Vanderpol Jitka, Jonker Leon
Consultant Neurologist, Neurology Department, Cumbria Partnership NHS Foundation Trust, Penrith, CA11 8HX, UK.
Science & Innovation Manager, R&D Department, Cumbria Partnership NHS Foundation Trust, Carlisle, CA1 3SX, UK.
Clin Neurol Neurosurg. 2019 Jan;176:73-77. doi: 10.1016/j.clineuro.2018.12.001. Epub 2018 Dec 3.
Greater occipital nerve (GON) block is a treatment option applied for a variety of primary headache disorders. Although a patient's body position is known to have an impact on the effect of local anaesthetics, this has not before been investigated for patients undergoing GON block. Therefore, the clinical effectiveness of either a sitting or supine position was assessed.
This evaluative prospective study took place in a single neurology department in the UK. Baseline and follow-up data were collated during standard clinic consultations for 95 consecutive patients who underwent GON block and follow-up consultations for treatment-refractory headache disorder. The GON block procedure was identical for all patients in terms of constitution of the applied medication and volume injected (lidocaine hydrochloride 20 mg and methylprednisolone acetate 80 mg in 2 ml vial). Directly afterwards, patients opted to either sit up (n = 34) or lie down (n = 61) for ten minutes.
Twenty-seven patients (44%) reported substantial benefit and 17 (28%) complete benefit (pain freedom) for a median duration of 70 days and 84 days in the 'supine' group, compared with 10 (29%) substantial and 6 (18%) complete benefit (pain freedom) for a median duration of 25 days (substantial) and 119 days (complete) in the 'sitting' group. Overall, a supine position results in a longer overall post-GON block headache-free period (p-value 0.007) and median relief score (p-value 0.017) compared to a sitting up position, as determined by Mann-Whitney U-test. Backward multiple linear regression analysis showed that the chronicity of the patient's condition is negatively associated (beta -0.24, p-value 0.024) and the post-GON block patient position is positively associated (beta 0.25, p-value 0.018) with the achieved headache-free period. Apart from variation in baseline headache characteristics, the 'sitting' and 'supine' cohorts did not significantly differ in terms of other clinical parameters and patient demographics.
Placing a patient in a supine position following a GON block procedure for headache may significantly improve the resulting clinical effectiveness of this treatment. Further research, through a prospective, multi-centre, randomised, controlled trial, is indicated to determine if the initial positive observations in this present pragmatic evaluation can be confirmed.
枕大神经（GON）阻滞是用于多种原发性头痛疾病的一种治疗选择。尽管已知患者的体位会影响局部麻醉药的效果，但此前尚未针对接受GON阻滞的患者对此进行研究。因此，评估了坐姿或仰卧位的临床效果。
这项评估性前瞻性研究在英国的一个单一神经科进行。在对95例连续接受GON阻滞的患者进行标准门诊咨询以及对难治性头痛疾病进行随访咨询期间收集基线和随访数据。就所用药物的组成和注射量（2ml小瓶中的20mg盐酸利多卡因和80mg醋酸甲基泼尼松龙）而言，所有患者的GON阻滞操作均相同。之后，患者选择坐起（n = 34）或躺下（n = 61）十分钟。
“仰卧”组中有27例患者（44%）报告有显著改善，17例（28%）完全缓解（无痛），中位持续时间分别为70天和84天；而“坐立”组中分别有10例（29%）显著改善和6例（18%）完全缓解（无痛），中位持续时间分别为25天（显著改善）和119天（完全缓解）。总体而言，通过曼-惠特尼U检验确定，与坐姿相比，仰卧位导致GON阻滞后总体无头痛期更长（p值0.007），中位缓解评分更高（p值0.017）。向后多元线性回归分析表明，患者病情的慢性程度与达到的无头痛期呈负相关（β -0.24，p值0.024），而GON阻滞后患者的体位与达到的无头痛期呈正相关（β 0.25，p值0.018）。除了基线头痛特征存在差异外，“坐立”和“仰卧”队列在其他临床参数和患者人口统计学方面没有显著差异。
头痛患者在GON阻滞操作后采取仰卧位可能会显著提高该治疗的临床效果。需要通过一项前瞻性、多中心、随机对照试验进行进一步研究，以确定在本次实用性评估中的初步阳性观察结果是否能够得到证实。
