الفهرس 
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Abstract
Postdural puncture headache (PDPH) is a complication commonly related to neuraxial anesthesia and dural puncture, with an incidence proportional to the diameter of the needle, ranging from 2% with a 29G to 10% with a 27G and 25% with a 25G.
The development of fine gauge spinal needles and needle tip modification, has enabled a significant reduction in the incidence of postdural puncture headache. Though it is clear that reducing the size of the dural perforation reduces the loss of CSF.
PDPH presents as a dull throbbing pain with a frontal-occipital distribution. Typically, the headache is aggravated by sitting or standing, and is reduced by lying down. The diagnosis should be questioned in the absence of a postural component of the headache. At least partial relief should occur when the patient assumes the supine position. According to the International Classification of Headache Disorders criteria for the diagnosis of PDPH, headache develops within 5 days after dural puncture and disappears spontaneously within 1 week.
PDPH is thought to be due to a cerebrospinal fluid leak that exceeds the production rate, causing downward traction of the meninges and parasympathetic mediated reflex vasodilatation of the meningeal vessels. The incidence and severity of PDPH is influenced by the types of needle, multiple attempts or in working with obstetric patients.
The sphenopalatine ganglion (SPG) is an extracranial neural structure located in the pterygopalatine fossa that has both sympathetic and parasympathetic components as well as somatic sensory roots. Sphenopalatine ganglion block (SPGB) has been used for the treatment of migraine, cluster headache and trigeminal neuralgia and can be performed through transcutaneous, transoral or transnasal approaches.
Obstetric patients are considered at increased risk for this condition because of their sex, young age, and the widespread use of neuraxial blocks. Although PDPH usually resolves spontaneously, it has the potential to cause significant morbidity in obstetric patients. It can also interfere with the mother’s ability to take care of herself or her baby, may extend the length of hospital stay or evolve into chronic headache.
SPGB is minimally invasive, carried out at the bedside without using imaging and has apparently rapid onset than EBP with better safety profile. Despite obvious contraindication in patients with basilar skull fractures, SPGB can be done in cases where epidural Blood Patch is contraindicated. In addition, being a noninvasive technique, it can be given in the case of infection anywhere else than the nasopharynx. Patients presenting with PDPH should be considered primarily for SPGB due to safety of the procedure, immediate and sustained pain relief.
The most common side effects of SPGB are all temporary, including numbness in the throat, low blood pressure and nausea. If you do experience throat numbness, this should not last more than a few hours, and is related to swallowing a small amount of the numbing medication. Nasal bleeding or infection has been reported in some cases. Rarely, a temporary increase in pain has been reported.
We evaluated the efficacy and safety of lidocaine 2%, lidocaine 5% and bupivacaine 0.5% in transnasal sphenopalatine ganglion block for the treatment of post dural puncture headache on 30 patients. This prospective, randomized and controlled clinical study was conducted at Sohag University Hospital after its approval by the Ethics and Research Committee of Sohag Faculty of Medicine. Written informed consent was obtained from each patient before participation
Our study showed that there were non significant differences between the three studied groups regarding age, gender, body mass index, type of operation, onset, site of headache, associated symptoms, relieving factors and exaggerated follow up.
In our study, there was a nonsignificant difference between the three studied groups regarding changes in visual analogue score for severity of headache.
In our study, there were nonsignificant differences between the three studied groups regarding presence of bleeding and results of treatment of postdural puncture headache.
Conclusion
SPGB is an effective initial modality for managing severe headache in patients with PDPH. Using SPGB as first line therapy for PDPH could shorten length of stay in hospital and emergency department visit time and therefore lower the cost to the health care system incurred from PDPH, as well as improve patient satisfaction by offering a less invasive procedure for treatment.