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50th Annual Regional Anesthesiology and Acute Pain Medicine Meeting
May 1 - 3, 2025 | Orlando, Florida
6703
SPHENOPALATINE GANGLION BLOCK FOR POST-DURAL PUNCTURE HEADACHE IN HIV POSITIVE PATIENT WITH REACTIVE RPR
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SPHENOPALATINE GANGLION BLOCK FOR POST-DURAL PUNCTURE HEADACHE IN HIV POSITIVE PATIENT WITH REACTIVE RPR
•Post-dural puncture headache (PDPH) is a recognized complication following spinal anesthesia
•Reported rates from 1.5-11.2%, vary based on several factors including age, history of headaches, and type and size of needle used (1,2).
•Natural course of PDPH is resolution within 2 weeks, but in cases of severe symptomatology, procedures are available to alleviate symptoms, which include epidural blood patch (EBP) and sphenopalatine ganglion block (SPGB).
•32-year-old male presented for anal condyloma removal under spinal anesthesia.
•PMH significant for HIV intermittently on Biktarvy and syphilis previously treated with doxycycline due to penicillin allergy (initial RPR 1:128, recently fluctuating between 1:1 to 1:4).
•25-guage pencil-tip needle was initially used but placement unsuccessful due to robust ligament. 22-guage pencil-tip needle used with successful subarachnoid placement on first pass. The rest of the perioperative course was uneventful, patient discharged same day.
•Patient contacted post-operative day 1 (POD#1) for follow-up, no complaints besides mild back pain at puncture site.
•POD#2 developed severe headache leading to presentation to the Emergency Department. Workup unremarkable and symptoms improved following IVF and medications, and he discharged home.
•Despite conservative measures, including hydration, caffeine consumption, and scheduled acetaminophen, severe headaches persisted through POD#6, and after being offered procedures including EBP and SPGB, he elected to present for SPGB.
•POD#7 SPGB was performed using transnasal catheter.
•2mL of 4% lidocaine with contrast media given through each naris under fluoroscopy to verify appropriate placement (figure).
•The patient experienced conjunctival injection, tearing, facial warmth and flushing, and had almost immediate relief of his symptoms.
•No recurrence of PDPH symptoms with follow-up on POD#10.
•Both HIV and syphilis seem to infect neuroaxis early in course
•Neuraxial procedures including EBP in patients with HIV have been established as safe without increasing risk of morbidity (3). Little information exists on outcomes of autologous EBP with syphilis. Patients with HIV and syphilis coinfection have elevated rates of syphilis recurrence and reinfection (4).
•Alternative epidural injectates include crystalloid, dextran, and fibrin glue, though evidence for efficacy and safety is lacking (2).
•Allogeneic EBP has also been described in case reports (5).
•In cases of patient refusal or if epidural access is contraindicated, greater occipital nerve blocks and SPGB have been utilized (2).
1.DelPizzo K, Cheng J, Dong N, Edmonds CR, Kahn RL, Fields KG, Curren J, Rotundo V, Zayas VM. Post-Dural Puncture Headache is Uncommon in Young Ambulatory Surgery Patients. HSS J. 2017 Jul;13(2):146-151. doi: 10.1007/s11420-017-9541-0. Epub 2017 Mar 16. PMID: 28690464; PMCID: PMC5481263.
2.Russell R, Laxton C, Lucas DN, Niewiarowski J, Scrutton M, Stocks G. Treatment of obstetric post-dural puncture headache. Part 1: conservative and pharmacological management. International journal of obstetric anesthesia. 2019 May 1;38:93-103.
3.Tom, Dari J. M.D.*; Gulevich, Steven J. M.D.†; Shapiro, Harvey M. M.D.‡; Heaton, Robert K. Ph.D.§; Grant, Igor M.D.§. Epidural Blood Patch in the HIV-positive Patient Review of Clinical Experience. The Journal of the American Society of Anesthesiologists 76(6):p 943-947, June 1, 1992. | DOI: 10.1097/00000542-199206000-00012
4.Wu Y, Lu L, Song X, Liu X, Yang Y, Chen L, Tang J, Han Y, Lv W, Cao W, Li T. Clinical and immunological characteristics of HIV/syphilis co-infected patients following long-term antiretroviral treatment. Front Public Health. 2024 Jan 15;11:1327896. doi: 10.3389/fpubh.2023.1327896. PMID: 38288435; PMCID: PMC10823526.
5.Trentman TL, Hoxworth JM, Kusne S, Torloni AS, Patel NP, Rosenfeld DM. Allogeneic epidural blood patch in the setting of persistent spinal headache and disseminated coccidioidomycosis. Pain Physician. 2009;12(3):639.