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Stieger A, Romero CS, Andereggen L, Heisenberg D, Urman RD, Luedi MM. Nerve Blocks for Craniotomy. Curr Pain Headache Rep 2024; 28:307-313. [PMID: 38472617 DOI: 10.1007/s11916-024-01236-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE OF REVIEW Postcraniotomy headache (PCH) is a common adverse event and can lead to various complications and decreased quality of life. RECENT FINDINGS To reduce postcraniotomy pain and associated complications, a multimodal pain therapy including analgesics, analgesic adjuncts, and regional anesthesia is essential. The use of opioids should be minimized to facilitate prompt postoperative neurosurgical assessment. Here, we provide an update on the latest evidence regarding the role of scalp nerve blocks in the pain management of patients undergoing craniotomy procedure. Nerve blocks are effective in alleviating postoperative pain after craniotomy. Scalp blocks contribute to lower pain levels and less opioid consumption in the first 48 h following surgery. Moreover, there is a significant decrease in patients suffering from PONV among patients who receive scalp block.
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Affiliation(s)
- Andrea Stieger
- Department of Anaesthesiology, Rescue and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland.
| | - Carolina S Romero
- Department of Anaesthesiology and Critical Care, Hospital General, Universitario De Valencia, Valencia, Spain
- Research Methods Department, Universidad Europea de Valencia, Valencia, Spain
| | - Lukas Andereggen
- Department of Neurosurgery, Cantonal Hospital of Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Daniel Heisenberg
- Department of Anaesthesiology, Rescue and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Richard D Urman
- Department of Anaesthesiology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
| | - Markus M Luedi
- Department of Anaesthesiology, Rescue and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Luo M, Zhao X, Deng M, Hu Y, Yang X, Mei Z, Meng L, Wang Y. Scalp Nerve Block, Local Anesthetic Infiltration, and Postoperative Pain After Craniotomy: A Systematic Review and Network Meta-analysis of Randomized Trials. J Neurosurg Anesthesiol 2023; 35:361-374. [PMID: 36040025 DOI: 10.1097/ana.0000000000000868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/27/2022] [Indexed: 11/25/2022]
Abstract
The most efficacious methods for controlling postoperative pain in craniotomy remain unknown. A systematic review and network meta-analysis were performed to compare the efficacies of different strategies of scalp nerve block (SNB), scalp infiltration (SI), and control in patients undergoing craniotomy. MEDLINE, Embase, and CENTRAL databases were searched for randomized controlled trials. The primary outcome was postoperative 24-hour pain score, and the secondary outcome was opioid consumption within the first 24 hour after surgery. The effect was estimated using the between-group mean difference and ranked using the surface under the cumulative ranking curve (SUCRA) score. Twenty-four randomized trials were identified for inclusion. SNB using ropivacaine reduced postoperative 24-hour pain score when compared with control (mean difference [95% credible interval], -2.04 [-3.13, -0.94]; low quality), and when compared with SI using ropivacaine (-1.77 [-3.04, -0.51]; low quality) or bupivacaine (-1.96 [-3.65, -0.22]; low quality). SNB using ropivacaine was likely the most efficacious method for pain control (SUCRA, 91%), and also reduced opioid consumption within the first postoperative 24 hours as compared with control (mean difference [95% credible interval], -11.91 [-22.42, -1.4]; low quality). SNB using bupivacaine, lidocaine, and epinephrine combined, and SNB using ropivacaine, were likely the most efficacious methods for opioid consumption reduction (SUCRA, 88% and 80%, respectively). In summary, different methods of SNB / SI seem to have different efficacies after craniotomy. SNB using ropivacaine may be superior to other methods for postcraniotomy pain control; however, the overall quality of evidence was low.
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Affiliation(s)
- Mengqiang Luo
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Xu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Meng Deng
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Yue Hu
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Xiaoyu Yang
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Zubing Mei
- Anorectal Disease Institute of Shuguang Hospital, Shanghai
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Lingzhong Meng
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yingwei Wang
- Department of Anesthesiology, Huashan Hospital, Fudan University
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Duda T, Lannon M, Gandhi P, Martyniuk A, Farrokhyar F, Sharma S. Systematic Review and Meta-Analysis of Randomized Controlled Trials for Scalp Block in Craniotomy. Neurosurgery 2023; 93:4-23. [PMID: 36762905 DOI: 10.1227/neu.0000000000002381] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/04/2022] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Scalp block is regional anesthetic injection along nerves innervating the cranium. Scalp blocks for craniotomy may decrease postoperative pain and opioid consumption. Benefits may extend beyond the anesthetic period. OBJECTIVE To analyze evidence for scalp block on postoperative pain and opioid use. METHODS This systematic review and meta-analysis, Prospective Register of Systematic Reviews registration (CRD42022308048), included Ovid Medical Literature Analysis and Retrieval System Online, Embase, and Cochrane Central Register of Controlled Trials inception through February 9, 2022. Only randomized controlled trials were included. We excluded studies not reporting either main outcome. Duplicate reviewers performed study selection, risk of bias assessment, data extraction, and evidence certainty Grading of Recommendations Assessment, Development, and Evaluation appraisal. Main outcomes were postoperative pain by visual analog scale within 72 hours and opioid consumption as morphine milligram equivalent (MME) within 48 hours. RESULTS Screening filtered 955 studies to 23 trials containing 1532 patients. Risk of bias was overall low. Scalp block reduced postoperative pain at 2 through 72 hours, visual analog scale mean differences of 0.79 to 1.40. Opioid requirements were reduced at 24 hours by 16.52 MME and 48 hours by 15.63 MME. CONCLUSION Scalp block reduces postoperative pain at 2 through 48 hours and may reduce pain at 72 hours. Scalp block likely reduces opioid consumption within 24 hours and may reduce opioid consumption to 48 hours. The clinical utility of these differences should be interpreted within the context of modest absolute reductions, overall care optimization, and patient populations. This is the first level 1A evidence to evaluate scalp block efficacy in craniotomy.
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Affiliation(s)
- Taylor Duda
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Ontario, Canada
- Department of Health, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Melissa Lannon
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Ontario, Canada
- Department of Health, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Pranjan Gandhi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario
| | - Amanda Martyniuk
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Ontario, Canada
| | - Forough Farrokhyar
- Department of Health, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Ontario, Canada
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Fiore G, Porto E, Pluderi M, Ampollini AM, Borsa S, Legnani FG, Giampiccolo D, Miserocchi A, Bertani GA, DiMeco F, Locatelli M. Prevention of Post-Operative Pain after Elective Brain Surgery: A Meta-Analysis of Randomized Controlled Trials. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050831. [PMID: 37241063 DOI: 10.3390/medicina59050831] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/02/2023] [Accepted: 04/20/2023] [Indexed: 05/28/2023]
Abstract
Background and Objective: To analyze the effects of several drug for pain prevention in adults undergoing craniotomy for elective brain surgery. Material and Methods: A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The inclusion criteria were limited to randomized controlled trials (RCTs) that evaluated the effectiveness of pharmacological treatments for preventing post-operative pain in adults (aged 18 years or older) undergoing craniotomies. The main outcome measures were represented by the mean differences in validated pain intensity scales administered at 6 h, 12 h, 24 h and 48 h post-operatively. The pooled estimates were calculated using random forest models. The risk of bias was evaluated using the RoB2 revised tool, and the certainty of evidence was assessed according to the GRADE guidelines. Results: In total, 3359 records were identified through databases and registers' searching. After study selection, 29 studies and 2376 patients were included in the meta-analysis. The overall risk of bias was low in 78.5% of the studies included. The pooled estimates of the following drug classes were provided: NSAIDs, acetaminophen, local anesthetics and steroids for scalp infiltration and scalp block, gabapentinoids and agonists of adrenal receptors. Conclusions: High-certainty evidence suggests that NSAIDs and acetaminophen may have a moderate effect on reducing post-craniotomy pain 24 h after surgery compared to control and that ropivacaine scalp block may have a bigger impact on reducing post-craniotomy pain 6 h after surgery compared to control. Moderate-certainty evidence indicates that NSAIDs may have a more remarkable effect on reducing post-craniotomy pain 12 h after surgery compared to control. No moderate-to-high-certainty evidence indicates effective treatments for post-craniotomy pain prevention 48 h after surgery.
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Affiliation(s)
- Giorgio Fiore
- Unit of Neurosurgery, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
| | - Edoardo Porto
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, 20133 Milan, Italy
- Department of Neurosurgery, School of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Mauro Pluderi
- Unit of Neurosurgery, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | | | - Stefano Borsa
- Unit of Neurosurgery, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | | | - Davide Giampiccolo
- Institute of Neuroscience, Cleveland Clinic London, Grosvenor Place, London SW1X 7HY, UK
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, University College, London WC1E 6BT, UK
| | - Anna Miserocchi
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
| | - Giulio Andrea Bertani
- Unit of Neurosurgery, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Francesco DiMeco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, 20133 Milan, Italy
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Marco Locatelli
- Unit of Neurosurgery, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
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Luo M, Zhao X, Tu M, Yang X, Deng M, Wang Y. The effectiveness of scalp nerve block on hemodynamic response in craniotomy: a systematic review and meta-analysis of randomized trials. Minerva Anestesiol 2023; 89:85-95. [PMID: 36448987 DOI: 10.23736/s0375-9393.22.16775-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Strategies that blunt noxious stimuli and stabilize hemodynamics may reduce perioperative cardiovascular complications and enhance recovery after craniotomy. EVIDENCE ACQUISITION Our systematic literature review and meta-analysis investigated whether scalp nerve block (SNB) reduces the acute hemodynamic response compared with non-SNB (scalp infiltration or control) in adult patients undergoing elective craniotomy. We searched MEDLINE, EMBASE, CENTRAL, and two Chinese databases for randomized trials. Primary outcomes included mean arterial pressure and heart rate during skull pin insertion and surgical incision in craniotomy. Secondary outcomes included incidence of hypertension and dosage of intraoperative analgesic opioids used. Random-effects models were used for meta-analyses. EVIDENCE SYNTHESIS SNB significantly reduced the mean arterial pressure (mean difference: -14.00 mmHg; 95% confidence interval [CI]: -19.71 to -8.28) and heart rate (mean difference: -11.55 beat/min; 95% CI: -19.31 to -3.80), when compared with non-SNB during skull pin insertion. A similar trend was observed during skin incisions (SNB vs. non-SNB, mean difference in mean arterial pressure: -9.46 mmHg; 95% CI: -14.53 to -4.38; mean difference in heart rate: -9.34 beat/min; 95% CI: -15.40 to -3.28). Subgroup analysis showed that, compared with scalp infiltration, SNB reduced mean arterial pressure and heart during pin insertion but not during skin incisions. SNB also reduced the incidence of intraoperative hypertension, but no difference was observed in intraoperative opioid consumption when compared with non-SNB. CONCLUSIONS SNB alleviated the craniotomy-associated hemodynamic response. SNB may be superior to scalp infiltration in maintaining hemodynamic stability during pin insertion. However, high-quality trials are still needed to provide more conclusive evidence.
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Affiliation(s)
- Mengqiang Luo
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mengyun Tu
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoyu Yang
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Meng Deng
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yingwei Wang
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China -
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Chen Y, Ni J, Li X, Zhou J, Chen G. Scalp block for postoperative pain after craniotomy: A meta-analysis of randomized control trials. Front Surg 2022; 9:1018511. [PMID: 36225222 PMCID: PMC9550001 DOI: 10.3389/fsurg.2022.1018511] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 09/12/2022] [Indexed: 12/02/2022] Open
Abstract
Background Postoperative pain after craniotomy is an important clinical concern because it might lead to brain hyperemia and elevated intracranial pressure. Considering the side effects of opioid, several studies have been conducted to investigate the effect of local anesthetics, especially the scalp block, on postoperative pain. However, the strength of evidence supporting this practice for postoperative pain after craniotomy was unclear and the best occasion of scalp block was also not identified. Therefore, we conducted a meta-analysis to evaluate the efficacy, safety, and the best occasion of scalp block for postoperative pain after craniotomy. Methods PubMed, Embase, and the Cochrane Library databases from database inception to October 10, 2021 were searched for all randomized controlled trials evaluating the effect of scalp block on postoperative pain after craniotomy. Data were assessed by StataMP 16 software. Results A total of 12 studies were included. A random-effect model was used to analyze all data. Patients under scalp block earned fewer scores than the non-scalp block group in visual analogue scale at the very early period (MD = −1.97, 95% CI = −3.07 to −0.88), early period (MD = −1.84, 95% CI = −2.95 to −0.73) and intermediate period (MD = −1.16, 95% CI = −1.84 to −0.49). Scalp block could also significantly prolong the time of the first request of rescue analgesia and reduce the use of additional analgesics without a significant difference in the incidence of complications. Subgroup analysis showed there was no significant difference in analgesia effect between pre-incision scalp block and post-incision scalp block in all periods. Conclusion Scalp block could lead to lower pain intensity scores, more time of the first request of rescue analgesia, and fewer analgesic drugs applied in the first 12 h after craniotomy. There was no significant difference between pre-incision and post-incision scalp block in the occurrence and severity of postoperative pain.
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Affiliation(s)
- Yanting Chen
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jianqiang Ni
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiang Li
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jialei Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Correspondence: Jialei Zhou Gang Chen
| | - Gang Chen
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Correspondence: Jialei Zhou Gang Chen
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Patel KS, Sun MZ, Willis SL, Alemnew M, De Jong R, Evans AS, Duong C, Gopen Q, Yang I. Selective scalp block decreases short term post-operative pain scores and opioid use after craniotomy: A case series. J Clin Neurosci 2021; 93:183-187. [PMID: 34656245 DOI: 10.1016/j.jocn.2021.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/12/2021] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Kunal S Patel
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Matthew Z Sun
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Shelby L Willis
- Department of Head & Neck Surgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Mahlet Alemnew
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Russell De Jong
- Department of Head & Neck Surgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Audree S Evans
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Courtney Duong
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Quinton Gopen
- Department of Head & Neck Surgery, University of California Los Angeles, Los Angeles, CA, United States
| | - Isaac Yang
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA, United States; Department of Head & Neck Surgery, University of California Los Angeles, Los Angeles, CA, United States; Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, United States; Department of Surgery, Harbor-UCLA Los Angeles, Los Angeles, CA, United States; Los Angeles Biomedical Research Center, Harbor-UCLA Los Angeles, Los Angeles, CA, United States.
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Preoperative Versus Postoperative Scalp Block Combined With Incision Line Infiltration for Pain Control After Supratentorial Craniotomy. Clin J Pain 2021; 37:194-198. [PMID: 33290346 DOI: 10.1097/ajp.0000000000000905] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 11/06/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Postoperative pain after craniotomy is a significant clinical problem that is sometimes underestimated, although moderate or severe pain in early postoperative period complicates up to 60% of cases. The purpose of this prospective randomized multicenter trial was to determine the optimal timing for selective scalp block in patients undergoing general anesthesia for supratentorial craniotomy. MATERIALS AND METHODS After ethics committee approval and informed consent, 56 adult patients were enrolled, and randomly assigned to receive a selective scalp block combined with incision line infiltration preoperatively or postoperatively. RESULTS Postoperative pain at 24 hours after the procedure was recorded in all 56 enrolled patients. In patients assigned to receive a scalp block preoperatively, median VAS score at 24 hours after surgery was 0 (0 to 2), and in patients assigned to receive a scalp block postoperatively it was 0 (0 to 3) (P>0.05). There was no difference in severity of pain at 24, 12, 6, and 2 hours after surgery between the 2 study groups, but the amount of fentanyl administered intraoperatively was lower in patients assigned to the preoperative scalp block group (1.6±0.7 vs. 2.4±0.7 mkg/kg/h, P=0.01). DISCUSSION This study confirms and extends available clinical evidence on the safety and efficacy of selective scalp blocks for the prevention of postoperative pain. Recorded data suggest that there is no difference in terms of occurrence and severity of postoperative pain regardless of whether the scalp block is performed preoperatively (after general anesthesia induction) or postoperatively (before extubation). Patients assigned to receive a scalp block combined with incision line infiltration preoperatively needed less intraoperative opioids than those assigned to postoperative scalp block.
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Padhy N, Moningi S, Kulkarni DK, Alugolu R, Inturi S, Ramachandran G. Sphenopalatine ganglion block: Intranasal transmucosal approach for anterior scalp blockade - A prospective randomized comparative study. J Anaesthesiol Clin Pharmacol 2020; 36:207-212. [PMID: 33013036 PMCID: PMC7480294 DOI: 10.4103/joacp.joacp_249_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 01/10/2019] [Accepted: 03/29/2019] [Indexed: 11/25/2022] Open
Abstract
Background and Aims: Peripheral nerve blocks in neurosurgical practice attenuate most stressful responses like pin insertion, skin, and dural incision. Scalp block is conventionally the blockade of choice. Further studies for less invasive techniques are required. Intranasal transmucosal block of the sphenopalatine ganglion has shown promising results in patients with chronic headache and facial pain. The primary objective of our study was to compare the gold standard scalp block and bilateral sphenopalatine ganglion block (nasal approach) for attenuation of hemodynamic response to pin insertion. Secondary objectives included hemodynamic response to skin and dural incision. Material and Methods: After IRB approval and informed consent, a prospective randomized comparative study was carried out on 50 adult patients undergoing elective supratentorial surgery. The hemodynamic response to pin insertion, skin incision, and dural incision was noted in both the groups. The data was analyzed with NCSS version 9.0 statistical software. Results: The HR and MAP were comparable between the groups. Following dural incision MAP was significantly lower at 1,2,3,4,5 and 10 min in group SPG whereas in group S it was significantly lower at 1 and 2min. (P = 0.02 at T1, P = 0.03 at T2). Conclusions: Concomitant use of bilateral SPG block with general anesthesia is an effective and safe alternative technique to scalp blockade for obtundation of hemodynamic responses due to noxious stimulus during craniotomy surgeries.
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Affiliation(s)
- Narmada Padhy
- Department of Anesthesia and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Srilata Moningi
- Department of Anesthesia and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Dilip K Kulkarni
- Department of Anesthesia and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Rajesh Alugolu
- Department of Anesthesia and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Srikanth Inturi
- Department of Anesthesia and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Gopinath Ramachandran
- Department of Anesthesia and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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Abstract
Regional anesthesia has been an undervalued entity in neuroanesthetic practice. However, in the past few years, owing to the development of more advanced techniques, drugs and the prolific use of ultrasound guidance, the unrecognised potential of these modalities have been highlighted. These techniques confer the advantages of reduced requirements for local anesthetics, improved hemodynamic stability in the intraoperative period, better pain score postoperatively and reduced analgesic requirements in the postoperative period. Reduced analgesic requirement translates into lesser side effects associated with analgesic use. Furthermore, the transition from the traditional blind landmark-based techniques to the ultrasound guidance has increased the reliability and the safety profile. In this review, we highlight the commonly practised blocks in the neuroanesthesiologist's armamentarium and describe their characteristics, along with their individual particularities.
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Affiliation(s)
- Ashutosh Kaushal
- Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Rudrashish Haldar
- Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
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Xiong W, Li L, Bao D, Wang Y, Liang Y, Lu P, Zhang D, Liu G, Qiao L, Zheng N, Jin X. Postoperative analgesia of scalp nerve block with ropivacaine in pediatric craniotomy patients: a protocol for a prospective, randomized, placebo-controlled, double-blinded trial. Trials 2020; 21:580. [PMID: 32586348 PMCID: PMC7318534 DOI: 10.1186/s13063-020-04524-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 06/16/2020] [Indexed: 02/12/2023] Open
Abstract
Background Moderate-to-severe postoperative pain following craniotomy has a high incidence in pediatric patients. Such pain may cause agitation, intracranial hypertension, epileptic seizures, and postoperative hematoma, which affect morbidity and mortality. Although scalp nerve block (SNB) achieves satisfactory pain relief except for suboccipital mid-craniotomy in adults and ropivacaine is widely used as a long-acting peripheral nerve block agent in children, there are few studies of SNB with ropivacaine in pediatric patients undergoing craniotomy. In addition, the neurosurgery operation time is relatively long, but the duration of action of SNB is limited. It is generally believed that postoperative SNB is better than preoperative SNB for postoperative analgesia. However, considering the concept of preemptive analgesia, we believe that preoperative SNB may achieve a longer postoperative analgesia effect than we expected. Methods This trial is a single-institution, prospective, randomized, controlled, double-blind study. A total of 180 children aged between 1 and 12 years who are undergoing elective craniotomy will be randomly allocated in a 1:1:1 ratio to three groups: group B (preoperative ropivacaine block group), group A (postoperative ropivacaine block group), and group N (nonblocking control group). This randomization will be stratified by age in two strata (1–6 years and 7–12 years). The primary outcome is the total consumption of sufentanil within 24 h after surgery. The secondary outcomes include assessment of pain scores, total consumption of sufentanil and emergency-remedy medicine consumption at observation points, the occurrence of postoperative complications, and the length of hospitalization after surgery. Discussion This study is designed to explore the effect and feasibility of SNB with ropivacaine for postoperative analgesia in pediatric patients undergoing craniotomy. Further aims are to compare the effects of preoperative and postoperative SNB on postoperative analgesia in order to identify whether there is a preemptive analgesic effect and determine the better time to implement SNB in pediatric patients during craniotomy. Trial registration Chinese Clinical Trial Registry ChiCTR1800017386. Registered on 27 July 2018.
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Affiliation(s)
- Wei Xiong
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Lu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Di Bao
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Yaxin Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Yi Liang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Pengwei Lu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Di Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Gaifen Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China
| | - Lanxin Qiao
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Na Zheng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Xu Jin
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
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Rigamonti A, Garavaglia MM, Ma K, Crescini C, Mistry N, Thorpe K, Cusimano MD, Das S, Hare GMT, Mazer CD. Effect of bilateral scalp nerve blocks on postoperative pain and discharge times in patients undergoing supratentorial craniotomy and general anesthesia: a randomized-controlled trial. Can J Anaesth 2020; 67:452-461. [PMID: 31879855 DOI: 10.1007/s12630-019-01558-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 11/07/2019] [Accepted: 12/13/2019] [Indexed: 11/30/2022] Open
Abstract
PURPOSE 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. METHODS 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 with 1:200,000 epinephrine compared with placebo on postoperative pain and opioid consumption. The primary outcome was the visual analogue scale (VAS) for pain at 24 hr postoperatively. RESULTS 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. CONCLUSION 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. TRIAL REGISTRATION www.ClinicalTrials.gov, NCT00972790; registered 9 September, 2009.
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Affiliation(s)
- Andrea Rigamonti
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
| | - Marco M Garavaglia
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Kan Ma
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Charmagne Crescini
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Nikhil Mistry
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Kevin Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Applied Health Research Centre, St. Michael's Hospital, Toronto, ON, Canada
| | - Michael D Cusimano
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Sunit Das
- Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Gregory M T Hare
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
- St. Michael's Hospital Center of Excellence for Patient Blood Management, Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
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Galvin IM, Levy R, Day AG, Gilron I. Pharmacological interventions for the prevention of acute postoperative pain in adults following brain surgery. Cochrane Database Syst Rev 2019; 2019:CD011931. [PMID: 31747720 PMCID: PMC6867906 DOI: 10.1002/14651858.cd011931.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pain following brain surgery can compromise recovery. Several pharmacological interventions have been used to prevent pain after craniotomy; however, there is currently a lack of evidence regarding which interventions are most effective. OBJECTIVES The objectives are to assess the effectiveness of pharmacological interventions for prevention of acute postoperative pain in adults undergoing brain surgery; compare them in terms of additional analgesic requirements, incidence of chronic headache, sedative effects, length of hospital stay and adverse events; and determine whether these characteristics are different for certain subgroups. SEARCH METHODS We searched MEDLINE, Embase, CINAHL, CENTRAL, Web of Science and two trial registries together with reference checking and citation searching on 28th of November 2018. SELECTION CRITERIA We included blinded and non-blinded, randomized controlled trials evaluating pharmacological interventions for the prevention of acute postoperative pain in adults undergoing neurosurgery, which had at least one validated pain score outcome measure. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We calculated mean differences for the primary outcome of pain intensity; any pain scores reported on a 0 to 100 scale were converted to a 0 to 10 scale. MAIN RESULTS We included 42 completed studies (3548 participants) and identified one ongoing study. Nonsteroidal anti-inflammatories (NSAIDs) Nonsteroidal anti-inflammatories (NSAIDs) reduce pain up to 24 hours (0 to 6 hours, MD -1.16, 95% CI -1.57 to -0.76; 12 hours, MD -0.62, 95% CI -1.11 to -0.14; 24 hours, MD -0.66, 95% CI -1.18 to -0.13; 6 studies, 742 participants; all high-quality evidence). Results for other outcomes were imprecise (additional analgesic requirements: MD 1.29 mg, 95% CI -5.0 to 2.46, 4 studies, 265 participants; nausea and vomiting RR 1.34, 95% CI 0.30 to 5.94, 2 studies, 345 participants; both low-quality evidence). Dexmedetomidine reduces pain up to 12 hours (0 to 6 hours, MD -0.89, 95% CI -1.27 to -0.51, moderate-quality evidence; 12 hours, MD -0.81, 95% CI -1.21 to -0.42, low-quality evidence). It did not show efficacy at 24 hours (MD -0.08, 95% CI -0.32 to 0.16; 2 studies, 128 participants; low-quality evidence). Dexmedetomidine may decrease additional analgesic requirements (MD -21.36 mg, 95% CI -34.63 to -8.1 mg, 2 studies, 128 participants, low-quality evidence). Results for other outcomes were imprecise (nausea and vomiting RR -0.43, 95% CI 0.06 to 3.08, 3 studies, 261 participants; hypotension RR 0.5, 95% CI 0.05 to 5.28, 3 studies, 184 participants; both low-quality evidence). Scalp blocks may reduce pain up to 48 hours (0 to 6 hours, MD -0.98, 95% CI -1.66 to -0.3, 10 studies, 414 participants; 12 hours, MD -0.95, 95% CI -1.53 to -0.37, 8 studies, 294 participants; 24 hours, MD -0.78, 95% CI -1.52 to -0.05, 9 studies, 433 participants, all low-quality evidence; 48 hours, MD -1.34, 95% CI -2.57 to -0.11, 4 studies, 135 participants, very low-quality evidence. When studies with high risk of bias were excluded, significance remained at 12 hours only. Scalp blocks may decrease additional analgesia requirements (SMD -1.11, 95% CI -1.97 to -0.25, 7 studies, 314 participants). Results for other outcomes were imprecise (nausea and vomiting RR 0.66, 95% CI 0.33 to 1.32, 4 studies, 165 participants, very low-quality evidence). Scalp Infiltration may reduce pain postoperatively but efficacy was inconsistent, with a significant effect at 12 and 48 hours only (12 hours, MD -0.71, 95% CI -1.34 to -0.08, 7 studies, 309 participants, low-quality evidence; 48 hours, MD - 1.09, 95% CI -2.13 to - 0.06, 3 studies, 128 participants, moderate-quality evidence). No benefit was observed at other times (0 to 6 hours, MD -0.64, 95% CI -1.28 to -0.00, 9 studies, 475 participants, moderate-quality evidence; 24 hours, MD -0.39, 95% CI -1.06 to 0.27,6 studies, 260 participants, low-quality evidence. Scalp infiltration may reduce additional analgesia requirements MD -9.56 mg, 95% CI -15.64 to -3.49, 6 studies, 345 participants, very low-quality evidence). When studies with high risk of bias were excluded, scalp infiltration lost the pain benefit at 12 hours and effects on additional analgesia requirements, but retained the pain-reducing benefit at 48 hours (MD -0.56, 95% CI -1.20 to -0.32, 2 studies, 100 participants, very low-quality evidence). Results for other outcomes were imprecise (nausea and vomiting, RR 0.74, 95% CI 0.48 to 1.41, 4 studies, 318 participants, low-quality evidence). Pregabalin or gabapentin may reduce pain up to 6 hours (2 studies, 202 participants), MD -1.15,95% CI -1.66 to -0.6, 2 studies, 202 participants, low-quality evidence). One study examined analgesic efficacy at 12 hours showing significant benefit. No analgesia efficacy was shown at later times (24 hours, MD -0.29, 95% CI -0.78 to -0.19; 48 hours, MD - 0.06, 95% CI -0.86 to 0.77, 2 studies, 202 participants, low-quality evidence). Additional analgesia requirements were not significantly less (MD -0.37 (95% CI -1.10 to 0.35, 3 studies, 234 participants, low-quality evidence). Risk of nausea and vomiting was significantly reduced (RR 0.51, 95% CI 0.29 to 0.89, 3 studies, 273 participants, low-quality evidence). Results for other outcomes were imprecise (additional analgesia requirements: MD -0.37, 95% CI -1.10 to 0.35, 3 studies, 234 participants, low-quality evidence). Acetaminophen did not show analgesic benefit (0 to 6 hours, MD -0.35, 95% CI -1.00 to 0.30; 12 hours, MD -0.51, 95% CI -1.04 to 0.03, 3 studies, 332 participants, moderate-quality evidence; 24 hours, MD -0.34, 95% CI -1.20 to 0.52, 4 studies, 439 participants, high-quality evidence). Results for other outcomes remained imprecise (additional analgesia requirements, MD 0.07, 95% CI -0.86 to 0.99, 4 studies, 459 participants, high-quality evidence; length of hospitalizations, MD -3.71, 95% CI -14.12 to 6.7, 2 studies, 335 participants, moderate-quality evidence). AUTHORS' CONCLUSIONS There is high-quality evidence that NSAIDs reduce pain up to 24 hours postoperatively. The evidence for reductions in pain with dexmedetomidine, pregabalin or gabapentin, scalp blocks, and scalp infiltration is less certain and of very low to moderate quality. There is low-quality evidence that scalp blocks and dexmedetomidine may reduce additional analgesics requirements. There is low-quality evidence that gabapentin or pregabalin may decrease nausea and vomiting, with the caveat that the total number of events for this comparison was low.
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Affiliation(s)
| | - Ron Levy
- Kingston General HospitalDepartment of NeurosurgeryDept of Surgery, Room 304 , Victory 3 ,76 Stuart StreetKingstonONCanadaK7L 2V7
| | - Andrew G Day
- Kingston General HospitalClinical Research CentreAngada 4, Room 5‐42176 Stuart StreetKingstonONCanadaK7L 2V7
| | - Ian Gilron
- Queen's UniversityDepartments of Anesthesiology & Perioperative Medicine & Biomedical & Molecular Sciences76 Stuart StreetVictory 2 PavillionKingstonONCanadaK7L 2V7
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Wardhana A, Sudadi S. Scalp block for analgesia after craniotomy: A meta-analysis. Indian J Anaesth 2019; 63:886-894. [PMID: 31772396 PMCID: PMC6868657 DOI: 10.4103/ija.ija_315_19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 06/07/2019] [Accepted: 09/03/2019] [Indexed: 11/04/2022] Open
Abstract
Background and Aims: A previous meta-analysis reported that scalp block had limited benefits (low-quality evidence) compared to no-scalp block modalities for analgesia after craniotomy. However, it included studies using two different pain intensity measurement scales. Therefore, we performed another meta-analysis using a single scale. Methods: We conducted the search for all randomised controlled trials evaluating the effect of scalp block on postcraniotomy pain compared to no-scalp block in Cochrane Central Register of Controlled Trials and PubMed database. We assessed the quality of included studies employing GRADE approach. We performed random-effects inverse-variance weighted meta-analysis of outcomes including pain intensity assessed by a 0--10 visual analog scale and opioid consumption during the first 24 h postoperative period using RevMan 5.3. Results: A total of 10 studies (551 patients) were included. It revealed a statistically significant mean pain intensity reduction in scalp block group when compared to no-scalp block at very early and early 24 h period (seven trials, very low-quality evidence, mean difference (MD) = −1.37, 95% confidence interval (CI): −2.23 to -0.05, I2 = 70%; nine trials, very low-quality evidence, MD = −1.16, 95% CI: −2.09 to −0.24, I2 = 57%, respectively). There was also reduction in the opioid requirements over the first 24 h postoperatively. Conclusion: Scalp block might be useful at <6 h postcraniotomy with very-low quality evidence. Additionally, it had uncertain but moderate effect on reducing total 24 h opioid consumption. Therefore, more studies are needed to reach optimal information size.
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Affiliation(s)
- Ardyan Wardhana
- Department of Anesthesiology and Intensive Therapy, Faculty of Medical, Public Health and Nursing, University of Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, Indonesia
| | - Sudadi Sudadi
- Department of Anesthesiology and Intensive Therapy, Faculty of Medical, Public Health and Nursing, University of Gadjah Mada/Dr. Sardjito General Hospital, Yogyakarta, Indonesia
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Vacas S, Van de Wiele B. Designing a pain management protocol for craniotomy: A narrative review and consideration of promising practices. Surg Neurol Int 2017; 8:291. [PMID: 29285407 PMCID: PMC5735429 DOI: 10.4103/sni.sni_301_17] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 10/02/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Craniotomy is a relatively common surgical procedure with a high incidence of postoperative pain. Development of standardized pain management and enhanced recovery after surgery (ERAS) protocols are necessary and crucial to optimize outcomes and patient satisfaction and reduce health care costs. METHODS This work is based upon a literature search of published manuscripts (between 1996 and 2017) from Pubmed, Cochrane Central Register, and Google Scholar. It seeks to both synthesize and review our current scientific understanding of postcraniotomy pain and its part in neurosurgical ERAS protocols. RESULTS Strategies to ameliorate craniotomy pain demand interventions during all phases of patient care: preoperative, intraoperative, and postoperative interventions. Pain management should begin in the perioperative period with risk assessment, patient education, and premedication. In the intraoperative period, modifications in anesthesia technique, choice of opioids, acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), regional techniques, dexmedetomidine, ketamine, lidocaine, corticosteroids, and interdisciplinary communication are all strategies to consider and possibly deploy. Opioids remain the mainstay for pain relief, but patient-controlled analgesia, NSAIDs, standardization of pain management, bio/behavioral interventions, modification of head dressings as well as patient-centric management are useful opportunities that potentially improve patient care. CONCLUSIONS Future research on mechanisms, predictors, treatments, and pain management pathways will help define the combinations of interventions that optimize pain outcomes.
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Affiliation(s)
- Susana Vacas
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, UCLA, Los Angeles, California, USA
| | - Barbara Van de Wiele
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, UCLA, Los Angeles, California, USA
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A Randomized Controlled Trial Studying the Role of Dexamethasone in Scalp Nerve Blocks for Supratentorial Craniotomy. J Neurosurg Anesthesiol 2017; 29:150-156. [DOI: 10.1097/ana.0000000000000272] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Can BO, Bilgin H. Effects of scalp block with bupivacaine versus levobupivacaine on haemodynamic response to head pinning and comparative efficacies in postoperative analgesia: A randomized controlled trial. J Int Med Res 2017; 45:439-450. [PMID: 28415943 PMCID: PMC5536685 DOI: 10.1177/0300060516665752] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective This study was performed to determine the effects of scalp blocks with bupivacaine versus levobupivacaine on the haemodynamic response during craniotomy and the efficacies and analgesic requirements of these drugs postoperatively. Methods This randomized, prospective, placebo-controlled, double-blind study included 90 patients (age, 18–85 years; American Society of Anesthesiologists physical status, I or II). The patients were randomly divided into three groups: those who received 20 mL of 0.5% bupivacaine (Group B, n = 30), 20 mL of 0.5% levobupivacaine (Group L, n = 30), or saline as a placebo (Group C, n = 30). Scalp blocks were performed 5 min before head pinning. The primary outcome was the mean arterial pressure (MAP), and the secondary outcomes were the heart rate (HR), visual analogue scale (VAS) scores, and additional intraoperative and postoperative drug use. Postoperative pain was evaluated using a 10-cm VAS. Results During head pinning and incision, the MAP and HR were significantly higher in Group C. The additional drug requirement for intraoperative hypertension and tachycardia was significantly higher in Group C. There were no significant differences in MAP, HR, or VAS scores between Groups B and L. Conclusion Both bupivacaine and levobupivacaine can be effectively and safely used for scalp blocks to control haemodynamic responses and postoperative pain.
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Affiliation(s)
- Banu O Can
- 1 Bursa Inegol State Hospital, Department of Anaesthesiology and Reanimation, Bursa, Turkey
| | - Hülya Bilgin
- 2 Uludag University, Faculty of Medicine, Department of Anaesthesiology and Reanimation, Bursa, Turkey
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18
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Which one is more effective for analgesia in infratentorial craniotomy? The scalp block or local anesthetic infiltration. Clin Neurol Neurosurg 2017; 154:98-103. [PMID: 28183036 DOI: 10.1016/j.clineuro.2017.01.018] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 01/24/2017] [Accepted: 01/27/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The most painful stages of craniotomy are the placement of the pin head holder and the skin incision. The primary aim of the present study is to compare the effects of the scalp block and the local anesthetic infiltration with bupivacaine 0.5% on the hemodynamic response during the pin head holder application and the skin incision in infratentorial craniotomies. The secondary aims are the effects on pain scores and morphine consumption during the postoperative 24h. METHODS This prospective, randomized and placebo controlled study included forty seven patients (ASA I, II and III). The scalp block was performed in the Group S, the local anesthetic infiltration was performed in the Group I and the control group (Group C) only received remifentanil as an analgesic during the intraoperative period. The hemodynamic response to the pin head holder application and the skin incision, as well as postoperative pain intensity, cumulative morphine consumption and opioid related side effects were compared. RESULTS The scalp block reduced the hemodynamic response to the pin head holder application and the skin incision in infratentorial craniotomies. The local anesthetic infiltration reduced the hemodynamic response to the skin incision. As well as both scalp block and local anesthetic infiltration reduced the cumulative morphine consumption in postoperative 24h. Moreover, the pain intensity was lower after scalp block in the early postoperative period. CONCLUSION The scalp block may provide better analgesia in infratentorial craniotomies than local anesthetic infiltration.
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Song J, Li L, Yu P, Gao T, Liu K. Preemptive scalp infiltration with 0.5% ropivacaine and 1% lidocaine reduces postoperative pain after craniotomy. Acta Neurochir (Wien) 2015; 157:993-8. [PMID: 25845547 DOI: 10.1007/s00701-015-2394-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 03/09/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND In order to reduce the consequences of narcotic-related side effects and provide effective analgesia after craniotomy, we conducted a randomized trial to compare the analgesic efficacy of preemptive scalp infiltrations with 1% lidocaine and 0.5% ropivacaine on the postoperative pain. METHODS Sixty adult patients scheduled for craniotomy were enrolled. A solution contained 0.5% ropivacaine and 1% lidocaine (40 ml) was prepared. In group A, local anesthetic was injected throughout the entire thickness of the scalp before skin incision. In group B, it was injected before skin closure. Additional intravenous injection and patient-controlled analgesia with morphine was used to control postoperative pain if the verbal numerical rating scale > 4. Cumulative morphine consumption; numerical rating scale of pain at 1, 2, 4, 6, 8, 12, and 24 h; postoperative nausea, vomiting, and respiratory depression, were recorded for 24 h after the operation. RESULTS Postoperative pain scores were lower in group A than in group B within the first 6 h after surgery. Mean time to demand for postoperative analgesic was statistically (p < 0.001) delayed in group A 300 (240, 360) min compared to group B 150 (105, 200) min. Ten patients in group A received morphine analgesia was half less than 21 patients in group B (p < 0.006). The median morphine consumption in 24 h after operation in group A 10.5 (8, 15) mg was less than that in group B 28 (22.5, 30.5) mg (p < 0.001). CONCLUSIONS Preemptive scalp infiltration with 0.5% ropivacaine and 1% lidocaine provides effective postoperative analgesia after craniotomy.
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Guilfoyle MR, Helmy A, Duane D, Hutchinson PJA. Regional Scalp Block for Postcraniotomy Analgesia. Anesth Analg 2013; 116:1093-1102. [DOI: 10.1213/ane.0b013e3182863c22] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Papangelou A, Radzik BR, Smith T, Gottschalk A. A review of scalp blockade for cranial surgery. J Clin Anesth 2013; 25:150-9. [DOI: 10.1016/j.jclinane.2012.06.024] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 04/30/2012] [Accepted: 06/08/2012] [Indexed: 11/16/2022]
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McGuirk S, Fahy C, Costi D, Cyna AM. Use of invasive placebos in research on local anaesthetic interventions. Anaesthesia 2011; 66:84-91. [PMID: 21254982 DOI: 10.1111/j.1365-2044.2010.06560.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Placebos play a vital role in clinical research, but their invasive use in the context of local anaesthetic blocks is controversial. We assessed whether recently published randomised controlled trials of local anaesthetic blocks risked harming control group patients in contravention of the Declaration of Helsinki. We developed the 'SHAM' (Serious Harm and Morbidity) scale to assess risk: grade 0 = no risk (no intervention); grade 1 = minimal risk (for example, skin allergy to dressing); grade 2 = minor risk (for example, subcutaneous haematoma, infection); grade 3 = moderate risk (with or without placebo injection) (for example, neuropraxia); and grade 4 = major risk (such as blindness, pneumothorax, or liver laceration). Placebo interventions of the 59 included trials were given a SHAM grade. Nine hundred and nineteen patients in 31 studies, including six studies with 183 children, received an invasive placebo assessed as SHAM grade ≥ 3. A high level of agreement (78%, κ = 0.80, p < 0.001) for SHAM grades 0-4 increased to 100% following discussion between assessors. More than half of the randomised controlled study designs subjected patients in control groups to risks of serious or irreversible harm. A debate on whether it is justifiable to expose control group patients to risks of serious harm is overdue.
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Affiliation(s)
- S McGuirk
- Women's and Children's Hospital, North Adelaide, SA, Australia
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Girard F, Quentin C, Charbonneau S, Ayoub C, Boudreault D, Chouinard P, Ruel M, Moumdjian R. Superficial cervical plexus block for transitional analgesia in infratentorial and occipital craniotomy: a randomized trial. Can J Anaesth 2010; 57:1065-70. [DOI: 10.1007/s12630-010-9392-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 09/15/2010] [Indexed: 10/19/2022] Open
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