Bilateral superficial cervical plexus block in combination with general anesthesia has a low efficacy in thyroid surgery: a meta-analysis of randomized controlled trials

Post-thyroidectomy bilateral cervical plexus block relieves pain: a systematic review

PURPOSE

To assess the effectiveness of bilateral superficial cervical plexus block (BSCPB) in treating post-thyroidectomy pain.

METHODS

MEDLINE, Embase, Google Scholar, LILACS, and the Cochrane Central Register of Controlled Trials, were extensively searched. The search period extended from 1968 until December 2022. Randomized controlled trials comparing BSCPB to placebo, no block in patients with thyroidectomy for benign or malignant thyroid disease were included. Outcomes were pain in the first 24 h after surgery. Analgesic rescue, period before the first rescue dosage, and 24-h opioid usage were secondary outcomes. The RoB 2 instrument was used to evaluate the risk of bias.

RESULTS

34 of 354 studies were eligible. There were 2,519 patients. BSCPB reduced the intensity of pain postoperatively [SMD: - 1.17 (95% CI: - 1.54 to - 0.81)] and in the first 24 h [- 0.62 (95%: 0.91 to 0.33)]. A considerable delay for the first opioid dose, rescue analgesics, and postoperative opioid usage was also found.

CONCLUSION

BSCPB's 24-h analgesic efficacy minimizes the requirement for rescue analgesia, postoperative opioid intake, and rescue analgesia start time. The choice of anesthetic and different application methods might affect its effectiveness.

The analgesic effects of bilateral superficial cervical plexus block in thyroid surgery: A systematic review and meta-analysis

Background and Aims

Thyroid surgery is moderately painful, and many techniques to reduce postoperative pain have been studied. Regional techniques are a part of multimodal analgesia employed for various surgical cases. Bilateral superficial cervical plexus block (BSCPB) is a commonly used regional anaesthesia technique for analgesia for thyroid surgery. A previous meta-analysis by this group had left questions about some facets of the technique, to which further trials have contributed.

Methods

The systematic review and meta-analysis was registered on the International Prospective Register of Systematic Reviews (PROSPERO) CRD42022315499. It is an update to a previously published paper in 2018. An updated systematic search, critical appraisal, and analysis of clinical trials were performed. Trials investigating preoperative or postoperative BSCPB compared to control in patients undergoing thyroid surgery were included in the search. The primary outcome was postoperative opioid consumption. The secondary outcomes were the duration of analgesia (time to request of analgesia), Visual Analogue Scale (VAS) pain scores at 0, 4, 12, and 24 h, postoperatively, rates of postoperative nausea and vomiting (PONV), postoperative rescue analgesic consumption, and intraoperative morphine use.

Results

A total of 31 studies and 2,273 patients were included in this analysis. BSCPB significantly reduced post-thyroidectomy opioid consumption (P < 0.001). Additionally, the duration of analgesia was prolonged following BSCPB. VAS scores for 24 h (postoperatively), intraoperative morphine use, and rescue analgesia (postoperatively) remained significantly lower in patients who received BSCPB. There was also a statistically significant reduction in PONV (P = 0.02).

Conclusion

BSCPB offers superior postoperative analgesia with a reduction in opioid use, reduction in PONV, and improvement in VAS scores.

Multimodal Analgesia with Local Wound Infiltration and Intravenous Parecoxib for Thyroidectomy

Background and objective: Adequate postoperative pain control is an important component to enhance recovery. Multimodal analgesia with various pain control techniques has been widely used to alleviate postoperative pain. The use of either wound infiltration or a superficial cervical plexus block has been reported to be effective for pain management after thyroid surgery. The present study evaluated the effect of multimodal analgesia using lidocaine wound infiltration combined with intravenous parecoxib for patients monitored after thyroidectomy. Materials and Methods: A total of 101 patients with a multimodal analgesia protocol being monitored after thyroidectomy were enrolled. After the induction of anesthesia, multimodal analgesia was performed through wound infiltration of 1% lidocaine and epinephrine at a ratio of 1:200,000 (5 μg/mL) combined 40 mg intravenous parecoxib before skin excision. Patients were divided into two groups for this retrospective analysis based on the injection dose of lidocaine they received. Patients in Group I (the control, n = 52) received a 5 mL injection solution, while those in Group II (the study, n = 49) received a 10 mL dosage in a time-sequential manner, in accordance with a previous clinical trial. The primary outcome was measuring postoperative pain intensity at rest, as well as during motion and coughing, which was measured at the postoperative anesthetic care unit (PACU) and on the first day after the operation (POD 1) in the ward. Pain intensity was assessed using a numerical rating scale (NRS). The secondary outcomes were postoperative adverse events including anesthetic-related side effects, as well as airway and pulmonary complications. Results: Most of the patients reported no pain or mild pain during the observation period. The patients in Group II had a lower pain intensity during motion than Group I (NRS 1.47 ± 0.89 vs. 1.85 ± 0.96, p = 0.043) when measured at the postoperative anesthetic care unit. Pain intensity during coughing was also significantly lower in the study group than in the control group (NRS 1.61 ± 0.95 vs. 1.96 ± 0.79, p = 0.049) when measured at the postoperative anesthetic care unit. There were no severe adverse events in either of the groups. Only one patient (1.9%) in Group I experienced temporary vocal palsy. Conclusions: The use of lidocaine with an equal volume of intravenous parecoxib provided comparable analgesia with minimal adverse events when monitoring thyroidectomy.

Perioperative Analgesia for Patients Undergoing Thyroidectomy and Parathyroidectomy: An Evidence-Based Review

Objective:

To perform an evidence-based systematic review evaluating perioperative analgesia, including opioid alternatives, used for patients undergoing thyroidectomy and parathyroidectomy.

Methods:

A comprehensive literature search from 1997 to January 2018 of Pubmed, Cochrane, and EmBase libraries was performed for studies reporting analgesic administration following thyroid or parathyroid surgery. This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies were evaluated for level of evidence and given a Jadad score to assess for risk of bias. Outcomes gathered included postoperative pain scores, time to rescue analgesia, rescue analgesic consumption, and adverse events.

Results:

Thirty-eight randomized controlled trials met inclusion criteria. The GRADE criteria determined the overall evidence to be moderate-high. Studies utilizing NSAIDs reported reduced requirements for rescue analgesics. Acetaminophen studies presented with conflicting data on effectiveness. Gabapentinoid studies demonstrated lower pain scores and an increased time to rescue analgesic. Local anesthetics were effective at decreasing Visual Analogue Scale (VAS) and Numeric Rating Scale (NRS) pain scores while also reducing rescue analgesic consumption. Ketamine was shown to increased postoperative nausea and vomiting. NSAIDs and local anesthetic studies had an aggregate grade of evidence A, while all others had grade B evidence.

Conclusion:

There is significant evidence supporting the use of NSAIDs and local anesthetics in the perioperative period for pain management for thyroid and parathyroid surgeries. Acetaminophen, gabapentinoid and ketamine have some supporting evidence and may serve as adequate alternatives. Further multi-institutional RCTs are warranted to delineate optimal analgesic regimens.

Level of Evidence:

NA

Wound infiltration with bupivacaine 0.5% with or without adrenaline does not decrease pain after thyroidectomy. A randomized controlled study

Objectives:

To study the effect of local wound infiltration with and without adrenaline on pain perception after thyroidectomy using the visual analog score (VAS).

Methods:

A prospective randomized controlled double-blinded study was conducted between May 2015 and June 2016 at The University of Jordan Hospital, Amman, Jordan. Eighty-nine patients undergoing planned thyroidectomy were included in the study. Patients were divided randomly into 3 groups: Group A, local wound infiltration with bupivacaine 0.5% was administered; Group B, bupivacaine 0.5% with adrenaline was administered; Group C (control), no infiltration was performed. Standardized thyroidectomies were performed in the 3 groups. Pain perception was measured using VAS at 2, 4, 6, 12, and 24 hours after surgery. A comparison between the 3 groups was carried out.

Results:

No significant differences among the 3 groups were observed at all time points (p=0.246). Visual analog scores were significantly lower at 12 and 24 hours after operations.

Conclusion:

Local wound infiltration with bupivacaine 0.5% does not decrease pain perception after thyroidectomy performed under general anesthesia, and adding adrenaline does not enhance its effect.

Effects of bilateral superficial cervical plexus block on sevoflurane consumption during thyroid surgery under entropy-guided general anesthesia: a prospective randomized study

Background

Bilateral superficial cervical plexus block (BSCPB) provides good postoperative analgesia, but its effect on anesthetic consumption is unknown. This study evaluated the effects of BSCPB on sevoflurane consumption during thyroid surgery.

Methods

Fifty patients were randomly allocated into groups A and B of 25 each in this prospective double-blind study. Group A received BSCPB with 20 ml 0.25% bupivacaine, whereas group B received 20 ml saline immediately before entropy-guided general anesthesia. Intraoperative hemodynamic parameters, end-tidal sevoflurane concentration, minimum alveolar concentration, and sevoflurane consumption were recorded. Postoperative pain was assessed using a visual analog scale, and the time of the first request for analgesia was noted. All side effects were recorded.

Results

Demographics were comparable. Mean sevoflurane consumption [for 30 min: group A = 7.2 (1.1) ml, group B = 8.8 (2.0) ml, P = 0.001; for 60 min: group A = 13.5 (1.7) ml, group B = 16.5 (3.9) ml, P = 0.002] and mean end-tidal sevoflurane concentration [for 30 min: group A = 1.2% (0.2%), group B = 1.4% (0.2%), P = 0.008; for 60 min: group A = 1.2% (0.1%), group B = 1.4% (0.2%), P = 0.010] were significantly lower in group A. Patients in group A had a longer duration of analgesia [361.6 (79.5) min vs. 151.0 (60.2) min, P < 0.001] compared to those in group B.

Conclusions

Preinduction BSCPB during thyroid surgery significantly reduced sevoflurane consumption and increased the duration of postoperative analgesia.

Ultrasound-guided peripheral nerve blocks for ventricular shunt revision in children

We describe using ultrasound-guided peripheral nerve blocks for postoperative pain control in 2 children undergoing ventricular shunt surgery. In the first patient undergoing ventriculo-peritoneal shunt revision, a combination of ultrasound-guided greater occipital nerve, superficial cervical plexus, and transversus abdominis plane blocks was used. In the second patient undergoing ventriculo-pleural shunt revision, a combination of ultrasound-guided greater occipital nerve, superficial cervical plexus, and intercostal blocks was used. Both patients, who underwent multiple revisions during their hospitalizations, showed decreased analgesic requirements after regional anesthesia. Our experience suggests this combined block technique may provide beneficial postoperative analgesia for patients undergoing shunt revision.

Randomized clinical trial of intraoperative superficial cervical plexus block versus incisional local anaesthesia in thyroid and parathyroid surgery

Background

Moderate wound pain and opiate analgesia requirement is reported following thyroid and parathyroid surgery. A randomized clinical trial was performed to investigate whether intraoperative superficial cervical plexus block (SCPB) would decrease postoperative pain and analgesia use.

Methods

Patients were randomized to incisional local anaesthesia (control) or incisional local anaesthesia plus intraoperative SCPB. The primary outcome measure was pain, assessed by a visual analogue scale (VAS). Secondary outcome measures were analgesia use (strong opiates defined as having potency at least as strong as that of oral morphine), respiratory rate and sedation score. Primary outcome measures were analysed with non-parametric tests, as well as with receiver operating characteristic (ROC) curves calculated as area under the curve (AUC) to discriminate between trial limbs.

Results

Twenty-nine patients were randomized to each group. Pain (VAS) scores were lower in patients who received intraoperative SCPB than in controls 30 min after surgery and subsequently (P &lt; 0·020 at all time points), with a median pain score of zero on the day of operation in the SCPB group. Corresponding analysis of ROC curves showed differences between groups at 30 min (AUC = 0·722, P = 0·012), 90 min (AUC = 0·747, P = 0·005), 150 min (AUC = 0·803, P &lt; 0·001) and 210 min (AUC = 0·849, P &lt; 0·001) after surgery, and at 07.00 hours on postoperative day 1 (AUC = 0·710, P = 0·017). Fewer patients in the SCPB group required strong opiates (5 of 29 versus 16 of 29 in the control group; P = 0·003) and rescue opiates (6 of 29 versus 20 of 29; P &lt; 0·001).

Conclusion

Intraoperative SCPB reduces pain scores following thyroid and parathyroid surgery, and reduces the requirement for strong and rescue opiates. Registration number: 2009-012671-98 (https://www.clinicaltrialsregister.eu).

Study protocol for a randomized, double-blind, placebo-controlled trial of a single preoperative steroid dose to prevent nausea and vomiting after thyroidectomy: the tPONV study

BACKGROUND

Postoperative nausea and vomiting after general anesthesia is not only an unpleasant problem affecting 20-30% of surgical patients but may also lead to severe postoperative complications. There is a particularly high incidence of postoperative nausea and vomiting following thyroidectomy. Dexamethasone has been described as highly effective against chemotherapy-induced nausea and vomiting and has been proposed as a first-line method of postoperative nausea and vomiting prophylaxis. Despite this possible beneficial effect, the prophylactic administration of dexamethasone before surgery to prevent or ameliorate postoperative nausea and vomiting has not been established. A bilateral superficial cervical plexus block during thyroid surgery under general anesthesia significantly reduces pain. Of even greater clinical importance, this block prevents the need for postoperative opioids. Therefore, patients undergoing thyroidectomy and a bilateral superficial cervical plexus block are an ideal group to investigate the efficacy of dexamethasone for postoperative nausea and vomiting. These patients have a high incidence of postoperative nausea and vomiting and do not require opioids. They have no abdominal surgery, which can cause nausea and vomiting via a paralytic ileus. Combined with the highly standardized anesthesia protocol in use at our institution, this setting allows all known biases to be controlled.

METHODS/DESIGN

We will perform a parallel two-arm, randomized (1:1), double-blind, placebo-controlled, single-center trial. Adults (≥18 years) scheduled for primary partial or total thyroidectomy because of a benign disease will be eligible for inclusion. The participants will be randomized to receive a single, intravenous preoperative dose of either 8 mg of dexamethasone in 2 ml saline (treatment group) or saline alone (placebo group). All the patients will receive a bilateral superficial cervical plexus block and standardized anesthesia. The primary outcome will be the incidence of postoperative nausea and vomiting. A total of 152 patients will be recruited, providing 80% power to detect a 50% reduction in the incidence of postoperative nausea and vomiting. Any patients who require opioid treatment will be excluded from the per-protocol analysis.

DISCUSSION

In the present protocol, we reduced bias to the greatest extent possible. Thus, we expect to definitively clarify the efficacy of dexamethasone for postoperative nausea and vomiting prophylaxis.

TRIAL REGISTRATION

http://www.clinicaltrials.gov: NCT01189292.

Analgesic efficacy of bilateral superficial cervical plexus block in robot-assisted endoscopic thyroidectomy using a transaxillary approach

BACKGROUND

Nerve blocks and infiltration with local anesthetics are commonly employed methods for postoperative pain control. This prospective, randomized trial was conducted to determine whether bilateral superficial cervical plexus block (BSCPB) is effective for reducing acute postoperative pain after robot-assisted endoscopic thyroidectomy (RAET) and to compare its effects with that of local wound infiltration (LWI).

METHODS

Ninety-seven patients who were to undergo RAET were randomly assigned to one of three groups to receive BSCPB with either 20 mL of 0.525% ropivacaine (BSCPB group, n=32) or 20 mL of isotonic sodium chloride solution (Control group, n=32) or LWI with 20 mL of 0.525% ropivacaine (LWI group, n=33). Postoperative pain scores were assessed at the postoperative anesthesia care unit (PACU) and at 6, 24, and 48 h postoperatively using a visual analog scale (VAS). Patients with VAS scores of ≥40 were administered rescue analgesics according to a standardized protocol. The main outcome variables were pain scores during the first postoperative 24 h and the number of patients requiring postoperative analgesic rescue.

RESULTS

The BSCBP and LWI groups showed lower pain scores compared with the Control group at the PACU. The BSCPB group continued to show significantly lower pain scores compared with the LWI and Control groups at postoperative 6 and 24 h. The number of patients requiring analgesic rescue at the PACU was lower in the BSCPB and LWI groups than in the Control group. The number of patients requiring additional rescue analgesics after discharge from the PACU until the first 24 postoperative h was lower in the BSCPB group than in the LWI group.

CONCLUSIONS

BSCPB and LWI are effective for reducing pain scores and analgesic requirements during the immediate postoperative period in patients who undergo RAET, with BSCPB being superior to LWI at postoperative 6-24 h.