Journal of Anaesthesia & Critical Care Case Reports

Vol 5 | Issue 1 | Jan-April 2019 | page: 11-13 | Sunil Malik, Shiv Kumar Singh

Authors: Sunil Malik [1], Shiv Kumar Singh [2].

[1] Department of Anesthesiology, Manipal Hospitals, Dwarka, New Delhi, India.
[2] Department of Anaesthesia 11th Floor, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK.

Address of Correspondence

Dr. Sunil Malik,
DNB, B-33 Vishal Enclave, New Delhi 110027, India
E-Mail: drsunilmalik@yahoo.co.in

Abstract

Objective: Managing Post Dural Puncture Headache (PDPH) is a challenge for most anesthesiologist as the gold standard, epidural blood patch (EBP) itself can lead to Dural Puncture that caused the complication in the first place. Medical management of PDPH may not provide symptomatic relief and anesthesiologists are on a constant lookout for techniques that can provide instant and sustained relief from this debilitating complication. Sphenopalatine Ganglion (SPG) and Greater Occipital Nerve (GON) Block have been used individually to manage PDPH in a selected number of patients. For the first time in the literature, we propose the use of a less invasive and acceptable technique using both these blocks (combined nerve and ganglion block) in the same patient to provide higher success rates. The hypothesis for this NAG Dual Block is because both these blocks act on two important but different paths in the pathogenesis of PDPH. In this case series, we describe our experience in 7 patients with PDPH who consented for the dual block.
Case Series: We describe the successful use of NAG dual block in seven patients with PDPH who had immediate and sustained relief. The patients were followed up for up to 48hrs.
Conclusions: We recommend combining both the blocks that are less invasive than EBP for managing PDPH. The Superiority of this new technique will need more data either by RCTs or larger case series. Along with ongoing supportive medical management, both these blocks can be offered as a rescue to all patients diagnosed with moderate to severe PDPH.
Keywords: NAG (Nerve And Ganglion), Post Dural Puncture Headache (PDPH), Greater Occipital Nerve (GON), Sphenopalatine Ganglion (SPG).

References

1. Cohen S, Sakr A, Katyal S, Chopra D. Sphenopalatine ganglion block for postdural puncture headache. Anaesthesia. 2009;64:574–575.
2. Niraj, G. et al. Greater occipital nerve block for postdural puncture headache (PDPH): A prospective audit of a modified guideline for the management of PDPH and review of the literature.Journal of Clinical Anesthesia, Volume 26, Issue 7, 539 – 544.
3. Kemp WJ III, Tubbs RS, Cohen-Gadol AA. The innervation of the cranial dura mater: neurosurgical case correlates and a review of the literature. World Neurosurgery 2012;78(5) 505-510.
4. Cumberbatch MJ, Williamson DJ, Mason GS, Hill RG, Hargreaves RJ. Dural vasodilation causes a sensitization of rat caudal trigeminal neurons in vivo that is blocked by a 5-HT1B/1D agonist. British Journal of Pharmacology 1999;126(6) 1478-1486.
5. Fuzhou Wang (July 10th 2014). Post Dural Puncture Headache – We Can Prevent It, Pain and Treatment Gabor Racz, Intech Open, DOI: 10.5772/57408
6. Ashkenazi A, Levin M. Greater occipital nerve block for migraine and other headaches: is it useful? Current Pain and Headache Reports 2007; 11: 231–5.
7. Matute E, Bonilla S, Gironés A, Planas A. Bilateral greater occipital nerve block for post-dural puncture headache. Anaesthesia 2008;63(5) 557-558.
8. Akin Takmaz S, UnalKantekin C, Kaymak C, Başar H. Treatment of post-dural puncture headache with bilateral greater occipital nerve block. Headache 2010;50(5) 869-872.
9. Piagkou M, Demesticha T, Troupis T, Vlasis K, Skandalakis P, Makri A, et al. The pterygopalatine ganglion and its role in various pain syndromes: from anatomy to clinical practice. Pain Pract 2012; 12: 399-412.
10. Robbins MS, Robertson CE, Kaplan E, et al. The sphenopalatine ganglion: anatomy, pathophysiology, and therapeutic targeting in headache. Headache. 2016; 56:240–258.
11. Lebrun C, Peek D, Vanelderen P, Van ZundertJ.Unintentional cervical dural tap treated with lumbar blood patch. PainPract. 2014 Jul;14(6):577-80.

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