclusion The average duration of analgesic effect of the block remains poorly defined. In the cases reported, blocking with ropivacaine was a simple, safe and effective technique, with immediate and sustained pain relief for at least 12-24 h.

Resumo Justificativa e objetivo O bloqueio do gânglio esfenopalatino é amplamente aceito em dor crônica; porém, esse bloqueio tem sido subestimado no tratamento de cefaleia pós-punção dural. O bloqueio do gânglio não restaura a dinâmica normal do líquido cefalorraquidiano, mas reduz de modo eficaz os sintomas associados à hipotensão resultante. Quando aplicado corretamente, pode evitar a realização de tampão sanguíneo epidural. A abordagem transnasal é uma técnica simples e minimamente invasiva. Nos casos apresentados, tentamos realizar o bloqueio do gânglio e relatar sua eficácia e duração usando ropivacaína. Características clínicas Apresentamos quatro pacientes de obstetrícia com cefaleia pós-punção dural, após técnica epidural ou técnicas combinadas, com agulha Tuohy (18 G), que foram submetidas ao bloqueio do gânglio esfenopalatino de forma segura e bem-sucedida. Realizamos o bloqueio após 24 a 48 horas da punção dural, com 4 mL de ropivacaína a 0,75% em cada narina. Em três casos, a dor voltou em 1-48 horas, embora menos intensa. Em uma paciente, um segundo bloqueio foi realizado com alívio completo e sem recorrência. Nas outras duas pacientes, um tampão sanguíneo foi feito sem sucesso. Todas as pacientes estavam assintomáticas dentro de sete dias. Conclusão A duração média do efeito analgésico do bloqueio continua mal definida. Nos casos relatados, o bloqueio com ropivacaína foi uma técnica simples, segura e eficaz, com alívio imediato e prolongado da dor durante pelo menos 12-24 horas.

Sphenopalatine ganglion block for postdural puncture headache in ambulatory setting / Bloqueio do gânglio esfenopalatino para cefaleia pós-punção dural em contexto de ambulatório

Abstract Background and objectives: Postdural puncture headache (PDPH) is a common complication following subarachnoid blockade and its incidence varies with the size of the needle used and the needle design. Suportive therapy is the usual initial approach. Epidural blood patch (EBP) is the gold-standard when supportive therapy fails but has significant risks associated. Sphenopalatine ganglion block (SPGB) may be a safer alternative. Case report: We observed a 41 year-old female patient presenting with PDPH after a subarachnoid blockade a week before. We administrated 1 l of crystalloids, Dexamethasone 4 mg, parecoxib 40 mg, acetaminophen 1 g and caffeine 500 mg without significant relief after 2 hours. We performed a bilateral SPGB with a cotton-tipped applicator saturated with 0.5% Levobupivacaine under standard ASA monitoring. Symptoms relief was reported 5 minutes after the block. The patient was monitored for an hour after which she was discharged and prescribed acetaminophen 1 g and ibuprofen 400 mg every 8 hours for the following 2 days. She was contacted on the next day and again after a week reporting no pain in both situation. Conclusions: SPGB may attenuate cerebral vasodilation induced by parasympathetic stimulation transmitted through neurons that have synapses in the sphenopalatine ganglion. This would be in agreement with the Monro-Kellie concept and would explain why caffeine and sumatriptan can have some effect in the treatment of PDPH. Apparently, SPGB has a faster onset than EBP with better safety profile. We suggest that patients presenting with PDPH should be considered primarily for SPGB. Patients may have a rescue EBP if needed.

Resumo Justificativa e objetivos: Cefaleia pós-punção dural (CPPD) é uma complicação comum após bloqueio subaracnoideo e sua incidência varia de acordo com o tamanho e desenho da agulha usada. Geralmente, a terapia de apoio é a abordagem inicial. O tampão sanguíneo peridural (TSP) é o padrão de terapia quando a terapia de apoio falha, mas tem riscos significativos associados. O bloqueio do gânglio esfenopalatino (BGEP) pode ser uma opção mais segura. Relato de caso: Atendemos uma paciente de 41 anos, com CPPD após bloqueio subaracnoideo uma semana antes. Administramos cristaloides (1 L), dexametasona (4 mg), parecoxib (40 mg), acetaminofeno (1 g) e cafeína (500 mg), sem alívio significativo após 2 horas. Fizemos um bloqueio bilateral do gânglio esfenopalatino, com um aplicador com ponta de algodão saturada com levobupivacaína a 0,5% sob monitoração padrão ASA. O alívio dos sintomas foi relatado 5 minutos após o bloqueio. A paciente foi monitorada por uma hora e depois recebeu alta com prescrição de acetaminofeno (1 g) e ibuprofeno (400 mg) a cada 8 horas para os dois dias seguintes. A paciente foi contatada no dia seguinte e novamente após uma semana e, em ambos os contatos, relatou não sentir dor. Conclusões: O BGEP pode ter atenuado a vasodilatação cerebral induzida pelo estímulo parassimpático transmitido através dos neurônios que têm sinapses no gânglio esfenopalatino. Esse mecanismo estaria de acordo com o conceito de Monro-Kellie e explicaria por que a cafeína e o sumatriptano podem ter algum efeito no tratamento da CPPD. Aparentemente, o BGEP tem um início mais rápido do que o do TSP, com um melhor perfil de segurança. Sugerimos que os pacientes que se apresentam com CPPD devam ser considerados primeiro para BGEP. Os pacientes podem ser submetidos a um TSP de resgate, caso necessário.

Sphenopalatine ganglion block for relieving postdural puncture headache: technique and mechanism of action of block with a narrative review of efficacy

The sphenopalatine ganglion (SPG) is a parasympathetic ganglion, located in the pterygopalatine fossa. The SPG block has been used for a long time for treating headaches of varying etiologies. For anesthesiologists, treating postdural puncture headaches (PDPH) has always been challenging. The epidural block patch (EBP) was the only option until researchers explored the role of the SPG block as a relatively simple and effective way to treat PDPH. Also, since the existing evidence proving the efficacy of the SPG block in PDPH is scarce, the block cannot be offered to all patients. EBP can be still considered if an SPG block is not able to alleviate pain due to PDPH.

Relaciones del ganglio esfenopalatino con las cavidades neumáticas de cráneo y cara / Sphenopalatine ganglion (sg) relationships with pneumatic cavities of skull and face

El ganglio esfenopalatino (GE) es un importante conglomerado de neuronas y fibras nerviosas, situado en laparte ántero- medial de la cara, en la profundidad de la fosa pterigopalatina. Desde el comienzo del siglo XX, el GEha sido involucrado en la génesis del dolor facial de ciertos tipos de cefaleas. En las últimas décadas, diversos autores también han relacionado al ganglio esfenopalatino con las algias faciales. Nuestra intención fue destacarla importancia de las relaciones anatómicas de este ganglio con las cavidades neumáticas en origen del dolorfacial, especialmente en la cefalea esfenopalatina, o cefalea de racimo. Material y método: Utilizamos para nuestrainvestigación treinta cadáveres adultos conservados en formol al 10% sin selección previa. El ganglio esfenopalatinofue abordado vía fosas nasales para describir la relación de este ganglio (GE) con las cavidades neumáticas decráneo y cara. Resultados: en el 100% de nuestras disecciones el ganglio fue hallado debajo de la mucosa nasal, en el extremo postero-superior de la fosa pterigopalatina, detrás del vértice del cornete medio, debajo del senoesfenoidal; detrás del seno maxilar y detrás y abajo de las celdillas etmoidales posteriores.Conclusiones: nuestras observaciones confirman que el GE tiene una relación directa con la mucosa nasal,con los senos esfenoidal, maxilar; y una relación indirecta con las celdillas etmoidales posteriores. Estas relaciones podrían explicar laetiología de la irritación del ganglio esfenopalatino como un disparador en el dolor facial, especialmente en laneuralgia esfenopalatina o neuralgia de Sluder. Creemos que ciertas enfermedades de los senos paranasales,inflamatorias, tumorales, traumáticas, etc. afectarían al ganglio esfenopalatino y / o algunas de sus ramas aferentes o eferentes las cuales dispararían esta sensación de dolor desagradable e invalidante.

MARYThe sphenopalatine ganglion is an important neuronal and nervous fiber conglomerate located in theanteromedial part of the face, in the deepness of the pterygopalatine fossa. From the beginning of the 20th century, thesphenopalatine ganglion has been involved with the facial pain genesis on certain types of headaches. In the last decades, various authors have related the sphenopalatine ganglion to the facial aches. Our intention was to emphasizethe importance of the anatomical relationship between this ganglion and the pneumatic cavities in the source offacial pain, especially in the sphenopalatine headache or cluster headache. Material and method: We investigated in30 adult corpses conserved in 10% phormol, without previous selection. The sphenopalatine ganglion was approachedthrough the nasal fosses for describing the relationships of the sphenopalatine ganglion (SG) with the pneumaticcavities of the skull and the face. Results: In 100% of our dissections the sphenopalatine ganglion was locatedunderneath the nasal mucosa in the posterior extreme of the pterygopalatine fossa, behind the vertex of the middleturbinate, under the sphenoid sinus, behind the maxillary sinus and under and behind the posterior ethmoidal cells. Conclusions: our observations confirm that the sphenopalatine ganglion has a direct relationship with the nasal mucosa, with the sphenoidal and maxillary sinuses, and an indirect relationship with the posterior ethmoidal cells. These relationships could explain the etiology of the sphenopalatine ganglion irritation as a trigger in facial pain, especially in sphenopalatine neuralgia or Sluder’s neuralgia. Finally, we believe that certain diseases of the paranasal sinuses e.g., inflammatory, tumoral, traumatic, would affect the sphenopalatine ganglion, and/or some of its afferent or efferent branches, which would trigger this disagreeable and invalidant pain sensation.

Stellate Ganglion Block for the Preventive Effect on the Attacks of Cluster Headache: A case report / 대한마취과학회지

Cluster headaches are recurrent, unilateral attacks of severe pain that almost always occur on the same side of the head. They are oculofrontal or oculotemporal, with radiation to the upper jaw. The precise cause of cluster headaches are still unknown and treatments are very difficult. A 34 year old male patient suffering from severe classical cluster headache was refered to the pain clinic from department of neurosurgery. The patient complained of severe pain on right oculotemporal area and his symptoms had been refractory to any other treatment. His symptoms were effectively relieved after oxygen inhalation and sphenopalatine ganglion block with 4% lidocaine 2 ml during his attack. I could effectively prevent the attack of the cluster headache using stellate ganglion block (SGB) with 0.25% bupivacaine 5 ml twice daily during 3 weeks.