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Bilateral greater occipital nerve block for post‐dural puncture headache

2008; Wiley; Volume: 63; Issue: 5 Linguagem: Inglês

10.1111/j.1365-2044.2008.05531.x

1365-2044

E. Matute, Sergio Armando Zapata Bonilla, A. Gironés, A. Planas Roca,

Spine and Intervertebral Disc Pathology

AnaesthesiaVolume 63, Issue 5 p. 557-558 Free Access Bilateral greater occipital nerve block for post-dural puncture headache E. Matute, E. MatuteSearch for more papers by this authorS. Bonilla, S. BonillaSearch for more papers by this authorA. Gironés, A. GironésSearch for more papers by this authorA. Planas, A. PlanasSearch for more papers by this author E. Matute, E. MatuteSearch for more papers by this authorS. Bonilla, S. BonillaSearch for more papers by this authorA. Gironés, A. GironésSearch for more papers by this authorA. Planas, A. PlanasSearch for more papers by this author First published: 11 April 2008 https://doi.org/10.1111/j.1365-2044.2008.05531.xCitations: 26 A response to a previously published article or letter can be submitted to the Online Correspondence section at http://www.anaesthesiacorrespondence.com. A selection of this correspondence is published several times a year in Anaesthesia. All correspondence intended for publication in Anaesthesia should be addressed to Dr David Bogod, Editor-in-Chief, and submitted as an e-mail attachment to [email protected]. For multi-author letters, a covering letter signed by all authors must be submitted either by post, fax (44 (0) 115 962 7670) or by e-mail as a scanned document before correspondence can be published. Alternatively, letters may be submitted typewritten on one side of paper, double spaced with wide margins to Anaesthesia, 1st Floor, Maternity Unit, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK. All paper submissions must include a signed covering letter, a disc or CD-ROM with a Word for Windows or .rtf version of the letter and an email address for the corresponding author. Copy should be prepared in the usual style of the Correspondence section. Authors must follow the advice about references and other matters contained in the Author Guidelines at http://www.blackwellpublishing.com/journals/ana/submiss.htm. Correspondence presented in any other style or format will be returned to the author for revision. AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Post-dural puncture headache (PDPH) is a frequent complication of procedures involving dural penetration for spinal anaesthesia, or following unintentional dural puncture during attempted epidural anaesthesia or analgesia. The International Headache Society has defined a PDPH as a bilateral headache that develops within 7 days and disappears within 14 days after the dural puncture. The headache worsens within 15 min of assuming an upright position and improves within 30 min of resuming the recumbent position [1]. The greater occipital nerve is formed by sensory fibres that originate in the C2 and C3 segments of the spinal cord. Its cutaneous sensory distribution extends over the posterior part of the head, spreading anteriorly to the vertex towards the area supplied by the ophthalmic division of the trigeminal nerve [2]. We present two cases of PDPH treated successfully with bilateral blockade of the greater occipital nerve. The first case was young healthy male who underwent surgery for umbilical herniorrhaphy. Spinal blockade was performed with a Whitacre 27 G needle. On the second postoperative day the patient complained of the typical symptoms of cervico-frontal PDPH. Conservative treatment was commenced with postural measures, hydration, caffeine and conventional analgesia. His symptoms did not improve and IV hydrocortisone was added the next day. Bilateral blockade of the greater occipital nerve was performed with bupivacaine 0.25% 4 ml and triamcinolone 20 mg. The headache completely disappeared a few minutes after the blockade. The patient was discharged on the fifth postoperative day. The second case was healthy young woman who developed a PDPH 40 h after accidental dural puncture during epidural blockade for labour analgesia. The catheter was left intrathecal during labour and after delivery we administered 0.9% saline 10 ml through the catheter. Conservative management, as in the first case, with IV hydrocortisone was started. The headache was accompanied by nausea and inability to breastfeed the baby, and we decided to perform a bilateral blockade of the greater occipital nerve with bupivacaine 0.25% and triamcinolone 20 mg. After the blockade, the symptoms improved significantly and the patient was able to resume normal activities. Forty-eight hours after performing the blockade, the patient was discharged home. Neither patient required further treatment after their discharge from hospital. PDPH is the result of the loss of cerebrospinal fluid lost through the dural tear into the epidural space. The headache is generally located in the frontal and occipital area, but may also involve the neck and upper shoulders [1, 3–5]. Many authors postulate that PDPH is caused by traction on pain-sensitive structures within the cranial cavity. However, there are no changes in the position of intracranial structures, suggesting that the traction theory does not fully explain the aetiology of the PDPH. Another hypothesis for PDPH is cerebral venous dilatation. The rationale for using greater occipital nerve block comes from the proximity of sensory neurons in the upper cervical spinal cord to the trigeminal nucleus caudalis (TNC) neurons and the convergence of sensory input to TNC neurons from both cervical and trigeminal fibres [2]. Blockade of the greater occipital nerve results in an interruption of pain from an area (the oculo-frontal area) where anaesthesia is not obtained [6, 7]. The greater occipital nerve only supplies the skin, muscles and vessels of the scalp [6]. The mechanism for the relief of the headache after blockade could be due to a ‘winding down’ of central sensitisation when afferent input to the dorsal horn and TNC is temporarily reduced [2]. Dorsal horn neurons at the C2 level respond to stimulation of both the dura mater and the greater occipital nerve. Moreover, stimulation of the greater occipital nerve facilitates C2 neuronal response to dural stimulation [2]. Greater occipital nerve block could, therefore, have a neuromodulatory effect on the central mechanism of the headache. Well-designed controlled studies are now needed to assess the role of greater occipital nerve block in the treatment of PDPH. References 1 Gaiser R. Postdural puncture headache. Current Opinion in Anaesthesiology 2006; 19: 249– 53. 2 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. 3 Sudlow C, Warlow C. Posture and fluids for preventing post-dural puncture headache. Cochrane Database of Systematic Reviews 2001; 2: CD001790. DOI: 10.1002/14651858.CD001790. 4 Sudlow C, Warlow C. Epidural blood patching for preventing and treating post-dural puncture headache. Cochrane Database of Systematic Reviews 2001; 2: CD001791. DOI: 10.1002/14651858.CD001791. 5 Moral Turiel M, Rodriguez Simon MO, Sahagun de la Lastra J, Yuste Pascual JA. Treatment of post-dural-puncture headache with intravenous cortisone. Revista Española de Anestesiología y Reanimación 2002; 49: 101– 4. 6 Bogduk N. Role of anesthesiologic blockade in headache management. Current Pain and Headache Reports 2004; 8: 399– 403. 7 Sjaastad O. The headache of challenge in our time: cervicogenic headache. Functional Neurology 1990; 5: 155– 8. Citing Literature Volume63, Issue5May 2008Pages 557-558 ReferencesRelatedInformation