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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.

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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.

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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.

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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.

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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.

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BACKGROUND: Postdural puncture headache (PDPH) is a common complication of neuraxial techniques which delays patients.ÇÖ 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 24hours after diagnosis) and a late (more than 24hours after diagnosis) SPGB group. Pain was evaluated 15minutes after the block and follow up occurred daily until patients were discharged. PATIENTS: ÇÖ 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.

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Coronavirus SARS-CoV-2 is responsible for the COVID-19 pandemic, and headache is reported in 6.5% to 34% of all cases. There is little published evidence on the pharmacological treatment of COVID-19 headache. This case series presents six COVID-19 infected patients with refractory headache in which intranasal bedside Sphenopalatine Ganglion Block was performed for analgesia. All patients had a reduction in headache intensity from severe to mild or no pain after the procedure with minor transient side effects. Proposed mechanisms of action include reduction of local autonomic stimuli, intracranial vasoconstriction, and reduction of vasoactive substances release in the pterygopalatine fossa.

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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.

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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.

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ABSTRACT BACKGROUND AND OBJECTIVES: Post-dural puncture headache is a common complication in neuraxial anesthesia and lumbar puncture diagnostic procedures. The pathogenesis of the headache is thought to be due to a leak of cerebrospinal fluid from the puncture site that exceeds the rate of cerebrospinal fluid production, causing a downward traction of the meninges and vasodilation of the meningeal vessels mediated by the autonomous nervous system. Nowadays, the conservative treatment involves hydration, and the use of caffeine, analgesics, hydrocortisone, gabapentin, and theophylline. However, an autologous epidural blood patch is considered the definitive treatment for post-dural puncture headache and has an efficacy of up to 75%. Since this procedure comes with intrinsic risks, an alternative is the sphenopalatine ganglion block. CASE REPORT: We describe a case report using a sphenopalatine ganglion block to treat post-dural puncture headache in a patient submitted to cerebrospinal fluid pressure monitoring with a subarachnoidal catheter inserted with a low-gauge needle. CONCLUSION: This is the first case report of a post-dural puncture headache caused by a subarachnoid monitoring catheter successfully treated with sphenopalatine ganglion block. This technique can be a non-invasive option in the management of post-dural puncture headache, which requires more study to evaluate its efficacy and safety.

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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.

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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 24-48h after dural puncture, with 4mL of ropivacaine 0.75% in each nostril. In three cases pain recurred within 12-48h, 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 12-24h.

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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.

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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. Supportive 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 1l of crystalloids, Dexamethasone 4mg, parecoxib 40mg, acetaminophen 1g and caffeine 500mg without significant relief after 2hours. We performed a bilateral SPGB with a cotton-tipped applicator saturated with 0.5% Levobupivacaine under standard ASA monitoring. Symptoms relief was reported 5minutes after the block. The patient was monitored for an hour after which she was discharged and prescribed acetaminophen 1g and ibuprofen 400mg every 8hours for the following 2 days. She was contacted on the next day and again after a week reporting no pain in both situations. 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.

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