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Table of Contents
EDITORIAL
Year : 2020  |  Volume : 36  |  Issue : 2  |  Page : 147-148

The use of sphenopalatine ganglion block for analgesia and attenuation of stress response induced by skull-pin head-holder during neurosurgery


Department of Anesthesia and Chronic Pain Medicine, University of Cincinnati College of Medicine, Medical Sciences Building Room 3502, 231 Albert Sabin Way, Cincinnati, OH 45267, USA

Date of Submission23-Mar-2020
Date of Acceptance23-Mar-2020
Date of Web Publication15-Jun-2020

Correspondence Address:
Dr. Shuchita Garg
Department of Anesthesia and Chronic Pain Medicine, University of Cincinnati College of Medicine, Medical Sciences Building Room 3502, 231 Albert Sabin Way, Cincinnati, OH 45267
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacp.JOACP_134_20

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How to cite this article:
Garg S, Sachdeva H. The use of sphenopalatine ganglion block for analgesia and attenuation of stress response induced by skull-pin head-holder during neurosurgery. J Anaesthesiol Clin Pharmacol 2020;36:147-8

How to cite this URL:
Garg S, Sachdeva H. The use of sphenopalatine ganglion block for analgesia and attenuation of stress response induced by skull-pin head-holder during neurosurgery. J Anaesthesiol Clin Pharmacol [serial online] 2020 [cited 2020 Aug 15];36:147-8. Available from: http://www.joacp.org/text.asp?2020/36/2/147/286795



It is estimated that approximately 13.8 million new cases will undergo surgery worldwide each year, with 3.5 million new neurosurgical cases expected in Southeast Asia alone.[1] Increased workload begets increased responsibilities for the neuroanesthesiologists. In craniotomy, stabilization of the patient's head with a skull-pin head-holder is an essential step to steady the skull for acceptable surgical exposure. These metallic pins penetrate the skin and go into the outer table of the cranium, where it is fixed at around a pressure of 30 lbs. in adults. The use of skull-pins may cause a severe nociceptive stimulus and trigger an intense sympathetic and neuroendocrine response in the patient. This could lead to an increase in intracranial pressure, cerebral edema, and likely intracranial hemorrhage.[2] This may be especially detrimental perioperatively in patients with an unruptured cerebral aneurysm. For both neurosurgeons and anesthesiologists, the sympathetic response becomes challenging if the patient has compromised intracranial compliance, cerebral autoregulation due to ruptured intracranial aneurysms, and/or intracranial hypertension. Cardiovascular comorbidities also complicate the patient's perioperative management. To obtund this predicament, various techniques and pharmacological interventions have been used, albeit with capricious benefits.

Inspired by their appreciation of the possible benefits of adequate regional anesthesia, Harvey Cushing and George Crile (in the early 1900s) proposed the notion of peripheral nerve block of the scalp. The first scalp blockade to improve hemodynamic control during cranial fixation was suggested by Pinosky et al.[3]

The use of local anesthetics and adjuncts come with various caveats. Earnest vigilance is required to prevent overdosing (scalp being very vascular, leading to increased absorption). There may be an occurrence of orbital ecchymosis due to the fluid percolating along the aponeurosis. Also noted is the occurrence of accidental intracerebral injection and subsequent generalized seizures.[4]

This necessitates out of the box, thinking. In this issue, Padhy N et al., have provided us with one such conception.[5] The authors have compared the efficacy of a scalp block and bilateral sphenopalatine ganglion block (nasal approach) for the attenuation of hemodynamic response during skull pin insertion [Figure 1]. The sphenopalatine ganglion is also known as the pterygopalatine ganglion or Meckel's ganglion. It is the largest extracranial parasympathetic ganglion found in the pterygopalatine fossa, near the sphenopalatine foramen. It is posterior to the middle turbinate and maxillary sinus, bilaterally. The greater petrosal nerve innervates it and its axons project to the lacrimal glands and nasal mucosa.
Figure 1: Sphenopalatine Ganglion Block for Attenuation of Stress Response Induced by Skull-Pin Head-Holder During Neurosurgery

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The blockade of this ganglion with local anesthetic is clinically denoted as the “sphenopalatine ganglion block.” Sphenopalatine ganglion blocks (SPG) can be accomplished with the use of lidocaine-soaked cotton tip applicator via placement through nose [Figure 1], trans-orally, trans-nasally using an endoscope, infratemporal approach, and noninvasive trans-nasal devices to inject local anesthetics into the sphenopalatine ganglion. In 1908, Sluder G first described the use of trans-nasal SPG using cocaine to treat Sluder's neuralgia and later Ruskin S, in 1925 he used it to treat trigeminal neuralgia. Since then, SPG has been used to manage migraine, cluster headache, and many more conditions.

The topical sphenopalatine ganglion block, when used for the treatment of persistent migraines and cluster headaches, demonstrated relief within 10–20 minutes. Increasingly, the SPG trials have also been used to treat postdural-puncture headache (PDPH) and it has been found that it may be as therapeutic as an epidural blood patch when used for PDPH. In anesthesia, sphenopalatine ganglion block has been used to alleviate postoperative pain in endoscopic sinus surgery and endoscopic trans-nasal resection of pituitary adenoma.

The study by Padhy N et al., opens up lots of possibilities for future studies to explore and evaluate the efficacy of sphenopalatine ganglion block in neuroanesthesia. These could include a comparison of various local anesthetics (longer acting) with or without adjuncts, their long-term benefits in the postoperative period, opioid sparring, associated side effects, and also if they are equally useful in awake craniotomies. Use of skull pin head holders is also prevalent in awake craniotomies where long-acting local anesthetics are infiltrated locally.[6]

Not everything that counts can be counted, and not everything that can be counted, counts.”.... Albert Einstein

Though the study by Padhy N et al. is limited by the lack of proper blinding technique and non-quantification of perioperative analgesic requirement, it does open up scope for future studies. Patient blinding is supported by traditional and theoretical contemplations. Balk EM et al., reported that absence or indistinct double blinding correlated with 23% exaggeration of intervention effect estimates (ROR 0.77, 95% CI 0.61 to 0.93).[7] The saying “Absence of evidence is not evidence of absence,” though very attractive is usually misconstrued for scientific research. Having said that, there is a need to publish uncertain results, thereby reducing the burden on the scientific scholars to report their results as absolute and definitive only. A culture is required to be created that provides ease of estimation and deliberating on uncertainty as well. It is imperative that we consider the results of a research in the context of all existing studies which deliberate upon the same question. This can help increase the statistical power, decrease the uncertainty, and therefore reduce the unclear reporting of underpowered studies. The authors must be detailed and accurate in their interpretation and use language that avoids the enticement of cutting down on the word limit wherein the gist and the exact connotation of their work is lost.

We hope that this research study will spur future, larger sample size studies on the use of sphenopalatine ganglion block for patients who come for endonasal surgeries, craniotomies as well as its use in various other chronic pain conditions. As experts in this specialty, we need to inculcate the capability to ask our self, every day: is there a more appropriate method of doing this? The answers will eventually follow. Promoting research requires our involvement as anesthesiologists and should be our commitment to our profession and our patients. We should strive to inspire the new generation of anesthesiologists to usher in a new era of scientific discoveries, innovations, and help make a meaningful change for the good of our patients.



 
  References Top

1.
Dewan MC, Rattani A, Fieggen G, Arraez MA, Servadei F, Boop FA, et al. Global neurosurgery: The current capacity and deficit in the provision of essential neurosurgical care. Executive summary of the global neurosurgery initiative at the program in global surgery and social change. J Neurosurg 2018:1-10. doi: 10.3171/2017.11.JNS171500.  Back to cited text no. 1
    
2.
Uyar AS, Yagmurdur H, Fidan Y, Topkaya C, Basar H. Dexmedetomidine attenuates the hemodynamic and neuroendocrinal responses to skull-pin head-holder application during craniotomy. J Neurosurg Anesthesiol 2008;20:174-9.  Back to cited text no. 2
    
3.
Pinosky ML, Fishman RL, Reeves ST, Harvey SC, Patel S, Palesch Y, et al. The effect of bupivacaine skull block on the hemodynamic response to craniotomy. Anesth Analg 1996;83:1256-61.  Back to cited text no. 3
    
4.
Lee WK, Kim H, Bae MI, Choi SH, Min KT. Accidental intracerebral injection and seizure during scalp nerve blocks for awake craniotomy in a previously craniotomized patient -a case report. Korean J Anesthesiol 2018;71:483-5.  Back to cited text no. 4
    
5.
Padhy N, Moningi S, Kulkarni DK, Alugolu R, Inturi S, Ramachandran G. Sphenopalatine ganglion block: Intranasal transmucosal approach for anterior scalp blockade - A prospective randomized comparative study. J Anaesthesiol Clin Pharmacol 2019;35:207-12.  Back to cited text no. 5
    
6.
Ghazanwy M, Chakrabarti R, Tewari A, Sinha A. Awake craniotomy: A qualitative review and future challenges. Saudi J Anaesth 2014;8:529-39.  Back to cited text no. 6
    
7.
Balk EM, Bonis PA, Moskowitz H, Schmid CH, Ioannidis JP, Wang C, et al. Correlation of quality measures with estimates of treatment effect in meta-analyses of randomized controlled trials. JAMA 2002;287:2973-82.  Back to cited text no. 7
    


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