Effect of Scalp Block on Postoperative Pain Relief in Craniotomy Patients

Posterior scalp block with bupivacaine and dexmedetomidine for pain management in posterior fossa surgeries: a prospective, double blind randomized controlled trial

BACKGROUND

Pain management in posterior fossa surgeries poses significant challenges, with opioid-based approaches causing unwanted side effects. This study evaluates the efficacy of posterior scalp block using bupivacaine and dexmedetomidine compared to skin infiltration for managing perioperative pain.

METHODS

In this prospective, double-blind, randomized controlled trial, 34 adult patients undergoing elective posterior fossa surgeries were equally assigned to either posterior scalp block or skin infiltration groups. Outcomes measured included hemodynamic parameters, pain scores, opioid consumption, time to first analgesic, and sedation levels.

RESULTS

The posterior scalp block group showed significantly lower opioid consumption (211.47 ± 101.95 mcg vs 305.88 ± 117.10 mcg; p < 0.01) and pain scores (VAS 2.29 ± 0.9 vs 5.06 ± 1.3; p < 0.001) at 24 hours post-surgery. This group also demonstrated better hemodynamic stability and fewer rescue opioid requirements (9 vs 15 patients; p < 0.009).

CONCLUSIONS

Posterior scalp block with bupivacaine and dexmedetomidine significantly improves pain management, reduces opioid use, and provides better hemodynamic stability compared to skin infiltration in posterior fossa surgeries.

CLINICAL TRIAL REGISTRATION

CTRI/2023/07/0554959.

Efficacy of Dexamethasone as an Adjuvant for Scalp Nerve Blocks to Prolong Analgesia: A Prospective, Double-Blind, Randomized Controlled Study

Background

Scalp nerve blocks (SNB) may significantly reduce post-craniotomy pain (PCP) but only for a short period of time. Dexamethasone, as an adjuvant to local anesthetics, was reported to prolong the analgesia duration of never block; however, the addition of dexamethasone to SNB is rare. We therefore tested the hypothesis that dexamethasone as an adjuvant to bupivacaine in SNB is positive after craniotomy.

Methods

Patients elective for craniotomy were randomly assigned to receive SNB with bupivacaine alone compared with dexamethasone and bupivacaine. The primary outcome was the duration of analgesia. The secondary outcomes include the cumulative amount of sufentanil consumption, the numeric rating scale (NRS), patient satisfaction score (PSS), the complications during the postoperative period, and SNB's relevant adverse events.

Results

There were 156 subjects included and 78 patients in each group (control and DEX group). The analgesia duration was significantly prolonged in the DEX group compared with the control group (660min (390,1005) vs 420min (314,504)) (p<0.001). The postoperative sufentanil consumption was lower in the DEX group compared with the control group at 12h (P<0.001), 24h (P=0.014), and 48h (P=0.049). The NRS scores were significantly lower in the DEX group compared with the control group at 8h (P<0.001) and 12h (P=0.007) after craniotomy. From 4h to 16h postoperative, the PSS in the control group was lower than the DEX group (P < 0.05).

Conclusion

Perineural dexamethasone as an adjuvant to bupivacaine without background glucocorticoid has the potential to improve the postoperative analgesic effect and patients' satisfaction without serious complications after craniotomy.

Nerve Blocks for Craniotomy

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.

Comparison of the Efficacy Between Regional Nerve Block and Ring Block as Local Anesthetic Techniques for Platelet-Rich Plasma Treatment

Introduction Platelet-rich plasma (PRP), a solution of concentrated platelets, has been widely used to promote wound repair and tissue regeneration. In the treatment of pattern hair loss, platelets in PRP secrete an abundance of growth factors, including platelet-derived growth factor (PDGF), fibroblast growth factor(FGF), and many more, which stimulate and increase signaling molecules and accelerate cell proliferation. In the PRP treatment for hair regrowth, the supratrochlear nerve (STN) block and supraorbital nerve (SON) block are given to anesthetize the scalp up to the vertex except for the temporal region. The ring block is the common local anesthetic technique used by infiltrating local anesthetic agents around the target area. The primary objectives were to compare the pain and anesthetic success rates produced by regional nerve blocks and ring blocks. Materials and methods A sample size of 100 patients undergoing PRP treatment for hair regrowth were taken as the subjects for the study. Patients were allotted into two groups by randomization. Group 1 was given regional nerve blocks as the anesthetic technique used for local anesthesia, and group 2 was given ring blocks. In the study group, STN and SON blocks as the regional nerve blocks were given 2% lignocaine with 1:80000 adrenaline to anesthetize the area, and the PRP was injected from the anterior hairline up to the vertex of the scalp, not involving the occipital and temporal regions. In the control group, a ring block was given for the same procedure. Participants from both groups were assessed for the pain and analgesia caused by ring block and regional nerve blocks using the visual analog scale (VAS). Results A mean rank of 30.28 was observed for the regional nerve block technique, and a mean rank of 70.72 was observed for the ring block technique. A p-value of 0.00 that is <0.05 was observed, which shows there is a significant difference in the pain and the analgesia experienced by the subjects between the two groups, during and three hours after the procedure. Conclusion PRP is one of the most commonly used treatments for hair regrowth. The ring block is the common local anesthetic technique used for producing anesthesia, while regional nerve blocks are more effective in producing local anesthesia. This study proves that STN and SON blocks are better anesthetic techniques than the ring block technique for PRP treatment in hair growth.

Systematic Review and Meta-Analysis of Randomized Controlled Trials for Scalp Block in Craniotomy

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.

Early Postoperative Opioid Requirement Is Associated With Later Pain Control Needs After Supratentorial Craniotomies

BACKGROUND

Despite a renewed focus in recent years on pain management in the inpatient hospital setting, postoperative pain after elective craniotomy remains under investigated. This study aims to identify which perioperative factors associate most strongly with postoperative pain and opioid medication requirements after inpatient craniotomy.

MATERIALS AND METHODS

Using an existing dataset, we selected a restricted cohort of patients who underwent elective craniotomy surgery requiring an inpatient postoperative stay during a 7-year period at our institution (n=1832). We examined pain scores and opioid medication usage and analyzed the relative contribution of specific perioperative risk factors to postoperative pain and opioid medication intake (morphine milligram equivalents).

RESULTS

Postoperative pain was found to be highest on postoperative day 1 and decreased thereafter (up to day 5). Factors associated with greater postoperative opioid medication requirement were preoperative opioid medication use, duration of anesthesia, degree of pain in the preoperative setting, and patient age. Notably, the most significant factor associated with a higher postoperative pain score and Morphine milligram equivalents requirement was the time elapsed between the end of general anesthesia and a patient's first intravenous opioid medication.

CONCLUSION

Postcraniotomy patients are at higher risk for requiring opioid pain medications if they have a history of preoperative opioid use, are of younger age, or undergo a longer surgery. Moreover, early requirement of intravenous opioid medications in the postoperative period should alert treating physicians that a patient's pain may require additional or alternative methods of pain control than routinely administered, to avoid over-reliance on opioid medications.

Prevention of Post-Operative Pain after Elective Brain Surgery: A Meta-Analysis of Randomized Controlled Trials

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.

Persistent incisional pain at 1 year after craniotomy: a retrospective observational study

BACKGROUND

There have been few reports on persistent incisional pain at 1 year after craniotomy. Hence, this study aimed to explore the distribution of pain at 1 year after elective craniotomy and its related factors.

METHODS

This retrospective study included data prospectively collected to assess postoperative functional disability. We included patients aged > 55 years at the time of recruitment for our initial study and who had complete data regarding the pain numeric rating scale (NRS) score at 1 year post craniotomy. The primary outcome was the pain NRS score, which was assessed at the postanesthetic clinic as well as at 3 months and 1 year after craniotomy. Multivariable negative binomial regression analysis was performed to analyze the relationship between the pain NRS score at 1 postoperative year and 12 clinically meaningful covariates. These included the Short Form-8 scores for bodily pain and mental health, with higher scores indicating better health.

RESULTS

We analyzed data from 102 patients. The mean (95% confidence interval) pain NRS scores at the three measurement points were 2.8 (2.3-3.3), 1.2 (0.8-1.6), and 0.6 (0.3-0.8), respectively. Multivariable analysis revealed that preoperative bodily pain (risk ratio, 0.93; 95% confidence interval, 0.88-0.98) and the pain NRS score at the postanesthetic clinic (risk ratio, 1.32; 95% confidence interval, 1.14-1.52) were associated with the risk of persistent pain at 1 postoperative year.

CONCLUSIONS

The pain score at 1 year after elective craniotomy was minor; however, preoperative bodily pain and postoperative pain scores were significantly related factors.

Anatomical considerations of cutaneous nerves of scalp for an effective anesthetic blockade for procedures on the scalp

Objective

The anatomy of the scalp nerves varies widely with age, race, and individuals of the same race and even within the same individual and hence need to be studied extensively to avoid complications and improve effectiveness during various surgical and anesthetic procedures of the scalp.

Materials and Methods

Gross dissection was carried out on 11 cadavers (22 Hemifaces: 11 right and 11 left) with no obvious scalp deformities or surgeries. The distances of the supraorbital nerve (SON), supratrochlear nerve (STN), and greater occipital nerve (GON) from commonly used bony landmarks were measured. The branching pattern and presence of accessory notches/foramina were noted.

Results

SON and STN were found almost midway and at the junction between medial and middle one-third of the line joining midline and lateral orbital margin, respectively. The distances of STN and SON from the midline were about ½ and 3/4th of the transverse orbital diameters of the individual. GON was found at the medial 2/5 and lateral 3/5 of the line joining inion to the mastoid. In 40.9% cases, SON gave three branches while STN and GON remained as single trunks in 77.27% and 40.0% cases, respectively. Accessory foramina/notches for SON and STN were found in 36.36% and 4.54% of the specimen, respectively. SON and STN remained lateral in the majority while GON ran medially to corresponding vessels.

Conclusion

These parameters on the Indian population would give a comprehensive idea of the distribution of these cutaneous scalp nerves and would be beneficial in the targeted and accurate deposition of local anesthetic.

REDUCE trial: the effects of perineural dexamethasone on scalp nerve blocks for relief of postcraniotomy pain-a study protocol for a randomized controlled trial

BACKGROUND

Pain is common in the first 2 days after major craniotomy. Inadequate analgesia may lead to an increased risk of postoperative complications. Most pain following craniotomy arises from the pericranial muscles and soft tissues of the scalp. Scalp nerve blocks with local anesthesia seem to provide effective, safe, however, transient postoperative analgesia which does not seem to meet the requirements of craniotomy. Currently, peripheral dexamethasone has been observed to significantly prolong the duration of analgesia of nerve blocks (e.g., saphenous nerve block, adductor canal block, thoracic paravertebral block, brachial plexus nerve block). On the contrary, a study reported that perineural dexamethasone did not appear to prolong the analgesic time after supratentorial craniotomy. However, all patients in this study were given 24 mg of oral or intravenous dexamethasone regularly for at least 7 days during the perioperative period, which possibly masked the role of single local low doses of perineural dexamethasone. Therefore, the analgesic effect of single dexamethasone for scalp nerve blocks without the background of perioperative glucocorticoid deserves further clarification.

METHODS

The REDUCE trial is a prospective, single-center, parallel-group randomized controlled trial involving a total of 156 adults scheduled for elective craniotomy with general anesthesia. Patients will be randomly divided among two groups: the control group (n = 78) will receive scalp nerve blocks with 0.5% bupivacaine, plus normal saline with epinephrine at 1:200,000; the DEX_4mg group (n = 78) will receive scalp nerve blocks with 0.5% bupivacaine, plus 4 mg dexamethasone with epinephrine at 1:200,000. The primary outcome will be the duration of analgesia, defined as the time between the performance of the block and the first analgesic request.

DISCUSSION

The REDUCE trial aims to further assess the analgesic effect of single dexamethasone as an adjuvant to scalp nerve blocks for relief of postcraniotomy pain without the background of perioperative glucocorticoid.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04648358 . Registered on November 30, 2020.

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.

Pain Quality Among Hospitalized Postcraniotomy Brain Tumor Patients

PURPOSE/AIMS

The aim of this study was to describe how persons given a diagnosis of a brain tumor who have had a craniotomy describe the quality of their pain after surgery.

DESIGN

A qualitative descriptive design was used.

METHODS

Qualitative descriptive methods as described by Sandelowski guided this study. Semistructured interviews were conducted with patients hospitalized on a neurological step-down unit in an urban teaching hospital in the Midwestern United States. Interviews focused on the quality of participants' pain after surgery. Narratives were analyzed using standard content analysis.

RESULTS

Twenty-seven participants were interviewed. Most were White and female. Most underwent a craniotomy using an anterior approach with sedation. Participants described the quality of their pain with 6 different types of descriptors: pain as pressure, pain as tender or sore, pain as stabbing, pain as throbbing, pain as jarring, and pain as itching.

CONCLUSIONS

Participants' descriptions of their pain quality after surgery provide a different understanding than do numerical pain ratings. Clinicians should use questions to explore patients' individual pain experiences, seeking to understand the quality of patients' pain and their perceptions.

Options to manage postcraniotomy acute pain in neurosurgery: no protocol available

The physical processes of incision, traction and hemostasis used for craniotomy, stimulate nerve fibers and specific nociceptors, resulting in postoperative pain. During the first 24 h after craniotomy, 87% of patients have postoperatory pain. The rate of suffering pain after craniotomy falls 3% for every year of life. The objective of this study is to review the available therapeutic options to help physicians treating this pain, and discuss pain mechanisms, pathophysiology, plasticity, risk factors and psychological factors. This is a narrative review of the literature from 1970 to June 2019. Data were collected by doing a search in PubMed, EMBASE, Cochrane Reviews and a manual search of all relevant literature references. The literature includes some drugs treatment: Opioids, codeine, morphine, and tramadol, anti-inflammatory non-steroids such as cyclooxygenase-2 inhibitors, gabapentin. It discusses: side effects, pharmacodynamics and indications of each drug, anatomy and Inervation of Skull and its Linigs, pathogenesis of pain Post-craniotomy, scalp nerve block, surgical nerve injury, neuronal plasticity, surgical factors and chronic post-surgical pain.

Comparison of Dexmedetomidine Infusion versus Scalp Block with 0.5% Ropivacaine to Attenuate Hemodynamic Response to Skull Pin Insertion in Craniotomy: A Prospective, Randomized Controlled Trial

Background The insertion of the skull pin head holder to stabilize the head during neurosurgery causes significant periosteal stimulation, resulting in hemodynamic responses, which may lead to brain edema, intracranial hypertension, and hemorrhage in patients with intracranial space-occupying lesions and intracranial aneurysms. We compared the efficacy of dexmedetomidine infusion and 0.5% ropivacaine scalp block in attenuating the hemodynamic response to the skull pin application.

Methods A total of 65 American Society of Anesthesiologists (ASA) class I and II patients aged between 18 and 65 years with a preoperative Glasgow Coma Scale score of 15 undergoing elective craniotomy were randomized to receive either a bolus of 1mcg/kg of dexmedetomidine followed by an infusion of 1 mcg/kg/hour (group D) or a scalp block with 0.5% ropivacaine (group S) in a single-blinded comparator study. Patients were monitored for the following hemodynamic changes following skull pin insertion: heart rate (HR), mean arterial pressure (MAP), the requirement of additional analgesia/anesthesia, and adverse events.

Results HR and MAP were comparable between the groups at baseline, before induction, and before pin insertion. HR and MAP at 1, 2, and 3 minutes after skull pin insertion were significantly higher in group D as compared with group S (p < 0.05) and were comparable between the groups at 5 minutes. The groups were comparable with respect to the requirement of additional analgesia, anesthesia, and incidence of adverse events.

Conclusion Scalp block with 0.5% ropivacaine is effective and superior to dexmedetomidine in attenuating the hemodynamic response to skull pin insertion in ASA I and II neurosurgical patients undergoing craniotomy. However, the hemodynamic effects achieved with dexmedetomidine were within the permissible limits.

Regional Anesthesia in Neuroanesthesia Practice

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.

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

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.

Effect of Scalp Nerve Block with Ropivacaine on Postoperative Pain in Patients Undergoing Craniotomy: A Randomized, Double Blinded Study

Scalp nerve block with ropivacaine has been shown to provide perioperative analgesia. However, the best concentration of ropivacaine is still unknown for optimal analgesic effects. We performed a prospective study to evaluate the effects of scalp nerve block with varied concentration of ropivacaine on postoperative pain and intraoperative hemodynamic variables in patients undergoing craniotomy under general anesthesia. Eighty-five patients were randomly assigned to receive scalp block with either 0.2% ropivacaine, 0.33% ropivacaine, 0.5% ropivacaine, or normal saline. Intraoperative hemodynamics and post-operative pain scores at 2, 4, 6, 24 hours postoperatively were recorded. We found that scalp blockage with 0.2% and 0.33% ropivacaine provided adequate postoperative pain relief up to 2 h, while administration of 0.5% ropivacaine had a longer duration of action (up to 4 hour after craniotomy). Scalp nerve block with varied concentration of ropivacaine blunted the increase of mean arterial pressure in response to noxious stimuli during incision, drilling, and sawing skull bone. 0.2% and 0.5% ropivacaine decreased heart rate response to incision and drilling. We concluded that scalp block using 0.5% ropivacaine obtain preferable postoperative analgesia compared to lower concentrations. And scalp block with ropivacaine also reduced hemodynamic fluctuations in craniotomy operations.

Pharmacological interventions for the prevention of acute postoperative pain in adults following brain surgery

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.

Scalp block for analgesia after craniotomy: A meta-analysis

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.

Efficacy of Dexmedetomidine as an Adjuvant to Local Anesthetic Agent in Scalp Block and Scalp Infiltration to Control Postcraniotomy Pain: A Double-Blind Randomized Trial

Context

Scalp infiltration and scalp block are being used to manage postcraniotomy pain. Dexmedetomidine has been successfully used as an adjuvant in regional anesthesia. The study was intended to compare whether addition of dexmedetomidine prolonged the duration of analgesia as well as to compare the two techniques.

Aims

The primary objective was to assess whether addition of dexmedetomidine to bupivacaine prolonged the duration of analgesia. The secondary objective was to compare between scalp nerve block and scalp infiltration as techniques for pain relief.

Settings and Design

The randomized control study was conducted in a tertiary care center from November 2013 to October 2014.

Materials and Methods

A total of 150 American Society of Anesthesiologists Physical Status I-II patients, aged 18-70 years undergoing elective craniotomy were included. Patients were randomized into three groups of 50 patients, i.e., Group BI (bupivacaine infiltration), Group BDI (bupivacaine and dexmedetomidine infiltration), and Group BDNB (bupivacaine and dexmedetomidine scalp nerve block). Patient's pain score, pain-free interval, rescue analgesic requirement, and hemodynamic and respiratory parameters were noted for 48 h. Patients were followed up at 1 and 3 months to assess postcraniotomy pain.

Results

Pain-free period was significantly longer in Group BDNB than Groups BDI and BI (P < 0.0001) and pain control was better in dexmedetomidine containing groups than in bupivacaine group (BI) (P < 0.0001). The rescue analgesic requirement was significantly lower in Group BDNB and Group BDI compared to Group BI.

Conclusion

The addition of dexmedetomidine (1 μg/kg) to bupivacaine prolonged the pain-free period. Scalp nerve block is a superior technique than scalp infiltration.

Anatomy of the greater occipital nerve block in infants

BACKGROUND

Pain relief for posterior fossa craniotomies as well as occipital neuralgia, are indications for the use of the greater occipital nerve block in children. The greater occipital nerve originates from the C2 spinal nerve and is accompanied by the occipital artery as it supplies the posterior scalp.

AIMS

The aim of this study was to develop a unique, yet simple technique for blocking the greater occipital nerve in children through the evaluation of the anatomy of this nerve and the accompanying occipital artery in the occipital region.

METHODS

The greater occipital nerve and occipital artery were dissected and exposed in six formalin-fixed cadavers (five infants [average age of 51.4 days] and one 2-year-old) from the Department of Anatomy, University of Pretoria. Measurements between the nerve and selected bony landmarks were obtained. The relationship between the greater occipital nerve and the occipital artery at the trapezius muscle hiatus was also evaluated.

RESULTS

The greater occipital nerve is on average 22.6 ± 5.6 mm from the external occipital protuberance in infants. The average width of the medial three fingers measured at the proximal interphalangeal joint, for each respective cadaver is 20.4 ± 4.0 mm, with a strong correlation coefficient of 0.97 between the aforementioned distances. In 83.3% of the specimens, the occipital artery lies lateral to the greater occipital nerve at the trapezius muscle hiatus.

CONCLUSION

In infants, the greater occipital nerve can be blocked approximately 23 mm from the external occipital protuberance, medial to the occipital artery. This distance is equal to the width of the medial three fingers at the proximal interphalangeal joint of the patient.

Bupivacaine scalp nerve block: hemodynamic response during craniotomy, intraoperative and post-operative analgesia

Background: Noxious stimuli during craniotomy may induce hypertension and tachycardia, giving rise to morbidity in patients with intracranial hypertension. Craniotomy is followed by moderate level of postoperative pain. Objective: Evaluate the effectiveness of scalp block on hemodynamic response to noxious stimuli, intraoperative fentanyl requirement and post-operative analgesia. Methods: Sixty patients undergoing elective craniotomy were randomly assigned to receive a scalp block with either 0.5% bupivacaine or 0.25% bupivacaine and 1:200,000 adrenaline (group A and B) or normal saline with 1:200,000 adrenaline (group C). Fentanyl 0.5 mcg/kg was administered for hemodynamic control. Intraoperative mean arterial blood pressure (MAP), heart rate (HR), fentanyl doses, and post-operative pain scores were recorded. Post-operative analgesia was provided by patient-controlled analgesia (PCA) morphine for 24 hours. Results: MAP was greater in group C than group A during pinning and incision (p <0.05), and was greater in group C than group B during pinning, incision and craniotomy (p <0.05). HR differences were not statistically significant between all groups (p >0.05). Intraoperative fentanyl requirement was significantly greater in group C compared with group A and B (p < 0.05). Pain score, time to the first morphine administration and total morphine consumption were not significantly different between all groups. Conclusion: Pre-incision scalp blocks using either 0.25% or 0.5% bupivacaine with 1:200,000 adrenaline were effective to prevent rising of MAP, but not HR in response to cranial pinning and skin incision, causing less intraoperative fentanyl requirement. However, they did not reduce post-craniotomy pain and morphine consumption.

Designing a pain management protocol for craniotomy: A narrative review and consideration of promising practices

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.

Effects of scalp block with bupivacaine versus levobupivacaine on haemodynamic response to head pinning and comparative efficacies in postoperative analgesia: A randomized controlled trial

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.

Which one is more effective for analgesia in infratentorial craniotomy? The scalp block or local anesthetic infiltration

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.

Regional Anesthesia to Scalp for Craniotomy: Innovation With Innervation

BACKGROUND

Effective management and pain prevention is of great importance to avoid postoperative complications such as hypertension, agitation, and vomiting. All these adverse events may lead to elevation in intracranial pressure and, in turn, unfavorable outcome and prolonged hospital stay. Development of multiple methods of analgesia may contribute to the alleviation of problems due to pain. We tested the effectiveness of bilateral maxillary block with greater and lesser occipital nerve block for providing analgesia to the scalp.

MATERIALS AND METHODS

This study was undertaken in 40 patients scheduled for craniotomy. Before skin incision, patients were assigned randomly to receive either bilateral maxillary (group M) or scalp block (group S). Data on intraoperative hemodynamics, postoperative analgesia, and sedation were collected and analyzed for statistical significance.

RESULTS

The primary outcome was the visual analog pain score. It was similar between the 2 groups at 1, 2, and 4 hours after extubation. At 12 hours, the maxillary block group had better analgesia (mean visual analog score: 3.4 cm for group M and 4.1 cm for group S with P-value of 0.0002) and sedation scores. Intraoperatively, there was no difference in the heart rate, blood pressure, and the anesthetic requirements between both the groups. Three patients in group S required fentanyl supplementation in the intraoperative period. There were no adverse events noted in the perioperative period among both the groups.

CONCLUSIONS

Maxillary block along with greater and lesser occipital nerve block is an effective alternative to scalp block for craniotomy and has longer duration of analgesia.

Postoperative analgesia for supratentorial craniotomy

OBJECTIVES

The prevalence of moderate to severe pain is high in patients following craniotomy. Although optimal analgesic therapy is mandatory, there is no consensus regarding analgesic regimen for post-craniotomy pain exists. This study aimed to investigate the effects of morphine and non-opioid analgesics on postcraniotomy pain.

PATIENTS AND METHODS

This prospective, randomized, double blind, placebo controlled study included eighty three patients (ASA 1, II, and III) scheduled for elective supratentorial craniotomy. Intravenous dexketoprofen, paracetamol and metamizol were investigated for their effects on pain intensity, morphine consumption and morphine related side effects during the first 24h following supratentorial craniotomy. Patients were treated with morphine based patient controlled analgesia (PCA) for 24h following surgery and randomized to receive supplemental IV dexketoprofen 50mg, paracetamol 1g, metamizol 1g or placebo. The primary endpoint was pain intensity, secondary endpoint was the effects on morphine consumption and related side effects.

RESULTS

When the whole study period was analyzed with repeated measures of ANOVA, the pain intensity, cumulative morphine consumption and related side effects were not different among the groups (p>0.05).

CONCLUSION

This study showed that the use of morphine based PCA prevented moderate to severe postoperative pain without causing any life threatening side effects in patients undergoing supratentorial craniotomy with a vigilant follow up during postoperative 24h. Although we could not demonstrate statistically significant effect of supplemental analgesics on morphine consumption, it was lower in dexketoprofen and metamizol groups than control group.

Options for perioperative pain management in neurosurgery

Moderate-to-severe pain following neurosurgery is common but often does not get attention and is therefore underdiagnosed and undertreated. Compounding this problem is the traditional belief that neurosurgical pain is inconsequential and even dangerous to treat. Concerns about problematic effects associated with opioid analgesics such as nausea, vomiting, oversedation, and increased intracranial pressure secondary to elevated carbon dioxide tension from respiratory depression have often led to suboptimal postoperative analgesic strategies in caring for neurosurgical patients. Neurosurgical patients may have difficulty or be incapable of communicating their need for analgesics due to neurologic deficits, which poses an additional challenge. Postoperative pain control should be a priority, because pain adversely affects recovery and patient outcomes. Inconsistent practices and the quality of current analgesic strategies for neurosurgical patients still leave room for improvement. Given the complexity of postoperative pain management for these patients, multimodal strategies are often required to optimize pain control and at the same time limit undesired side effects.

Integrative review: postcraniotomy pain in the brain tumour patient

AIM

To conduct an integrative review to examine evidence of pain and associated symptoms in adult (≥21 years of age), postcraniotomy, brain tumour patients hospitalized on intensive care units.

BACKGROUND

Healthcare providers believe craniotomies are less painful than other surgical procedures. Understanding how postcraniotomy pain unfolds over time will help inform patient care and aid in future research and policy development.

DESIGN

Systematic literature search to identify relevant literature. Information abstracted using the Theory of Unpleasant Symptoms' concepts of influencing factors, symptom clusters and patient performance. Inclusion criteria were indexed, peer-reviewed, full-length, English-language articles. Keywords were 'traumatic brain injury', 'pain, post-operative', 'brain injuries', 'postoperative pain', 'craniotomy', 'decompressive craniectomy' and 'trephining'.

DATA SOURCES

Medline, OVID, PubMed and CINAHL databases from 2000-2014.

REVIEW METHOD

Cooper's five-stage integrative review method was used to assess and synthesize literature.

RESULTS

The search yielded 115 manuscripts, with 26 meeting inclusion criteria. Most studies were randomized, controlled trials conducted outside of the United States. All tested pharmacological pain interventions. Postcraniotomy brain tumour pain was well-documented and associated with nausea, vomiting and changes in blood pressure, and it impacted the patient's length of hospital stay, but there was no consensus for how best to treat such pain.

CONCLUSION

The Theory of Unpleasant Symptoms provided structure to the search. Postcraniotomy pain is experienced by patients, but associated symptoms and impact on patient performance remain poorly understood. Further research is needed to improve understanding and management of postcraniotomy pain in this population.

A single preoperative dose of diclofenac reduces the intensity of acute postcraniotomy headache and decreases analgesic requirements over five postoperative days in adults: A single center, randomized, blinded trial

OBJECTIVE

Postcraniotomy headache causes considerable pain and can be difficult to treat. We therefore tested the hypothesis that a single 100-mg preoperative dose of diclofenac reduces the intensity of postcraniotomy headache, and reduces analgesic requirements.

METHODS

200 patients having elective craniotomies were randomly assigned to diclofenac (n = 100) or control (n = 100). Pain severity was assessed by an independent observer using a 10-cm-long visual analog scale the evening of surgery, and on the 1st and 5th postoperative days. Analgesics given during the first five postoperative days were converted to intramuscular morphine equivalents. Results were compared using Mann-Whitney-tests; P < 0.05 was considered statistically significant.

RESULTS

Baseline and surgical characteristics were comparable in the diclofenac and control groups. Visual analog pain scores were slightly, but significantly lower with diclofenac at all times (means and 95% confidence intervals): the evening of surgery, 2.47 (1.8-3.1) vs. 4. 37 (5.0-3.7), (P < 0.001); first postoperative day, 3.98 (3.4-4.6) vs. 5.6 (4.9-6.2) cm (P < 0.001) and 5th postoperative day: 2.8 (2.2-3.4) vs. 4.0 ± (3.3-4.7) cm (P = 0.013). Diclofenac reduced systemic analgesic requirements over the initial five postoperative days (mean and 95% CI): 3.3 (2.6-3.9) vs. 4.3 (3.5-5.1) mg morphine equivalents (P < 0.05).

CONCLUSIONS

Preoperative diclofenac administration reduces postcraniotomy headache and postoperative analgesic requirements - a benefit that persisted throughout five postoperative days.

Transient facial nerve palsy after auriculotemporal nerve block in awake craniotomy patients

In this case series, we describe transient postoperative facial nerve palsy in patients after awake craniotomy using selective scalp nerve blocks. In a 1-year period, 7 of the 42 patients receiving scalp nerve blocks at our institutions developed this complication. This is significant because there is only 1 previously reported case of postoperative facial nerve palsy related to scalp nerve blocks. The exact cause of transient postoperative facial nerve palsy after auriculotemporal nerve block is unknown and likely multifactorial. This technique may need to be refined to avoid such complications.

Perioperative pain management in the neurosurgical patient

Perioperative pain management in neurosurgical patients has been inadequately recognized and treated. An increased awareness of pain management and advances in understanding of pain modulation and pathophysiology have led to improved perioperative care of patients. There is a need to assess neurologic function while providing superior analgesia with minimal side effects. Several classes of drugs are currently available or under investigation for use as adjuvants or alternative therapies. There remains a need to determine the best treatment of perioperative pain in this patient population. Improved awareness, assessment, and treatment of pain result in better care and overall patient outcome.

Development of a safe and pragmatic awake craniotomy program at Maine Medical Center

BACKGROUND

Awake craniotomy offers an excellent means of performing intraoperative mapping and optimizing surgical resection of brain tumors. Awake craniotomy relies on a strong collaboration between anesthesiologists, neurosurgeons, and operating room staff. The authors recently introduced awake craniotomy for tumor resection at the Maine Medical Center and propose that it can be performed safely, effectively, and efficiently in a high-volume community hospital.

METHODS

We describe a practical approach to performing awake craniotomy involving streamlined anesthetic protocols and simplified intraoperative testing parameters in a carefully selected group of patients. Our first 25 patients are retrospectively reviewed with particular attention to the anesthetic protocol, the extent of resection, the operative time, post-operative complications, the length of hospitalization, and their functional status at follow-up.

RESULTS

The authors established an anesthetic protocol based primarily on midazolam, fentanyl, propofol, and local anesthetic. The authors note that all but one patient was able to tolerate the awake procedure. Gross total resection was achieved in nearly 80% of patients with a glial tumor. Operative time was short, averaging 159 minutes of entire anesthesia care. Length of stay averaged 3.7 days. Persistent new post-operative deficits were noted in 2 of 25 patients. There was no substantial difference in total hospital charges for patients undergoing awake craniotomy when compared to a matched historical control.

CONCLUSIONS

With attention focused on patient selection and a streamlined anesthetic protocol, the authors were able to successfully implement an awake craniotomy protocol in a community setting with satisfying results, including low operative morbidity, short operative times, low anesthetic complications, and excellent patient tolerance.

Safety and efficacy of continuous morphine infusions following pediatric cranial surgery in a surgical ward setting

PURPOSE

Morphine is avoided by many neurosurgeons following cranial surgery. There exists a concern regarding the potential complications and a perception that cranial surgery is less painful than other surgical procedures. At British Columbia Children's Hospital continuous morphine infusions (CMI) have been used to control pain in pediatric neurosurgical patients. The purpose of this study was to compare the safety and efficacy of continuous intravenous morphine infusion to standard oral analgesics in a neurosurgical ward setting.

METHODS

A retrospective review of medical records for 71 children was completed. The patients underwent either cranial reconstruction (2002-2007) or craniotomies for intradural pathology (2005-2007) at British Columbia Children's Hospital. Outcome measures included pain control and adverse events. Comparison was made between patients receiving a CMI and patients receiving acetaminophen and codeine.

RESULTS

Thirty-seven children received CMI on the ward (30 cranial reconstruction and 7 craniotomy), while 34 (10 cranial reconstruction and 24 craniotomy) received acetaminophen and codeine. There was no statistical difference in pain control. There was significantly more nausea on post-operative day one in the CMI group (p = 0.002). There were no other significant adverse events.

CONCLUSIONS

These findings suggest that CMI is comparable to acetaminophen and codeine with respect to analgesia and serious side effects. We recommend the use of CMIs as an alternative when pain is poorly controlled in post-operative pediatric neurosurgical patients to prevent the potential adverse consequences of inadequate analgesia.

[Scalp blocks. A useful technique for neurosurgery, dermatology, plastic surgery and pain therapy]

Safe and effective cranial analgesia can be achieved by blocking the sensitive nerves of that region. These include the supraorbital nerve, the supratrochlear nerve, the zygomaticotemporal nerve, the auriculotemporal nerve and the greater and lesser occipital nerves which are accessible at typical and most proximal points. Preferably long acting local anesthetics such as ropivacaine 0.75% or levobupivacaine 0.5% are used supplemented with 5 microg/ml epinephrine to reduce systemic resorption and to elongate the duration. Scalp blocks are useful for intraoperative neurologic testing of the patient during awake craniotomy or for supplementation of general anesthesia for other forms of craniotomy. Other applications are minimally invasive and stereotactic neurosurgery including deep brain stimulation, photodynamic therapy of actinic ceratosis, cranial plastic surgery and pain therapy.

Parecoxib for analgesia after craniotomy

BACKGROUND

Pain after craniotomy is often under-treated. Opiates carry distinct disadvantages. Non-steroidal anti-inflammatory drugs have an anti-platelet action and carry a bleeding risk. Cyclo-oxygenase 2 inhibitors such as parecoxib are not associated with a bleeding risk and would be welcome analgesics if shown to be effective.

METHODS

In a prospective double-blind, randomized, placebo-controlled study, we investigated the analgesic effect of a single dose of parecoxib 40 mg given at dural closure in 82 patients undergoing elective craniotomies. Remifentanil was used intraoperatively, and i.v. morphine was titrated to the requirement in the post-anaesthetic unit. On the ward, i.m. morphine 5 mg as required and regular acetaminophen was prescribed. Morphine use and visual analogue pain scores were recorded at 1, 6, 12, and 24 h after surgery.

RESULTS

Parecoxib reduced pain scores at 6 h and morphine use at 6 and 12 h after operation. However, overall, it had only minimal impact on postoperative analgesia. We found a wide variability in analgesic requirements where 11% of patients required no opioids and 16% required more than 15 mg i.v. morphine 1 h after the surgery.

CONCLUSIONS

We found only limited evidence to support parecoxib as an analgesic after craniotomy.

Effect of ropivacaine skull block on perioperative outcomes in patients with supratentorial brain tumors and comparison with remifentanil: a pilot study

Object

Skull blockade for craniotomy may result in the reduction of sympathetic stimulation associated with the application of head pins (“pinning”), improvement in intraoperative hemodynamic stability, and a decrease in intraoperative anesthetic requirements. Postoperative benefits may include a decrease in pain, in analgesic requirements, and in the incidence of nausea and vomiting. The authors examined the potential benefits of a skull block in patients in whom a maintenance anesthetic consisting of sevoflurane and a titratable remifentanil infusion was used. In other studies examining the ability of a skull block to improve perioperative outcomes, investigators have not used remifentanil.

Methods

Thirty patients presenting for resection of a supratentorial tumor were prospectively enrolled. Patients were randomized into 2 groups as follows: 14 patients (skull block group) received a skull block with 0.5% ropivacaine at least 15 minutes prior to pinning, whereas the remaining 16 patients (control group) did not.

Results

Patients in the skull block group did not have a significant increase in blood pressure or heart rate with placement of head pins, whereas patients in the control group did. Nevertheless, there was no difference in blood pressure variability between the groups. The mean intraoperative concentration of sevoflurane (1.0% in both groups, p = 0.703) and remifentanil (0.163 μg/kg/min compared with 0.205 μg/kg/min, p = 0.186) used was similar in both groups. During the postoperative period, there was no difference in the 1-, 2-, or 4-hour visual analog scale scores; in the need for postoperative narcotic analgesia (0.274 morphine equivalent mg/kg compared with 0.517 morphine equivalent mg/kg, p = 0.162); or in the incidence of nausea or vomiting.

Conclusions

Prospective analysis of perioperative skull blockade failed to demonstrate significant benefit in patients treated with a remifentanil infusion.