Regional Scalp Block Research Articles

Effectiveness of Scalp Nerves Block in Reducing the Immediate Postoperative Pain in Patients Undergoing Craniotomy in Elective Neurosurgical Procedures

Objective: To determine the usefulness of regional scalp block in controlling pain after craniotomy. Methodology: This prospective, randomized, double-blind, placebo-controlled study was conducted at the Pakistan Institute of Health Sciences, Islamabad from November 2021 to April 2022. Adult patients aged 18 to 65 years, scheduled for elective craniotomy for neurosurgical procedures with an American Society of Anesthesiologists (ASA) physical status of I or II, of either gender, were included. Patients underwent craniotomy for their respective lesions. Patients were randomized into two groups: one receiving a regional scalp nerve block of 0.5% bupivacaine with 1:100,000 epinephrine after general anesthesia, and the other undergoing general anesthesia as a placebo. Pain intensity was assessed using the Visual Analog Scale (VAS) pain score at baseline (preoperatively), at 1 hour postoperatively, and at 6 hours postoperatively. Results: The mean age of patients in the treatment group was 43.14 years, while in the control group, it was 42.55 years. The treatment group had 26 males (54.2%) and 22 females (45.8%), while the control group had 25 males (52.1%) and 23 females (47.9%). There was no significant difference in the VAS score preoperatively (p > 0.05). Patients undergoing surgeries lasting less than 3 hours showed that the treatment group had a significantly lower mean VAS score of 3.08 at 1 hour compared to the control group's score of 5.11 (p = 0.027), while at the 6-hour post-surgery it was insignificant (p = 0.844). For surgeries lasting more than 3 hours, the treatment group had a significantly lower mean VAS score at 1 hour and at 6 hours post-surgery compared to the control group (p < 0.05). There were no overall complications associated with the subcutaneous injection of epinephrine and bupivacaine in blocking the scalp nerves. Conclusion: The administration of scalp nerve blocks using bupivacaine and epinephrine prior to surgical incisions has demonstrated notable advantages in terms of postoperative pain management. Such nerve blocks can offer superior postoperative analgesia compared to the control group.

Regional Scalp Blockade for Painless Removal ofIntracranial Pressure Bolts: Technical Note and Patient-Reported Outcomes

Elective insertion of intracranial pressure (ICP) monitoring bolts is useful for the diagnosis and treatment of disorders of cerebrospinal fluid dynamics. Patients typically report severe discomfort on bolt removal, which negatively impacts overall patient satisfaction of ICP monitoring. We assessed the efficacy and safety of using supratrochlear and supraorbital nerve block-a commonly used form of scalp anesthesia-alongside oral analgesia before bolt removal. We compared the efficacy and safety of regional scalp block anesthesia alongside oral analgesia versus oral analgesia alone in a cohort of 85 patients undergoing removal of diagnostic ICP bolts between June 2017 and April 2019 using retrospective patient questionnaires, as well as electronic admission documentation. We found that scalp block alongside oral analgesia improved bolt removal experience (4/5 vs. 3/5 on a 1-5 point Likert scale) and that a majority (70.6%) of patients would have preferred local anesthetic before removal in the oral analgesia-only group. Only 2 patients experienced mild and localized side effects: mild bruising and temporary facial and eyelid swelling following regional scalp block. We conclude that regional supraorbital and supratrochlear nerve block is a simple, safe, and effective adjunct to minimizing discomfort during bolt removal and improving overall patient satisfaction of ICP monitoring.

Selective scalp block decreases short term post-operative pain scores and opioid use after craniotomy: A case series

There is no consensus on the management of post-craniotomy pain. Several randomized controlled trials have examined the use of a regional scalp block for post-craniotomy pain. We aim to investigate whether scalp block affected short or long-term pain levels and opioid use after craniotomy. This study prospectively administered selective scalp blocks (lesser occipital, preauricular nerve block + pin site block) in 20 consecutive patients undergoing craniotomy for semicircular canal dehiscence. Anesthesia, pain, and opioid outcomes in these patients were compared to 40 consecutive historic controls. There was no significant difference in patient demographics between the two groups and no complications related to selective scalp block. The time between the end of procedure and end of anesthesia decreased in the scalp block group (16 vs 21 min, P = 0.047). Pain scores were significantly less in the scalp block group for the first 4 h, after which there was no statistically significant difference. Time to opioid rescue was longer in the scalp block group (3.6 vs 1.8 h, HR 0.487, P = 0.0361) and opioid use in the first 7 h was significantly less in the scalp block group. Total opioid use, outpatient opioid use, and length of stay did not differ. Selective scalp block is a safe and effective tool for short-term management of postoperative pain after craniotomy and decreases the medication requirement during emergence and recovery. Selective scalp block can speed up OR turnover but is not efficacious in the treatment of postoperative pain beyond this point.

Preoperative regional scalp block versus intraoperative intravenous fentanyl for attenuating intraoperative surgical stress response to supratentorial craniotomy in adult patients under general anaesthesia

During brain tumour resection a lot of noxious stimuli are released resulting in a significant hemodynamic and stress response, its control is challenging during anaesthesia, and can be evaluated by monitoring blood pressure (BP), heart rate (HR) Attenuating autonomic cardiovascular responses to pain resulting from skull pinning, skin incision, and craniotomy are considered significant benefits of Regional Scalp Block (RSB) in addition to reducing postoperative analgesic requirements. This study aims to evaluate the effect of preoperative regional scalp block (RSB) versus intraoperative intravenous fentanyl for attenuating intraoperative surgical stress response to supratentorial craniotomy in adult patients under general anaesthesia. The study included 30 patients randomly distributed into two equal groups with 15 patients in each, Group A: Preoperative RSB was done after induction of general anaesthesia and before skull pinning, Group C: Control group: patients were given conventional intraoperative analgesia in the form of intravenous fentanyl with no block. This study included patients with Supratentorial brain tumours were admitted to Zagazig University Hospitals. Patients have been gathered over two years duration from march 2018 to march 2020. The results showed that there were highly significant differences between RSB group and control group. Preoperative RSB showed advantages over Standard analgesia in terms of better attenuation of stress response to pain in the form of heart rate and blood pressure intraoperatively, decrease opioid consumption, lower Visual Analogue Score (VAS), Preoperative RSB can be performed easily in a short time with very high success rate allowing better intraoperative control of haemodynamics, less postoperative pain. We recommend using preoperative RSB in supratentorial craniotomy as a gold standard in our hospital to get the advantages mentioned above.

Influence of Levobupivacaine Regional Scalp Block on Hemodynamic Stability, Intra- and Postoperative Opioid Consumption in Supratentorial Craniotomies: A Randomized Controlled Trial.

The anesthetic management of supratentorial craniotomy (CR) necessitates tight intraoperative hemodynamic control. This type of surgery may also be associated with substantial postoperative pain. We aimed at evaluating the influence of regional scalp block (SB) on hemodynamic stability during the noxious events of supratentorial craniotomies and total intravenous anesthesia, its influence on intraoperative anesthetic agents' consumption, and its effect on postoperative pain control. Sixty patients scheduled for elective CR were prospectively enrolled. Patient, anesthesiologist, and neurosurgeon were blind to the random performance of SB with either levobupivacaine 0.33% (intervention group [group SB], n = 30) or the same volume of saline (control group [group CO], placebo group, n = 30). General anesthesia was induced and maintained using target-controlled infusions of remifentanil and propofol that were adjusted according to hemodynamic parameters and state entropy of the electroencephalogram (SE), respectively. Mean arterial blood pressure (MAP), heart rate (HR), SE, and propofol and remifentanil effect-site concentrations (Ce) were recorded at the time of scalp block performance (Baseline), and 0, 1, 3, and 5 minutes after skull-pin fixation (SP), skin incision (SI), CR, and dura-mater incision (DM). Morphine consumption and postoperative pain intensity (0-10 visual analog scale [VAS]) were recorded 1, 3, 6, 24, and 48 hours after surgery. Propofol and remifentanil overall infusion rates were also recorded. Data were analyzed using 2-tailed Student unpaired t tests, 2-way mixed-design analysis of variance (ANOVA), and Tukey's honestly significant difference (HSD) tests for post hoc comparisons as appropriate. Demographics and length of anesthetic procedure of group CO and SB were comparable. SP, SI, and CR were associated with a significantly higher MAP in group CO than in group SB, at least at one of the time points of recording surrounding those noxious events. This was not the case at DM. Similarly, HR was significantly higher in group CO than in group SB during SP and SI, at least at 1 of the points of recording, but not during CR and DM. Propofol and remifentanil Ce and overall infusion rates were significantly higher in group CO than in group SB, except for propofol Ce during SP. Postoperative pain VAS and cumulative morphine consumption were significantly higher in group CO than in group SB. In supratentorial craniotomies, SB improves hemodynamic control during noxious events and provides adequate and prolonged postoperative pain control as compared to placebo.

Postoperative Regional Scalp Block versus Intravenous Fentanyl for Postsupratentorial Craniotomy Analgesia in Adult Patients under General Anesthesia

Majority of patients undergoing experienced moderate to severe pain in surgical site after the procedure, and there is a reluctance to manage this pain with systemic that is understandable as it may impair neurological assessment, that is crucial in the postoperative period. In addition to that, evidence concerning alternative analgesia techniques to manage post pain is deficient. This research aims at evaluating the effect of postoperative regional scalp block (RSB) versus intravenous for analgesia in adult patients under general . Patients were automatically divided into two groups with 15 patients in each, Group B: postoperative RSB was done after the end of skin closure and before emergence from general , Group C: control group: in which standard analgesia was given in the form of intravenous with no block. This study included patients with brain were admitted to Zagazig University Hospitals. We gathered the cases in the time between March 2018 and March 2020. Results: the results displayed highly significant differences between RSB group and control group. Postoperative RSB showed advantages over standard analgesia in the point of more significant reduction of response to pain in the form of heart rate and blood pressure , decrease consumption, lower Visual Analogue Score(VAS), Postoperative RSB can be performed easily in a short time with very high success rate allowing better postoperative control of , less postoperative pain. We recommend using postoperative RSB in as a gold standard in our hospital to get the advantages as mentioned above.

Effect of bilateral scalp nerve blocks on postoperative pain and discharge times in patients undergoing supratentorial craniotomy and general anesthesia: a randomized-controlled trial.

Post-craniotomy pain is a common clinical issue and its optimal management remains incompletely studied. Utilization of a regional scalp block has the potential advantage of reducing perioperative pain and opioid consumption, thereby facilitating optimal postoperative neurologic assessment. The purpose of this study was to assess the efficacy of regional scalp block on post-craniotomy pain and opioid consumption. We performed a prospective randomized-controlled trial in adults scheduled to undergo elective supratentorial craniotomy under general anesthesia to assess the efficacy of postoperative bilateral scalp block with 0.5% bupivacaine with1:200,000 epinephrinecompared with placebo on postoperative pain and opioid consumption. The primary outcome was the visual analogue scale (VAS) for pain at 24 hr postoperatively. Eighty-nine patients were enrolled (n = 44 in block group; n = 45 in control group). There was no difference in the mean (standard deviation) VAS score at 24 hr postoperatively between the treatment group and the control group [31.2 (21.4) mm vs 23.0 (19.2) mm, respectively; mean difference, 6.6; 95% confidence interval, -2.3, 15.5; P = 0.15]. There was also no significant difference in postoperative opioid consumption. Distribution of individual VAS score and opioid consumption revealed that postoperative pain was highly variable following craniotomy. Time to hospital discharge was not different between treatment and placebo groups. No adverse events associated with scalp block were identified. These data show that bilateral scalp blocks using bupivacaine with epinephrine did not reduce mean postoperative VAS score or overall opioid consumption at 24 hr nor the time-to-discharge from the postanesthesia care unit or from hospital. www.ClinicalTrials.gov, NCT00972790; registered 9 September, 2009.

Comparative study on the operative outcome of EDH done under Regional Scalp Block and under General Anesthesia

Comparative study on the operative outcome of EDH done under Regional Scalp Block and under General Anesthesia

Efficacy and safety of dexmedetomidine infusion for patients undergoing awake craniotomy: An observational study.

Background:The goal of awake craniotomy is to maintain adequate sedation, analgesia, respiratory, and hemodynamic stability and also to provide a cooperative patient for neurologic testing. An observational study carried out to evaluate the efficacy of dexmedetomidine sedation for awake craniotomy.Materials and Methods:Adult patients with age >18 year who underwent awake craniotomy for intracranial tumor surgery were enrolled. Those who were uncooperative and had difficult airway were excluded from the study. In the operating room, the patients received a bolus dose of dexmedetomidine 1 μg/kg followed by an infusion of 0.2–0.7 μg/kg/h (bispectral index target 60–80). Once the patients were sedated, scalp block was given with bupivacaine 0.25%. The data on hemodynamics at various stages of the procedure, intraoperative complications, total amount of fentanyl used, intravenous fluids required, blood loss and transfusion, duration of surgery, Intensive Care Unit (ICU), and hospital stay were collected. The patients were assessed for Glasgow outcome scale (GOS) score and patient satisfaction score (PSS).Results:A total of 27 patients underwent awake craniotomy during a period of 2 years. Most common intraoperative complication was seizures; observed in five patients (18.5%). None of these patients experienced any episode of desaturation. Two patients had tight brain for which propofol boluses were administered. The average fentanyl consumption was 161.5 ± 85.0 μg. The duration of surgery, ICU, and hospital stays were 231.5 ± 90.5 min, 14.5 ± 3.5 h, and 4.7 ± 1.5 days, respectively. The overall PSS was 8 and GOS was good in all the patients.Conclusion:The use of dexmedetomidine infusion with regional scalp block in patients undergoing awake craniotomy is safe and efficacious. The absence of major complications and higher PSS makes it close to an ideal agent for craniotomy in awake state.

Postoperative pain management after craniotomy: Literature review and evaluation of evidence

Background: The effective management of postoperative pain have the tendency to reduce morbidity and mortality. Currently it is becoming clear that appropriate and adequate analgesia is a significant component of post craniotomy care. The goal of this review is to analyse and appraise evidence for postoperative analgesia following craniotomy. Methods: Literature search conducted using EMBASE, Medline and Cochrane database for systematic reviews. Key words applied were” postoperative analgesia”, “neurosurgery”, “neurosurgical procedures”. Resultant yield limited to 10 years, English language journal, intracranial (craniotomy) surgeries. Studies were limited to English and those involving humans. Studies limited from 1995 to 2015. Relevant studies were isolated for further critique. About 30 trials were identified but some could not be retrieved. Results: Total of 140 citations were identified, after thorough screening non relevant studies and non-randomised clinical trials were exempted. One systematic review and three randomised controlled study, Studies were limited to English and those involving humans. Conclusion: The data available showed improved analgesia with use of codeine sulphate against the backdrop of the popular tramadol which is a weak opioid fraught with significant post-operative nausea and vomiting. Also some evidences support use of regional scalp block for post craniotomy analgesia. The non-narcotics paracetamol and NSAIDs such Ketoprofen are useful analgesia compliments

Awake Craniotomy for the Treatment of a Cortical Pseudoaneurysm in a Pregnant Patient

Neurosurgical pathologies presenting during pregnancy are uncommon. If present, the situation creates a unique diagnostic, observational, and therapeutic challenge as both lives are placed at potential risk. Surgical procedures during pregnancy are approached carefully as physiological stressors associated with surgery and anesthesia may cause fetal or maternal compromise. We present the only known case of a pseudoaneurysm treated with an awake craniotomy, allowing us to abate the risks associated with general anesthesia in pregnancy.A female suffered a superficially penetrating gunshot wound to the head for which she underwent a craniotomy with complete neurological recovery. She had complaints of intermittent headaches, dizziness, and tingling of her hands five months thereafter. The cerebral angiogram demonstrated an 8 mm pseudoaneurysm under her craniotomy site. A surgical repair of this aneurysm was undertaken in the 23rd week of pregnancy via an awake craniotomy with regional scalp block. The aneurysm was resected without complication, and the patient tolerated the procedure without neurological deficit during or subsequent to the operation.Cerebrovascular pathology in pregnant patients remains a difficult situation that poses challenges associated with the pathology itself as well as the anesthetic implications inherent with operative management. The neurosurgical literature demonstrates that surgical management of cerebrovascular pathology is well-tolerated in pregnancy, and our case further demonstrates the capability of utilizing an awake craniotomy for the treatment of this type of lesion without causing a residual deficit.

The problem of acute postoperative pain in neurosurgical patients

This is review article concerned to problem of acute postoperative pain in neurosurgical patients. Many ears ago it was widely accepted that wast majority of neurosurgical patients don't have any pain sensation after craniotomy. Following investigations show that it mistake. In this article we discuss new data on statistics of acute postoperative pain after intracranial and spinal neurosurgical interventions, patophysiology of acute p/o pain and various methods preventing and treatment of this pain sensation. Regional scalp block, NSAID, i/v morphine on PCA approach, transdermal therapeutic forms of fentanyl and regional analgesia in spinal neurosurgery - are most perspective directions in solving of this problem.

Abstract PR166

Background & Objectives: The anesthetic goal for awake craniotomy is not only to maintain adequate sedation, analgesia, respiratory and hemodynamic stability but also to provide an awake yet co-operative patient for proper neurological testing. Dexmedetomidine, an a2-agonist, has advantages of being a minimal respiratory depressant with cardiac stabilization properties. We carried out an observational study to evaluate the efficacy of dexmedetomidine sedation for awake craniotomy. Materials & Methods: All patients with age more than 18yr who underwent awake craniotomy for intracranial tumor surgery were enrolled. The patients who were un-cooperative, had difficult airway and had medical conditions preventing them to lie down for many hours, were excluded. In the operating room, the patients received a bolus dose of dexmedetomidine 1µg/kg over 10min followed by an infusion of 0.2–0.7µg/kg/hr (BIS target 60–80). Once the patients were sedated, scalp block was given with bupivacaine 0.25%. The data on hemodynamics at various painful stages of the procedure, intraoperative complications, nausea/vomiting, brain bulge, seizures etc were collected. Total amount of fentanyl used, intravenous (IV) fluids required, blood loss and transfusion, duration of surgery, ICU and hospital stay were also recorded. Postoperatively, the patient’s satisfaction was assessed using numerical rating scale. Results: A total of 24 patients (18 male, 6 female) underwent awake craniotomy during a period of 20 months. The mean age and weight was 39.7±11.4yrs and 64.9±9.1kg respectively. All patients were scheduled for craniotomy and excision of left sided supratentorial tumors except for 3 patients who had right sided tumor. Most common intraoperative complication was seizures; observed in five patients (20.8%). None of these patients experienced any episode of desaturation. Two patients had tight brain for which propofol boluses were administered. The average fentanyl consumption was 161.5±85.0 µg. The duration of surgery, ICU and hospital stays were 231.5±90.5min., 14.5±3.5hrs and 4.7±1.5days, respectively. The overall patient satisfaction score was 8. Development of new neurologic deficit or worsening of the deficit occurred in six (25%) patients. Conclusion: The use of dexmedetomidine infusion with regional scalp block in patients undergoing awake craniotomy is safe and efficacious. Absence of major complications and higher patient satisfaction score makes it close to an ideal agent for craniotomy in awake state.

Regional Scalp Block for Postcraniotomy Analgesia

Up to two-thirds of patients report moderate to severe surgical site pain after craniotomy procedures, and there is understandable reluctance to manage these symptoms with systemic opioids that may impair neurological assessment. Furthermore, there is a lack of consensus and evidence concerning alternative analgesia strategies for cranial neurosurgery. Regional scalp block (RSB) is an established technique that involves infiltration of local anesthetic (LA) at well-defined anatomical sites targeting the major sensory innervation of the scalp. However, the efficacy of RSB in reducing postoperative pain remains unclear. In this study, we sought to systematically identify and review randomized controlled trials (RCTs) of RSB and synthesize an overall estimate of efficacy in a quantitative meta-analysis. Medline, EMBASE, and the Cochrane Central Register of Controlled Trials databases were searched for all RCTs evaluating the effect of RSB on postoperative pain after craniotomy. Titles, abstracts, and papers were reviewed independently by 2 authors against predefined inclusion criteria. Two authors independently assessed the quality of included studies and extracted data on patient-reported pain scores, other analgesia requirements, and complications of RSB. Pain scores were scaled to a common 0 to 10 interval with higher scores indicating more severe pain. Meta-analysis of the pooled treatment effect was performed with a random-effects inverse-variance weighted model; heterogeneity was quantified with the I(2) statistic. The literature search identified 138 unique citations, from which 7 RCTs with a total recruitment of 320 patients met the inclusion criteria. All studies used standard LA drugs (lidocaine, bupivacaine, or ropivacaine); in 3 studies, LA was combined with epinephrine. In 3 studies, RSB was performed preoperatively; in the other 4 studies, it was administered postoperatively after wound closure. No complications attributable to RSB were reported. Meta-analysis found a pooled reduction in pain score at 1 hour postoperatively (N = 5 studies; mean difference, -1.61; 95% confidence interval, -2.06 to -1.15; P < 0.001; I(2) = 0%). Subgroup analysis of preoperative RSB showed significant reduction in pain scores at 2, 4, and 6 to 8 hours after surgery whereas postoperative RSB was associated with significant reduction in pain scores at 2, 4, 6 to 8 and 12 hours assessments. There was also an overall reduction in the opioid requirements over the first 24 hours postoperatively, although with significant heterogeneity among the studies (N = 6 studies; standardized mean difference, -0.79; 95% confidence interval, -1.55 to -0.03; P = 0.04; I(2) = 86%). Published RCTs of RSB are small and of limited methodological quality but meta-analysis shows a consistent finding of reduced postoperative pain. This evidence supports the use of RSB for patients undergoing craniotomy.