Greater Occipital Nerve Block at Two Levels Spares the Need for an Epidural Blood Patch for Managing Postdural Puncture Headache: A Randomized Comparative Trial

Background: 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. Objectives: 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. Study Design: Randomized controlled trial. Setting: Department of Anesthesia, ICU and Pain, Faculty of Medicine, Benha University in conjunction with multiple private centers, Cairo, Arab Republic of Egypt. Methods: 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. Results: 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% Limitations: 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. Conclusion: 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.