Background: Low pressure cerebral spinal fluid (CSF) headache following intended or non intended dural puncture occurs mostly in obstetrics and its recommended treatment consists in performing an epidural blood patch. Sphenopalatine ganglion block (SPGB) is an alternative treatment that is being used in obstetrics with success (1). We report its use, a novelty to our knowledge, to treat a patient with severe headache after the placement of a lumboperitoneal shunt (LPS).
Case Report: A 20 years old male, ASA II, GCS 15, was submitted to surgical insertion of a silicone LPS under general anesthesia to treat intracranial hypertension secondary to venous sinus thrombosis. Twenty four hours later he developed head and neck pain, rated 8 in the Numeric Rating Scale (NRS), accompanied by nausea, vomiting and diplopia. A low CSF pressure headache was diagnosed and a transnasal SPGB with 7,5% ropivacaine was performed. Pain relief was immediate, complete and sustained for about 24 hours with no complications. The following day pain recurred and was rated as 4 when lying and as 8 when supine, so a second block was performed resulting in complete pain relief.On the third day the pain remained well controlled with oral analgesics and so the patient was discharged home.When contacted 5 days, and 2 months later, he was asymptomatic.
Discussion: Severe headache may occur following the placement of a LPS (2). While symptomatically identical to the most frequent obstetrics related postdural puncture headache, in obstetrics the headache is due to the unintended CSF leakage following dural puncture, while in LPS it is due to intended CSF drainage. While the treatment for postdural puncture headache uses a blood patch, this may not work for LPS headache (3) due to the ethiology of CSF hypotension, since sealing an eventual leak around the catheter does not stop CSF drainage. Based on this physiologic approach we decided to perform, as first treatment, a SPGB. The success obtained in this case suggests that SPGB may be a new and valid analgesic approach, as the underlying analgesic mechanism relies on the meningeal nociceptive transmission block without cerebral fluid dynamics modification.
References:1. Cohen S, Reg Anesth Pain Medicine 2014 Nov;39(6):563; 2. Sinclair A, Cephalalgia, 31(16)1627–1633; 3. Allmond L, Anesth Analg 2005;101:1497–8
Learning points: SPGB may be a safe and efficient treatment option for the CSF hypotension headache secondary to lumboperitoneal shunt.