Lignocaine nasal spray: An easy remedy for Post Dural Puncture Headache

S. Khaja Mohideen, J. Indupriyadarshini, N. Mohamed Eliyas, K. Akila

Department of Anaesthesiology, Kauvery Hospitals, Trichy

Abstract

Current treatment of post dural puncture headache (PDPH) includes epidural blood patch (EBP), which is invasive and may result in rare but severe complications. Sphenopalatine ganglion block is suggested as a simple, minimally invasive treatment for post dural puncture headache. There are various techniques of performing sphenopalatine ganglion block. We report here an easy technique of performing sphenopalatine ganglion block.

Keywords: PDPH, sphenopalatine ganglion block, nasal spray

Background

Sphenopalatine ganglion block (SPG) 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. We report here an easy technique of performing sphenopalatine ganglion block

Case Presentation

A 55-old man, a chronic smoker with history of coronary artery disease on antiplatelet drugs (aspirin 75 mg and clopidrogel 75 mg) underwent ureteroscopy under spinal anaesthesia. Clopidrogel was stopped 5 days before surgery. Spinal anaesthesia was done with 26G Quincke needle at L3-L4 interspace in a single prick. 3 ml of 0.5% Bupivacaine and 25 µg Fentanyl was given intrathecally. On second postoperative day, he complained of fronto-occipital headache which worsened with movement and sitting position. After detailed history and clinical examination a diagnosis of postdural puncture headache (PDPH) was made. Patient was advised to avoid sitting position. He was prescribed oral paracetomol 650 mg with caffeine 50 mg four times a day along with plenty of oral fluids. But his symptoms persisted. Hence sphenopalatine ganglion block was suggested to the patient. But the patient was anxious about the applicator with the cotton swab that was used for the block. Instead we planned to use the 10% lignocaine spray and explained the patient that the tip of nozzle would not touch the nasopharynx. With the patient in sitting position and neck slightly extended, lignocaine spray was applied to both the nostrils. After 30 minutes, the patient was made to sit and asked for the headache. He had significant relief of pain. The lignocaine spray had to be repeated twice on postoperative day 2. Next day the patient did not complain of headache.

Discussion

A topical sphenopalatine ganglion (SPG) block is a simple and minimally invasive procedure to treat PDPH. Few observational studies suggest its effects comparable with Epidural Blood Patch (EBP) [1]. Anatomically sphenopalatine ganglion is located in the pterygopalatine fossa posterior to middle turbinate, covered only by a 1-1.5 mm thick layer of mucus membrane and connective tissue, which makes topical application of local anaesthetic effective [2]. Conventional SPG block involves insertion of local anaesthetic soaked cotton applicator along the floor of nostril upto the posterior pharyngeal wall. The patient should be in supine position with neck slightly extended while performing the procedure (Fig. 1).

There are no major complications described with this technique. But, paresthesia and initial discomfort of the nasopharynx, related to the spread of anesthetic, minor bleeding due to traumatic applicator introduction have been reported [3]. As our patient was on dual antiplatelet drugs and was also anxious about the procedure, we did not use the cotton-soaked applicator for SPG block. Hence, we tried the lignocaine spray for SPG block and found it to be effective. Few modifications of transnasal SPG block for PDPH have been reported. Singla et al [2] used an epidural catheter for the instillation of local anaesthetic. Bhargava et al [4], in a patient with deranged coagulation and PDPH used a syringe to apply local anaesthetic as nasal drops. Even though the lignocaine spray is of 10% concentration, each spray gives 10 mg and overdose is unlikely.

Conclusion

Sphenopalatine ganglion block by nasal spray can be an easy solution for PDPH. Also it can be safely administered by nursing staff. With adequate training even the patient can self-administer this spray at home for the treatment PDPH.

References

Jespersen MS, et al. Sphenopalatine ganglion block for the treatment of postdural puncture headache: a randomised, blinded, clinical trial. Br J Anaesth. 2020;124:739-47.
Singla D, et al. Sphenopalatine ganglion block: A newer modality for management of postdural puncture headache. J Anaesthesiol Clin Pharmacol. 2018;34:567-8.
Furtado I, et al. Ropivacaine use in transnasal sphenopalatine ganglion block for post dural puncture headache in obstetric patients: a case series. Rev Bras Anestesiol. 2018;68:421-4.
Bhargava T, et al. A simple modification of sphenopalatine block for post dural puncture headache. Indian J Anaesth. 2020;64:531-2.

Dr. S. Khaja Mohideen

Anaesthesiologist

Dr. Mohamed Eliyas

Department of Anesthesiology Registrar

Dr. K. Akila

Anesthesiologist

Lignocaine nasal spray: An easy remedy for Post Dural Puncture Headache