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A Pediatric Patient w/ Acute Lymphoblastic Leukemia (ALL) being Treated w/ Intrathecal Chemotherapy Suffers Post-Dural Puncture Headache.
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Preet Patel, MD, Scott Mellender, MD, William Grubb, MD, DDS
Department of Anesthesiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ 08901
HPI: A 20 year-old female with pre-B cell acute lymphoblastic leukemia (ALL) currently undergoing maintenance therapy, with PMH of prednisone-induced diabetes, presented with persistent headache for 5 days. The patient describes pressure/pulsing pain spanning across her occipital region. At worst, the pain is 9/10 in intensity, constant and characteristic of the headaches she routinely gets post lumbar puncture (LP). Her last lumbar puncture with intrathecal Methotrexate (MTX) was two days prior to headache onset. Patient has been taking 2 tablets of ibuprofen BID x 2 days with minimal relief. The pain is partially relieved when lying supine (VAS 2/10). The patient has no previous history of head injury.
Treatment: Post-dural puncture headache (PDPH) due to intrathecal administration of chemotherapy agents has become increasingly recognized, and there are an increasing number of requests to anesthesiologists for epidural blood patch (EBP). A major concern in the patient population with hematological malignancies is the possibility of neuraxial seeding of malignancies [1-2]. One recently published case report describes the use of flow cytometry to screen for blast cells in the circulating blood . Careful analysis and minimization of this potential risk is required to ensure the safety of the EBP in this specific patient population. Due to the complexities associated with the use of an EBP in this patient, we chose to perform a sphenopalatine ganglion block (SPGB) instead.
Discussion: SPGB is a noninvasive anesthetic intervention with minimal adverse effects and high efficacy . It can be performed by inserting a cotton-tipped applicator saturated with 5% water-soluble lidocaine ointment through each nares bilaterally and positioning the end of the applicator tip just superior to the middle turbinate and anterior to the pterygopalatine fossa and sphenopalatine ganglion (SPG) for 10 minutes with the patient in supine or Trendelenburg position. Block of the SPG with local anesthetic (1 cc of 4% lidocaine) requires good anatomical and physiological placement of the cotton-tipped applicator and leads to rapid termination of severe headache.