A study to compare efficacy of oral methylprednisolone and sphenopalatine block in postdural puncture headache

Need for the study :

The international headache society (IHS) defines PDPH(post dural puncture headache) as a headache occurring within 5 days of a lumbar puncture caused by CSF leakage through the dural puncture. PDPH is one of most common complications in spinal anesthesia after obstetrics and gynaecological surgeries.  The PDPH clinically is very characteristic, with frontal and/or occipital headache, exacerbated with orthostatism, and relieved in decubitus, which appears 6 to 72 hours after the procedure (90% starts up to 3 days after the procedure and 66% in the first 48 hours). Other symptoms may also be associated, such as nausea, dizziness, stiff neck, visual and/or auditory changes. Without any treatment, PDPH can persist for about two weeks (it is estimated that 72% of cases will resolve spontaneously after 7 days). Incidence of PDPH ranges from 4-18% in obstetrics and gynaecology surgical cases. It is often exhausting, hindering the mother from taking care of the newborn baby in obstetrics cases. This causes raised healthcare costs, extended stay in the hospital, and frequent visits to the emergency department. PDPH can be managed with conservative treatment like bed rest, good hydration, analgesics like paracetamol, methylxanthines like caffeine and gamma aminobutyric acid like pregabalin or gabapentin. Some researchers have also used corticosteroids for the management of PDPH. PDPH resistant to all therapy can be managed with epidural blood patch. Corticosteroids have been widely used for as multimodal analgesia protocols for managing postoperative pain. Oral methylprednisolone has been used for low pressure headache associated with syndrome of spontaneous intracranial hypotension (SSIH). Hence it has been used in the treatment of PDPH. Sphenopalatine ganglion block (SPGB), a non-invasive intervention with minimal adverse effects and high efficacy, had been tried as a treatment modality of PDPH. SPGB efficacy has been proved in the management of migraine and facial pain. There are a number of case reports and case series reporting the success of SPGB for the management of spinal headache in obstetric patients. But due to its minimal invasive nature along dyscomfort to patient while application and easy acceptibility of oral medication for patients, we decided to study and compare the efficacy of oral methylprednisolone and sphenopalatine ganglion block in postdural puncture headache after spinal anesthesia in obstetrics and gynaecology surgical cases.

Aim and objectives:

To observe and compare the efficacy of oral methylprednisolone and sphenopalatine ganglion block in postdural puncture headache after spinal anesthesia in obstetrics and gynaecology surgical cases

Methodology:

Patients who developed postdural puncture headache(PDPH) after obstetrics and gynaecology surgeries will be selected for study in command hospital Air Force Bangalore and randomnly assigned to two groups. Group A (n=15) cases will be managed with oral methylprednisolone 8 mg once a daily for 3 days along with other conservative treatment like bed rest, adequate hydration therapy. Group B (n=15) will be managed with sphenopalatine ganglion block using bupivacaine 2 % intranasal route for spinal headache along with other conservative treatment like bed rest and adequate hydration therapy. Both groups will be assessed with visual analogue scale(VAS) graded 0-10 for pain severity post treatment at just before starting of treatment (0 hr) then followed by at 12 hr, 24 hr, 48 hr, and 72 hr. Zero was considered as no pain and 10 as severe pain; 0-1 (no headache),2-4 (mild headache), 5-7 (moderate headache) and 8-10 (severe headache). If headache was persist even after 3 days of treatment the autologous epidural blood patch (EBP) will be given to patients. Both groups will be compared and assessed for efficacy of methylprednisolone compared to sphenopalatine block in treating PDPH.