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Sphenopalatine block with lidocaine spray for treatment of obstetric postdural puncture headache

利多卡因喷雾剂行蝶腭神经节阻滞治疗产科硬膜外穿刺后头痛

翻译：苗 排版：叮当丸子麻

Epidural analgesia（硬膜外镇痛） is the technique of choice for labor analgesia（分娩镇痛）． Post－dural puncture headache （PDPH） is the most frequent complication （incidence up to 88％ after an accidental dural puncture）． Sometimes， the headache disables the woman to take care of her newborn and lengthens the hospital stay． The most effective treatment for PDPH is the epidural blood patch（硬膜外血补丁）， but it is not without risks； sphenopalatine ganglion block（碟腭神经节阻滞） is an effective and minimally invasive alternative， After obtaining written informed consent， we present three cases of PDPH in puerperal women sucessfully treated with bilateral sphenopalatine ganglion block using a 10％ lidocaine spray （Xilonibsa aerosol 10％， Laboratorios Inibsa， Barcelona， Spain）．

硬膜外镇痛是分娩镇痛的首选技术。硬膜外穿刺后头痛（PDPH）是最常见的并发症（意外穿破硬脊膜后发生率高达88％）。有时，头痛使妇女无法照顾她的新生儿，并延长住院时间。对PDPH最有效的治疗方法是硬膜外血补丁，但它并非没有风险；蝶腭神经节阻滞是一种有效和微创的选择，在获得书面知情同意后，我们报告了3例产后女性成功地使用10％利多卡因喷雾行双侧蝶腭神经节阻滞治疗PDPH（Xilonibsa aerosol 10％， Laboratorios Inibsa， Barcelona， Spain）。

Case 1 was 42－year－old female with an accidental dural puncture during labor epidural analgesia． Two days later， she developed a PDPH， which persisted after three days despite analgesic treatment （VAS score ＝ 5）， limiting for ambulation（行走）． A bilateral sphenopalatine block was performed with lidocaine spray （two puffs of 10 mg on each nostril）， with significant pain relief for 12 h （VAS ＝ 1） and good tolerance to ambulation． The following day， the patient was discharged（出院） after a second block． After a third self－administered block at home， she remained asymptomatic（无症状的）．

病例1为42岁女性，分娩期间行硬膜外镇痛时意外穿破硬脊膜。两天后，她出现PDPH，尽管进行了镇痛治疗（VAS评分＝5），但疼痛持续3天后，限制了行走。使用利多卡因喷雾剂进行双侧蝶腭神经节阻滞（每侧鼻孔喷2次，每次10mg）， 12小时后疼痛显著缓解（VAS＝1），行走耐受性良好。第二天，病人在进行了第二次治疗后出院。在家中进行第三次自我控制后，她仍然没有症状。

Case 2 was 32－year－old patient who presented PDPH after an uneventful labor epidural analgesia（硬膜外分娩镇痛）， without improvement with analgesics and corticosteroids （糖皮质激素）（VAS ＝ 8）． The next day， bilateral sphenopalatine block was performed with significant pain relief （VAS ＝ 3）． One day later， the patient was discharged without headache．

病例2为32岁患者，在硬膜外分娩镇痛后出现PDPH，使用镇痛药和糖皮质激素后均无改善（VAS＝8）。第二天行双侧蝶腭神经节阻滞后疼痛明显缓解（VAS＝3）。一天后患者出院，无头痛。

Case 3 was 36－year－old patient with accidental dural puncture during labor epidural analgesia． A few hours later， she developed PDPH （VAS ＝ 6） with no response to conventional treatment． The following day， bilateral sphenopalatine block was performed with pain improvement （VAS ＝ 3） lasting 6 h； over the next 24 h， the patient performed herself two additional blocks． On the third day， the patient presented slight residual pain （VAS ＝ 2） so she was discharged． Three days later， she remained asymptomatic．

病例3为36岁患者，硬膜外分娩镇痛时意外穿破硬脊膜。几小时后，患者出现PDPH （VAS＝6），常规治疗无反应。隔天行双侧蝶腭神经节阻滞，疼痛改善（VAS＝3）持续6 h；在接下来的24小时里，病人自己做了两次阻滞。第3天，患者自觉轻微疼痛（VAS＝2），患者出院。三天后，她没有任何症状。

PDPH is very common in obstetric patients after a dural puncture． If the pain is severe after 24–48 h of conservative treatment（保守治疗）， an epidural blood patch would be indicated， although this technique is not without complications and is not always accepted by patients．

PDPH在产科患者硬膜外穿刺后非常常见。如果保守治疗24－48小时后疼痛仍严重，则需要硬膜外血补丁，尽管这种技术并非没有并发症，也并非总是被患者所接受。

In recent years， it has been documented that sphenopalatine ganglion block may be an effective treatment for PDPH ［1–3］， and has been proposed as an alternative to the epidural blood patch， which would remain as a rescue technique． This blockade would inhibit parasympathetic－mediated cerebral vasodilation（副交感神经介导的大脑血管舒张） induced by loss of cerebrospinal fluid（脑脊液） by the dural gap ［4］． It is a simple procedure， minimally invasive， quickly effective， and can be repeated if necessary． Complications are rare and minor （bleed， transient discomfort， anesthesia of the pharynx（咽）） and there are almost no contraindications（禁忌症） （local infection， skull base fractures）． It is performed transnasally， with the patient in supine position and the neck hyperextended， introducing swabs impregnated with local anesthetic deeply into both nostrils and maintaining them for 5–10 min． However， this technique requires trained personnel to perform it and carries a risk of nasal bleeding due to mucosal congestion（黏膜水肿） associated with pregnancy．

近年来，有文献报道蝶腭神经节阻滞可能是治疗PDPH的有效方法［1－3］，并提出可以替代硬膜外血补片，也可以作为一种抢救技术。这种阻滞可抑制脊膜（蛛网膜和软脊膜之间）间隙［4］的脑脊液流失所引起的副交感神经介导的脑血管舒张。手术简单，微创，见效快，必要时可重复。并发症少见且轻微（出血、短暂不适、咽部麻醉），几乎无禁忌证（局部感染、颅底骨折）。蝶腭神经节阻滞是通过鼻腔进行的，病人在仰卧位和颈部过伸位，用棉签浸满局部麻醉药深入鼻孔并维持5－10分钟。然而，这种技术需要训练有素的人员来执行，由于粘膜充血与怀孕有关，所以患者有鼻出血的风险。

A simpler alternative is to perform the blockade with a 10％ lidocaine spray ［5］． The patient is placed in the previously described position， the applicator is inserted in each nostril and two puffs are administered（施行） while the patient takes a deep breath through the nose； then the patient is kept supine for some minutes． The patient should be advised not to eat or drink while feeling numbness throat（喉咙麻木）． The advantage of this technique is that the patient can be instructed to carry it out by herself， and it can be applied on demand （up to a maximum of four times a day）， allowing the mother＇s autonomy and facilitating hospital discharge．

一种更简单的方法是使用10％利多卡因喷雾剂［5］进行阻滞。将患者置于前述位置，将喷药器插入每个鼻孔，并在患者通过鼻子深呼吸时进行两次喷药；然后让病人仰卧几分钟。建议患者在感到喉咙麻木时不要进食或饮水。这项技术的优点是，可以指导病人自己进行这项操作，而且可以根据需要应用（最多一天四次），使产后母亲可以自主活动，便于出院。

Keywords：

Obstetric analgesia 产科镇痛

Postdural puncture headache 硬膜外穿刺后头痛

Sphenopalatine ganglion block 碟腭神经节阻滞