Mahdy Enas Wageh, Elsaid Asmaa Mohamed A, Dabour Yehya Shahin, Salman Samar A
Department of Anesthesia, Pain, and ICU, Faculty of Medicine, Benha University, Benha, Arab Republic of Egypt.
Department of Anesthesia, Pain, and ICU, Faculty of Medicine, Cairo University, Cairo, Arab Republic of Egypt.
Pain Physician. 2025 Mar;28(2):E137-E146.
Anesthesia through neuroaxial approaches is an effective option for lower abdominal surgeries, but postdural puncture headache (PDPH) is often an adverse effect of this procedure.
Evaluation of the effect of bilateral bi-level greater occipital nerve blocks (GONB) on the severity of PDPH and its effect on patients' quality of life.
Randomized controlled trial.
Department of Anesthesia, ICU and Pain, Faculty of Medicine, Benha University in conjunction with multiple private centers, Cairo, Arab Republic of Egypt.
A total of 180 patients with PDHP were evaluated using the Numeric Rating Scale (NRS-11) to assess pain in an upright position and the 36-Item Short-form Survey Instrument (SF-36) was used to assess the effect of PDPH on quality of life. Patients were randomly divided into an intramuscular group and received an intramuscular injection. Other injection location groups were distal (DG), proximal (PG), and bilevel (BG). All groups received bilateral GONB using 2 mL of lidocaine 2% mixed with 2 mL of dexamethasone. Pain scores were evaluated at 24 hours postprocedure. At one month pain and SF-36 scores were recorded. The success rate was defined as the frequency of pain-free (NRS-11 < 4) among the trial patients. Recurrent cases received bilevel GONB and nonresponsive patients received an epidural blood patch.
At 24 hours postprocedure, 82.8% of the total patients and all BG patients were pain-free. NRS-11 pain scores were significantly lower in BG patients than patients in other groups; 7 patients required an epidural blood patch. At one month, 114 total patients (63.3%) had a zero pain score and 95.6% of BG patients were pain-free; the BG patients had significantly lower pain scores than the other groups. Also, SF-36 scores were improved in all patients with significantly higher scores in the BG and PG groups compared to the other groups. Twenty-seven total patients had recurrent PDPH; intramuscular injection patients had a significantly higher frequency of recurrent PDPH and shorter pain-free duration. The success rate of bilevel GONB management for recurrent PDPH was 81.5%.
The limitations of this trial are two-fold: missing of blocking the other occipital nerves and omission of blocking at the recently defined area of the three main occipital nerves communicate.
Bilevel GONB provided was superior to single level blocks and intramuscular injection with no 24 hour postprocedure failure, a low recurrence rate, and totally negated the need for an epidural blood patch; it also significantly improved patients' quality of life. Bilevel GONB is an efficient first-line therapy for recurrent PDPH.
神经轴索途径麻醉是下腹部手术的有效选择，但硬膜穿刺后头痛（PDPH）常是该手术的一种不良反应。
评估双侧双水平枕大神经阻滞（GONB）对PDPH严重程度的影响及其对患者生活质量的影响。
随机对照试验。
埃及阿拉伯共和国开罗贝纳大学医学院麻醉科、重症监护病房和疼痛科，以及多个私人中心。
共180例PDPH患者使用数字评分量表（NRS-11）评估直立位疼痛情况，并用36项简明调查问卷（SF-36）评估PDPH对生活质量的影响。患者随机分为肌肉注射组，接受肌肉注射。其他注射部位组为远端组（DG）、近端组（PG）和双水平组（BG）。所有组均使用2 mL 2%利多卡因与2 mL地塞米松混合进行双侧GONB。术后24小时评估疼痛评分。在1个月时记录疼痛和SF-36评分。成功率定义为试验患者中无痛（NRS-11<4）的频率。复发患者接受双水平GONB，无反应患者接受硬膜外血贴。
术后24小时，所有患者中的82.8%以及所有BG组患者均无痛。BG组患者的NRS-11疼痛评分显著低于其他组患者；7例患者需要进行硬膜外血贴。1个月时，114例患者（63.3%）疼痛评分为零，95.6%的BG组患者无痛；BG组患者的疼痛评分显著低于其他组。此外，所有患者的SF-36评分均有所改善，BG组和PG组患者的评分显著高于其他组。共有27例患者出现PDPH复发；肌肉注射组患者PDPH复发频率显著更高，无痛持续时间更短。双水平GONB治疗复发PDPH的成功率为81.5%。
本试验的局限性有两方面：未阻滞其他枕神经以及遗漏在最近定义的三条主要枕神经交汇区域进行阻滞。
双水平GONB优于单水平阻滞和肌肉注射，术后24小时无失败情况，复发率低，完全无需硬膜外血贴；还显著改善了患者的生活质量。双水平GONB是复发PDPH的有效一线治疗方法。
