Sphenopalatine ganglion block (SPGB) has been used for the treatment of headaches for almost a century. Chronic headache tends to respond better to SPGB by blocking parasympathetic outflow which is vital in headache pathophysiology. We present a Case Series of 10 patients where SPGB was done under fluoroscopy using the “Sphenocath device” to treat different headache and facial pain syndromes. Though case reports exist using the traditional “blind” transnasal approach, there is limited literature using fluoroscopy for SPGB.
Materials and Methods & Results:
No IRB approval was indicated. No conflict of interest. Informed consent was obtained from patients for this presentation.
We reviewed ten SPGB cases done over the past year for different head and neck pain syndromes. Characteristics of each case have been summarized in Table 1.
With patient supine and neck extended, the nares were topicalized with 2% lidocaine. Lateral fluoroscopic view of face, basal skull and nose was obtained to identify the landmarks. With the lubricated “Sphenocath” in the retracted position, the catheter was advanced under live fluoroscopy via the right nares parallel to the nasal bridge until the tip of the catheter contacted the nasal roof. It was turned medially and the inner catheter deployed into the extended position using a pull-push motion to ensure the curved tip was positioned above the middle turbinate. 1 ml of Isovue 300M dye was injected under live fluoroscopy to ensure dye spread between the middle and superior turbinates with pooling in the sphenopalatine fossa with minimal spillover into the posterior nasopharynx (Fig. 1). 3 ml of 4% lidocaine was injected through the catheter prior to removal. Procedure was similarly repeated on the left. Patient was kept recumbent for 10 minutes for proper disbursement of injectate in the sphenopalatine fossa. Successful blockade of SPG was indicated by 2o F rise in facial temperature.
The Sphenopalatine ganglion is an inverted triangular structure located posterior to the middle nasal turbinate in the pterygopalatine fossa. It contains postganglionic sympathetic fibers, synapses between pre- and postganglionic parasympathetic fibers and somatosensory fibers of the head and neck, making it an ideal target for interventional pain physicians. Newer devices have allowed for more effective blockade of the SPG, expanding the indications to a variety of pain syndromes (Fig. 2).
In our case series, certain patient factors predicted success while others failed, emphasizing the need for good patient selection.
1- Patients with migraine, trigeminal neuralgia, post-dural puncture headache responded well.
2- Patients with previous surgeries over the head and neck failed to respond well.
3- Patients who were on prior chronic opioid therapy failed to get good relief.
There is limited evidence advocating for the efficacy of “blind” transnasal SPGB in the treatment of head and neck pain syndromes. We believe that adding fluoroscopic guidance can provide additional advantage by visually confirming delivery of the medication right over the ganglion. Appropriate patient selection increases the likelihood of a successful outcome in terms of pain relief following SPGB. Further studies are required to explore the efficacy of this less invasive option and determine the appropriate indications for the use of SPGB in the treatment of chronic headache syndromes.