Disclosures: Thomas Chai, MD: No financial relationships or conflicts of interest

Case Diagnosis: 62-year-old male with oncologic history of cervicomedullary-junction glioma, status post proton therapy, presented with severe, persistent headache, base of skull/neck pain, and left-sided facial pain.

Case Description or Program Description: The patient failed multiple pain regimens (opioids and adjuvants) and interventions, including occipital nerve/other cranial peripheral nerve blocks, cervical facet joint injections, onabotulinum-A toxin chemodenervation of craniofacial muscles, ketamine infusions, and intrathecal trials of opioids and ziconotide. He was then deemed a candidate for sphenopalatine ganglion blockade for refractory pain.

Setting: Tertiary Care Center

Assessment/Results: The patient underwent left-sided sphenopalatine ganglion (SPG) block via a transnasal approach, utilizing a catheter designed specifically for this procedure. Patient was placed supine with head slightly extended. The tip of the catheter was advanced intranasally through the left nostril, superior to the middle nasal turbinate, and 1.5 mL of viscous lidocaine 2% was injected to flow towards the nasal mucosa overlying the SPG. Patient position held for 5 minutes. After this period, patient reported substantial relief of his pain, which he had not felt with any of the other previously discussed treatments. The relief lasted for several weeks, prompting the patient to undergo repeat blocks monthly.

Discussion (relevance): The sphenopalatine ganglion (SPG) is considered the autonomic hub within the skull. The SPG is located within the pterygopalatine fossa, and numerous sympathetic and parasympathetic fibers synapse at, or course through, the sphenopalatine ganglion. SPG blockade for pain can be performed via a transnasal, infrazygomatic, or transoral approach. Based on the highest level of evidence available, SPG blockade is indicated for cluster headache, trigeminal neuralgia of the maxillary division, and migraine headaches. There is sparse evidence in the literature for SPG blockade in the treatment of neoplasm-related head, neck, and facial pain.

Conclusions: Sphenopalatine ganglion blockade should be considered for head/neck and facial pain due to neoplastic processes.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/refractory-headache-neck-and-facial-pain-due-to-cervicomedullary-junction-glioma-relieved-with-sphenopalatine-ganglion-blockade-a-case-report/