Bilateral Greater Occipital Nerve Block; Distal Versus Proximal Approach for Postdural Puncture Headache: A Randomized Clinical Trial.

Abstract

One of the common neuraxial anesthesia complications is postdural puncture headache (PDPH). Greater occipital nerve block (GONB) is a simple and safe maneuver with a faster onset than other treatment modalities. Our work aims to compare the pain-relieving effect between distal and proximal ultrasound (US)-guided bilateral GONBs for PDPH. A randomized, double-blinded study. Aswan University Hospital, Egypt. The study included 50 patients of both genders, aged 20 to 60 years, who had PDPH with a sitting Numeric Rating Scale (NRS-11) >= 4. Patients were randomized into 2 equal groups. Group D received a US-guided distal bilateral GONB (at the superior nuchal line level). Group P received a US-guided proximal bilateral GONB (at the second cervical vertebra level). Three milliliters of isobaric bupivacaine 0.5% and 4 mg dexamethasone were injected in both blocks. There was a significant decrease in lying down and sitting NRS-11 at 10 minutes, 6, 12, 24, 36, and 48 hours after the intervention compared to before the intervention in both groups. Only sitting NRS-11 was significantly lower in group P than group D in all measurements after the intervention. Success rate (sitting NRS-11 < 4) at 24 hours was 60% in group D and 84% in group P, with an insignificant difference. The total 48-hour paracetamol and tramadol consumption was significantly lower in group P than in group D (P = 0.038 and 0.036, respectively). Transient cervicalgia occurred in 8% of each group. The small number of cases to prove the secondary outcomes and the absence of a control group. US-guided proximal and distal GONBs were minimally invasive, simple, and effective ways to treat PDPH, with the superiority of proximal GONB in alleviating PDPH. Postdural puncture headache, distal, proximal, greater occipital nerve, block, ultrasound, pain-relieving, neuraxial anesthesia.