Sphenopalatine Ganglion Block Research Articles

COMPLICATIONS OF EPIDURAL BLOOD PATCH AND HOW TO AVOID THEM: A NARRATIVE REVIEW

Purpose of review. Postdural puncture headache (PDPH) is a common complication after spinal anaesthesia or inadvertent dural puncture. The most effective treatment option for patients with unsuccessful conservative management is an epidural blood patch (EBP), which is invasive and may result in rare but severe complications. The purpose of this article is to review the efficacy of the most studied alternatives to EBP for treatment of PDPH.Recent findings. Conservative therapies such as bed rest, hydration, and caffeine are commonly used as prophylaxis and treatment for this condition; however, no substantial evidence supports routine bed rest and aggressive hydration. Although EBP is the most reliable, there are some patients in whom this treatment is refused or contraindicated. Sphenopalatine ganglion block with bilateral transnasal local anaesthetic instillation is suggested as a simple, minimally invasive treatment for PDPH, but the most recent studies showed no statistically significant effect on pain intensity. Much more effective is the semi-forgotten intravenous aquatherapy after Leriche with distilled water (20-40 ml), giving fast effect (in several minutes).Conclusions. In cases of ineffective conservative therapy, we recommend the seriatim treatment, beginning from the least invasive sphenopalatine ganglion block with intranasal local anaesthetic instillation, then intravenous aquatherapy after Leriche, then EBP.

Topical intranasal lidocaine is not a sphenopalatine ganglion block

There is renewed interest in the central role of the sphenopalatine ganglion (SPG) in cerebrovascular autonomic physiology and the pathophysiology of different primary and secondary headache disorders. There are diverse...

The Efficacy of Sphenopalatine Ganglion Block and Radiofrequency Denervation in the Treatment of Cluster Headache: A Case Series.

BackgroundCluster headache is a variant of primary neurovascular headaches. some patients with cluster headache are not responsive to medical treatment and may benefit from interventional modalities, including sphenopalatine ganglion block and denervation.ObjectivesOur purpose was to evaluate the efficacy of sphenopalatine ganglion block/denervation in the treatment of cluster headache.MethodsIn this study, we performed the sphenopalatine ganglion block for patients with cluster headaches, intractable to medical therapy, who were referred to our pain clinic between 2014 and 2018. We registered the following information for all patients: demographic data, pain relief, and pain intensity. First, we conducted a prognostic C-arm-guided sphenopalatine ganglion block. If there was at least 50% pain relief within the first 5 h, then we denervated the ganglion by radiofrequency ablation. The main outcome of the study (dependent variable) was pain relief. We followed the patients for 6 months.ResultsAmong 23 enrolled patients, 19 consented to interventional treatment. Fifteen out of 19 patients (79%) had an acceptable response to the prognostic block. Ultimately, 11 patients underwent ganglion denervation, and 4 patients did not consent for ganglion ablation. Pain relief at intervals of 48 h, and 1, 3, and 6 months after ganglion denervation was 77, 59, 50, and 31 percent, respectively.ConclusionsSphenopalatine ganglion conventional radiofrequency denervation can effectively decrease the pain intensity of the patients with cluster headache for at least several months.

How I do it: sphenopalatine ganglion block and radiofrequency ablation

How I do it: sphenopalatine ganglion block and radiofrequency ablation

Bilateral sphenopalatine ganglion block reduces blood pressure and blood pressure variability in never treated patients with essential hypertension

Abstract Background Sphenopalatine ganglion (SPG) area is connected through sympathetic fibers with the central nervous system. It is already known that SPG infiltration by lidocaine reduced blood pressure in naïve hypertensive patients. Blood pressure variability (BPV) has been associated with an increased risk of cardiovascular events and mortality, independently of elevated BP levels. We aimed to study the effect of SPG block in BPV in never treated patients with stage I–II essential hypertension. Methods We performed bilateral SPG block with lidocaine 2% in 47 newly diagnosed and never treated hypertensive patients (study group, mean age 50±12 years, 31 men) and a sham operation with water for injection in 11 patients (control group, mean age 51±12 years, 8 men). All patients have been subjected to 24 hour ambulatory blood pressure monitoring (ABPM) prior and a month after the SPG block in order to estimate any differences in BP parameters derived from ABPM (BP, BPV). We defined as responders to SBG block those patients with a 24h average SBP decrease >5 mmHg. Results We noticed the following significant differences in the study group: a. 24h average DBP and daytime DBP were reduced by 1.6±5 mmHg (p=0.04) and 1.9±5 mmHg (p=0.01) respectively and b. systolic BPV during daytime (11±2 mmHg vs. 10±2 mmHg, p<0.05). Interestingly, in the responders group (14/47, 30%, 9 men, age = 47±8 mmHg) and a month after SPG block we noticed that: a. 24h average, daytime, night-time SBP and 24h average, daytime, night-time DBP were reduced by 9±4 mmHg (p<0.001), 9±3 mmHg (p<0.001), 7±7 mmHg (p=0.002) and 6.5±3 mmHg (p<0.001), 6.5±3 mmHg (p<0.001), 4±7 mmHg (p=0.02), respectively and b. systolic BPV during daytime (13±2 mmHg vs. 9±2 mmHg, p=0.01). No differences regarding BPV were found in the non-responders and the sham operation group. Conclusions SPG block is a promising, minimally invasive option of significant BP and BPV decrease in never treated hypertensive patients, especially during daytime activities when SNS is activated. It acts probably through SNS modulation. Since its effect is only anesthetic and non-permanent, SPG block might permit the selection of the hypertensive patients with an activated SNS before any other invasive antihypertensive procedure. SPG block reduces BP variability Funding Acknowledgement Type of funding source: None

Endoscopic Sphenopalatine Ganglion Block Efficacy in the Management of Periorbital Edema and Ecchymosis After Septorhinoplasty.

This study aims to evaluate the efficacy of sphenopalatine ganglion block (SPGB) on postoperative edema and ecchymosis for the patients undergoing septorhinoplasty (SRP). In the study, a total number of 55 participant patients (40% male and 60% female, aged between 18 and 42 years) undergoing hump resection and osteotomies were allocated into 2 groups. The SPGB (+) group consisted of 27 patients who underwent SPGB, while the SPGB (-) group consisted of 28 patients who underwent SRP without SPGB. On the first, third, and seventh postoperative days (POD1, POD3, POD7), the score marks of periorbital edema and ecchymosis of the patients were evaluated. Additionally, postoperative upper eyelid edema and upper eyelid ecchymosis as well as lower eyelid edema, and lower eyelid ecchymosis on POD1, POD3, POD7 were evaluated. A comparison with regard to intraoperative bleeding, surgical field, and operation time between the 2 groups was also conducted. Upper eyelid edema, upper eyelid ecchymosis, lower eyelid edema, lower eyelid ecchymosis on POD 1, 3, 7 were found to be significantly lower in SPGB (+) group in comparison to SPGB (-) group (P < 0.001). Intraoperative blood loss and surgical field were found to be significantly lower in SPGB group (+) than in SPGB (-) group (P < 0.00). The operation time was not found statistically significant between the 2 groups (P = 0.212). Sphenopalatine ganglion block is a safe and effective way of reducing postoperative edema and ecchymosis after SRP. Besides, it provides a better surgical field and reduced bleeding intraoperatively.

Images in anesthesiology: three safe, simple, and inexpensive methods to administer the sphenopalatine ganglion block

The sphenopalatine ganglion (SPG) block is a simple and valuable technique that was discovered over a century ago, but, unfortunately, very few anesthesiology providers are familiar with this block. After...

Cortical and subcortical changes following sphenopalatine ganglion blocks in chronic migraine with medication overuse headache: a preliminary longitudinal study

ObjectiveThe purpose of this pilot study was to investigate potential changes in brain morphology (cortical thickness and cortical/subcortical volume) accompanying a series of sphenopalatine ganglion (SPG) blockade treatments in chronic migraine with medication overuse headaches (CMw/MOH).BackgroundLocal anesthetization of the SPG via intranasal application is used for the treatment for multiple types of headache disorders, including CM. Our previous longitudinal fMRI study revealed improved network connectivity after such treatment. However, the impact of SPG blocks on cortical, subcortical gray matter volume and cortical thickness has yet to be assessed.MethodsUsing magnetic resonance imaging (MRI), cortical/subcortical volume were measured in 12 chronic migraine patients before and after a series of 12 SPG blocks administered over a 6-week period (2 per week). The average time between MRI assessments was 6 weeks. Targeted, within-subjects t-tests comparing pre-treatment and post-treatment values in specific apriori brain regions of interest, including the hippocampus, amygdala, basal ganglia, somatosensory cortex, temporal cortex and occipital cortex, were used to estimate the impact of repetitive SPG blocks treatment on brain morphology in CMw/MOH.ResultsCompared to baseline values, the number of moderate/severe headache days per month, HIT-6, PHQ-9 scores and allodynia scores were all significantly improved at the end of treatment. Analysis of MRI data revealed that the volume of the right hippocampus and the right palladium significantly decreased following SPG block treatment, while the volume of the left nucleus accumbens significantly increased following treatment. Cortical thickness in the left temporal pole and left lateral occipito-temporal gyrus significantly decreased following SPG block treatment.ConclusionOur results suggest SPG block treatment is associated with significant symptom improvement as well as significant structural brain changes in regions known to be associated with migraine and chronic pain processing in CMw/MOH.

Sphenopalatine Ganglion Block in Endoscopic Sinus Surgery: A Comparative Study

Objectives: The aim of this study was to find the effect of sphenopalatine ganglion block given via greater palatine foramen in managing intraoperative bleeding, postoperative pain and its effect on functional outcome and postoperative adverse effects in Functional Endoscopic Sinus Surgery (FESS). Methods: In this prospective study, a total of 60 consenting patients posted for FESS for chronic sinusitis were selected and randomised into two groups. Group A received sphenopalatine ganglion block via greater palatine foramen and group B did not. Intraoperative surgical field visibility was measured by Average Category Scale by Fromm and Boezaart. Postoperatively those with pain score more than 4 in VAS were given diclofenac injection. Functional outcome was measured by SNOT 22. Results: There was no significant difference in age and sex distribution of patients in both groups. Preoperative SNOT scores were comparable in both groups. There was improvement noted in surgical field in block group compared to non- block group. Significantly lesser requirement of postoperative analgesics was noted in this study with p value <.01. Postoperatively functional outcome with SNOT22 scores significantly improved in both groups compared to preoperative SNOT 22 scores. Better improvement was seen in block (A) group. Mean postoperative SNOT22 score in group B (14.3) was significantly higher than that in group A (5.2). Number of adverse effects reported in both groups was comparable. Conclusion: Intraoperative bleeding which reduces surgical field visibility and postoperative pain which results in excessive use of analgesics are common problems faced by endoscopic sinus surgeons. In this study, addition of sphenopalatine ganglion block to general anesthesia was tried in FESS to overcome these problems and to improve the outcome. This study showed a significantly reduced need for postoperative analgesics with use of SPG block. Patients who received SPG block showed better improvement in functional outcome and comparable occurrence of adverse effects with the no block recipients. Even though there was improvement in surgical field in SPG block group, we couldn’t establish a statistically significant outcome.

Retrospective Study on Ganglionic and Nerve Block Series as Therapeutic Option for Chronic Pain Patients with Refractory Neuropathic Pain.

Objective Current recommendations controversially discuss local infiltration techniques as specific treatment for refractory pain syndromes. Evidence of effectiveness remains inconclusive and local infiltration series are discussed as a therapeutic option in patients not responding to standard therapy. The aim of this study was to investigate the effectiveness of infiltration series with techniques such as sphenopalatine ganglion (SPG) block and ganglionic local opioid analgesia (GLOA) for the treatment of neuropathic pain in the head and neck area in a selected patient group. Methods In a retrospective clinical study, 4960 cases presenting to our university hospital outpatient pain clinic between 2009 and 2016 were screened. Altogether, 83 patients with neuropathic pain syndromes receiving local infiltration series were included. Numeric rating scale (NRS) scores before, during, and after infiltration series, comorbidity, and psychological assessment were evaluated. Results Maximum NRS before infiltration series was median 9 (IQR 8–10). During infiltration series, maximum NRS was reduced by mean 3.2 points (SD 3.3, p < 0.001) equaling a pain reduction of 41.0% (SD 40.4%). With infiltration series, mean pain reduction of at least 30% or 50% NRS was achieved in 54.2% or 44.6% of cases, respectively. In six percent of patients, increased pain intensity was noted. Initial improvement after the first infiltration was strongly associated with overall improvement throughout the series. Conclusion This study suggests a beneficial effect of local infiltration series as a treatment option for refractory neuropathic pain syndromes in the context of a multimodal approach. This effect is both significant and clinically relevant and therefore highlights the need for further randomized controlled trials.

Lidocaine Versus Bupivacaine in the Treatment of Headache with Intranasal Sphenopalatine Nerve Block

Intranasal sphenopalatine ganglion (SPG) block has been shown to be an effective treatment for headaches. Multiple therapeutic agents have been studied, although the wide availability and low cost of lidocaine and bupivacaine have made them attractive treatment options. To the authors knowledge, no study has yet demonstrated superiority of one anesthetic over the other. To determine the efficacy of lidocaine versus bupivacaine when performing intranasal sphenopalatine ganglion (SPG) block for the treatment of headaches. Retrospective cohort study. A single tertiary care academic institutionMETHODS: This retrospective study identified patients who underwent SPG block at a single institution from January 1, 2014 to December 20, 2017. Patients were included if they were treated with either lidocaine or bupivacaine and had both pre- and post-procedure pain scores recorded on a 0-10 scale. Patients were excluded if they were less than 18 years of age. 386 total procedures were performed. 303 (78.5%) were lidocaine delivered via the SphenoCath device, and 83 (21.5%) were bupivacaine delivered via the Tx360 device. 90.2% of treatments (n = 348) decreased the patient's pain level. Of the treatments performed with lidocaine, 89.1% (n = 270) resulted in improvement of the patient's pain level with a mean decrease in pain level of 3.1 (SD ± 2.3). Of the treatments performed with bupivacaine, 94.0% (n = 78) resulted in improvement of the patient's pain level, with a mean decrease in pain level of 3.0 (SD ± 1.9). No statistically significant difference was found between the 2 anesthetics. The retrospective study design may introduce selection bias. Both lidocaine and bupivacaine were administered by different devices (Sphenocath and Tx360 respectively) which may account for differences in initial treatment success. There were differences in the size of the two groups, which may also introduce error. This study demonstrates similar efficacy of SPG block performed with lidocaine or bupivacaine. While no difference was found, the particular advantages and disadvantages of the intranasal delivery device may influence physician choice. Sphenopalatine ganglion nerve block, lidocaine, bupivacaine, sphenocath, Tx360, pain intervetnio, headache, miimally invasive therapy.

EFFECTS OF BILATERAL SPHENOPALATINE GANGLION BLOCK IN FUNCTIONAL ENDOSCOPIC SINUS SURGERY UNDER GENERAL ANESTHESIA

Background: Functional endoscopic sinus surgery (FESS) is considered as one of the most common surgical procedure. General anesthesia (GA) is usually required during FESS. Regional analgesic techniques can use during GA that is inhibits the intra- and the post-operative detrimental stimuli. Objective: To evaluate the effects of bilateral sphenopalatine ganglion block (SPGB) in FESS by using different types of local anesthetic agents. Patients and Methods: A double-blinded, randomized, controlled-trial study was performed on 80 patients undergoing FESS with bilateral SPGB under GA. This study was conducted at departments of Otorhinolaryngology and Anesthesia & Intensive care, Al-Jafel International Hospital, Riyadh, KSA. The current study was conducted since May 2018 till January 2020. The patients were categorized into 4 groups; group I using (bupivacaine 0.5%), group II using (ropavacine 0.75%), group III using (xylocaine 2%), and group IV using (saline) as a control group. Observed variables included hemodynamic parameters, surgical field visibility, intra-operative blood loss, post-operative analgesia use, and complications related to the used technique. Results: Averages of the heart rate, mean arterial blood pressure, bleeding, operative time, and visual analogue scale (VAS) in the three groups were statistically significant different from the controls (P=000). The clarities of the operative field and bleeding amount in the three groups separately were statistically significant different from the controls (P=0.000). The differences in the post-operative complications in the three groups and the controls were statistically insignificant except for group III. The differences in the analgesics usage in the three studied groups and the controls were statistically insignificant except group I. Conclusion: Using of bilateral SPGB in FESS under GA is proved to be of great importance in reducing the heart rate, arterial blood pressure, bleeding, operation time, and VAS in the studied groups. Further, xylocaine 2% is significantly reducing the post-operative complications. Also, bupivacaine 0.5% is significantly reducing the analgesics usage.

Sphenopalatine ganglion block for the treatment of postdural puncture headache: a randomised, blinded, clinical trial

BackgroundCurrent treatment of postdural puncture headache includes epidural blood patch (EBP), which is invasive and may result in rare but severe complications. Sphenopalatine ganglion block is suggested as a simple, minimally invasive treatment for postdural puncture headache. We aimed to investigate the analgesic effect of a transnasal sphenopalatine ganglion block with local anaesthetic vs saline. MethodsWe conducted a blinded, randomised clinical trial including adults fulfilling the criteria for EBP. Participants received a sphenopalatine ganglion block bilaterally with 1 ml of either local anaesthetic (lidocaine 4% and ropivacaine 0.5%) or placebo (saline). Primary outcome was pain in upright position 30 min post-block, measured on a 0–100 mm VAS. ResultsWe randomised 40 patients with an upright median pain intensity of 74 and 84 mm in the local anaesthetic and placebo groups at baseline, respectively. At 30 min after sphenopalatine ganglion block, the median pain intensity in upright position was 26 mm in the local anaesthetic group vs 37 mm in the placebo group (estimated median difference: 5 mm; 95% confidence interval: –14 to 21; P=0.53). In the local anaesthetic group, 50% required an EBP compared with 45% in the placebo group (P=0.76). ConclusionsAdministration of a sphenopalatine ganglion block with local anaesthetic had no statistically significant effect on pain intensity after 30 min compared with placebo. However, pain was reduced and EBP was avoided in half the patients of both groups, which suggests a major effect not necessarily attributable to local anaesthetics. Clinical trial registrationNCT03652714.

English

English

Postdural puncture headache in the obstetric population: a new approach?

Background and objectivesThe gold standard for the treatment of postdural puncture headache (PDPH) is the epidural blood patch (EBP). Regional techniques—sphenopalatine ganglion block (SPGB), greater occipital nerve block (GONB) and...

The Effect of Sphenopalatine Ganglion Block on the Postoperative Pain in Patients Undergoing Septorhinoplasty.

This study aimed to evaluate the effect of preoperative sphenopalatine ganglion block (SPBG) on the postoperative pain (POP) in patients undergoing septorhinoplasty (SRP). A retrospective cohort study was performed. A total of 42 patients that had received septorhinoplasty included in the study. The patients that had received SPBG before the surgery included in the Block group (n:20) and the patients that had not received SPBG before the surgery included in the Control group (n:22). POP was questioned with a numeric rating scale (NRS) at the 30th minute (t1), 1st hour (t2), 4th hour (t3), 12th hour (t4), and 24th hour (t5) and noted. The intraoperative details and the dose of the postoperative rescue analgesics were also noted. The average dose of Paracetamol that was used in the postoperative first 24 hours was 500 mg in the Block group and 1363 mg in the Control group, and the difference was statistically significant (P = .001). The average dose of Tramadol was 0 mg in the Block group and 45 mg in the Control group, and the difference was statistically significant (P = .001). There was a statistically significant difference among the groups with respect to NRS in the first 24 hours postoperatively (P < .05). The number of the patients requiring rescue analgesics was lower in the Block group than the Control group. The difference was statistically significant at the t1, t2, and t5 time intervals (P > .05). Preoperative SPGB is an effective option to reduce POP and the need for rescue analgesics for patients undergoing SRP. NCT04020393.

Comparative evaluation of conservative management and sphenopalatine ganglion block for postdural puncture headache: A randomized controlled trial

Background: Postdural puncture headache (PDPH) is a well-known iatrogenic and distressing complication of a subarachnoid block. In this study, we aimed to see if the sphenopalatine ganglion block (SPGB) is beneficial for the treatment of PDPH in comparison to conservative management or not. Patients and Methods: This prospective, randomized, observational study registered in the Clinical Trials Registry of India (CTRI/2018/02/011883). We included 60 patients, divided into three groups of 20 each. Group C patients were managed conservatively. Group L4 patients were given SPGB with 4% lignocaine per SPGB. Group L10 patients were given SPGB with lignocaine 10% puffs. The patients were assessed at predefined durations for Visual Analog Scale (VAS) score, readiness to discharge, and feel-good index. SPSS 20.0 software was used for data analysis. Results: There was a statistically significant reduction in VAS score and mean treatment duration in group L4 and group L10 in comparison to group C. At 72 h of treatment, 5.26% of Group C patients, 88.89% of Group L4, and 95% of Group L10 patients were found ready to discharge. The feel-good index was assessed after 15 min of treatment was found best in Group L10, followed by L4 and C groups. Conclusion: SPGB increases the proportion of patients ready to discharge at 72 h of treatment. Lignocaine 10% is more effective than lignocaine 4% solution for SPGB. SPGB decreases the hospital stay, hence cost-effective.

The efficacy of bilateral sphenopalatine ganglion block under general anesthesia in trans-sphenoidal endoscopic hypophysectomy

Background:The most important goal in endoscopic pituitary surgery is bloodless field with better visualization under hemodynamic stability and good analgesia to improve the outcome, the current study was performed to evaluate the intraoperative anesthetic and postoperative analgesic effects of bilateral sphenopalatine ganglion block(SPGB)as adjuvant to general anesthesia in endoscopic transsphenoidal resection of pituitary adenoma. Patients and methods:thirty patients(ASA I-II)aged 22–55 years, randomly assigned into two equal groups. After stabilization of general anesthesia, the patients received bilateral sphenopalatine ganglion block with 2ml of either2% lidocaine: 1:200000 epinephrine(SPGB group)or sterile normal saline(control group). Mean arterial blood pressure was maintained at 60–70mmHg by using nitroglycerine. Intraoperative MAP and heart rate, Nitroglycerine and propranolol consumption, blood loss, average category scale, emergence time were recorded. Also, pre and postoperative plasma B-endorphin, VAS and time of first request for analgesia, total dose of meperidine consumption in the first 24hours postoperatively, patient’s satisfaction and post-operative complication were recorded. Results: Sphenopalatine ganglion block group showed decrease in blood loss(P<0.001), ACS(P<0.01), nitroglycerine consumption(P<0.0001)and emergence time(P< 0.001). At PACU, visual analogue pain score were lower in SPGB at 0,1,6(P<0.001), there were a high difference between two groups in B-endorphin levels(P<0.001)and also in dose of meperidine, % of patients needs analgesia and patients satisfaction(P<0.002), Conclusion:Use of sphenopalatine ganglion block with general anesthesia is a safe and effective technique, it contributes in adequate intra and postoperative analgesia needed for stabilization of hemodynamics with less blood loss, improving the quality of surgical field instead of controlled hypotensive technique during endoscopic endo-nasal trans-sphenoidal hypophysectomy.

Low-temperature plasma radiofrequency ablation for the management of refractory cluster headache.

IntroductionAlthough the sphenopalatine ganglion (SPG) has been considered a site of therapeutic potential for cluster headache (CH), the optimal technique of SPG is still to be determined. Low-temperature plasma radiofrequency ablation (LTPRA) has been proposed as an alternative treatment for several neuropathic pain diseases.AimTo evaluate the effect of LTPRA of SPG in treating chronic and episodic CH.Material and methodsThe patients with CH, who achieved temporary pain relief following SPG block, treated using LTPRA between January 2015 and October 2017 were reviewed. Seventy-six patients were included: 50 patients suffered from episodic CH and the remaining 26 patients from chronic CH. The primary outcomes were clinical improvement rate, defined as the percentage of partial and complete pain relief results at 1 day, 12 months, and 24 months of follow-up after the operation.ResultsClinical improvement rates were 92.3%, 92.3% and 73.1% in chronic CH and 73.1%, 84% and 68% in episodic CH at each follow-up time point, respectively. 3 chronic CH patients and 7 episodic CH patients showed no pain relief after the operation. Drooping eyelids were found in 2 cases, one recovered at the 3-month follow-up but another one did not in the 24-month follow-up. No serious complications occurred intraoperatively or postoperatively.ConclusionsLTPRA can be considered an effective and alternative surgical modality in treating patients with chronic and episodic CH, based on SPG block.

Treat PDPH (Post dural puncture headache) with sphenopalatine ganglion block: Transnasal approach

Background and Study Objective: To treat PDPH by simple and effective means using transnasal Sphenopalatine ganglion block. PDPH (post dural puncture headache) is one of the very well known complications. Management of PDPH is always challenging to anesthesiologist. Though the incidence of PDPH has reduced with new small spinal needles and needle tip designs, still occasional PDPH cases are observed.