Verification of Sphenopalatine Ganglion Block Success Using Transcranial Doppler in Management of Patients with Postdural

Abstract

BACKGROUND: Sphenopalatine ganglion block (SPGB) is traditionally advised in the management of head and neck pain. Since SPGB is a minimally invasive, repeatable, and simple technique, SPGB should be tried first in the management of postdural puncture headaches (PDPH). Verification of the block’s success in diagnostic, prognostic, and therapeutic nerve blocks, is of paramount importance in pain management. OBJECTIVES: This study intends to prove the ability of SPGB in the management of PDPH. Transcranial Doppler (TCD) is utilized as an objective measure to assess the block’s success by monitoring variations in the cerebral hemodynamics before and after the block procedure. Noninvasive intracranial pressure (nICP) was applied to support the theory which assumes that the vasodilation of the cerebral blood vessels is the precipitating cause of the PDPH, rather than intracranial hypotension. STUDY DESIGN: Prospective, triple blinded, controlled, clinical trial. SETTING: This clinical trial was conducted at Zagazig University. METHODS: In the present study, 123 patients were considered who had spinal and/or epidural anesthesia; 63 patients who developed PDPH joined treatment group A and received the SPGB block. The control group B included 60 patients with no PDPH. The patients in group A were evaluated preprocedure by a numerical pain score and at 30 minutes, 2 hours, 4 hours, 6 hours, 12 hours, and 24 hours postprocedure. Furthermore, patients in both groups were evaluated employing TCD before the transnasal block was given, then it was repeated to group A only within one hour after the block. RESULTS: Results analysis revealed that preprocedural pulsatility index (PI) and mean flow velocity (MFV) values in treatment group A were (mean ± standard deviation [SD]) 0.63 ± 0.04 and 57.20 ± 4.85 cm s-1, respectively. Values of PI and MFV were significantly increased up to (mean ± SD) 0.87 ± 0.08 and 71.15 ± 7.686 cm s-1, respectively after the block. The computed nICP values preblock and postblock were also within the normal range. LIMITATIONS: Performing SPGB without standardized equipment may limit the results of the current study CONCLUSIONS: SPGB should be considered as a first treatment modality for PDPH. Moreover, the results indicate that TCD is a successful objective tool in assessing a transnasal sphenopalatine ganglion block. KEY WORDS: Noninvasive intracranial pressure, postdural puncture headache, sphenopalatine ganglion block, transcranial Doppler

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

“…These findings highlight trends for faster relief from headache after block. 39 Similar findings were reported in previous retrospective studies comparing SPG block with EBP 18 , 19 , 40 where effective pain relief was noted within 30 min of a block. In our analysis, no significant difference was observed for later time intervals (6 h, 8 h, 12 h, 24 h, and 7 days), which is in line with previous studies.…”

Evidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group

“…One observational study using transcranial Doppler found a correlation between pulsatile index and mean flow velocity of intracranial arteries when SPGBs provided pain relief versus those that did not. 222 This method may be able to determine the success of an SPGB; however, further studies are needed to ensure its validity. The transcutaneous approach remains the most direct means of performing an SPGB; however, there are no published studies where this approach is used.…”

Application of Controlled Hypotension During Surgery for Spinal Metastasis

“…58 The results of Abdelhaleem et al show that there is a significant difference between PI and the mean blood flow velocity of the middle cerebral artery before and after the operation, so TCD measurement of PI can be regarded as a more effective monitoring method. 59 Chaix et al used TCD to monitor the blood flow velocity of the middle cerebral artery (Vm) and recorded the systolic velocity (Vs.), diastolic velocity (Vd), and pulsatile index ([Vs.−Vd]/Vm) to evaluate cerebral perfusion during the induction and maintenance of general anesthesia. It was found that the decrease in cerebral perfusion measured by Vm was related to the decrease in MAP in high-risk patients.…”