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Year : 2016  |  Volume : 1  |  Issue : 4  |  Page : 202-204

Regional anesthesia to scalp for craniotomy surgery

Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Date of Web Publication7-Nov-2016

Correspondence Address:
Pathomporn Pin-on
Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2468-5577.193149

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The main purposes of the review in the scalp blockade topic are to explore the background and the importance of post-craniotomy pain, briefly review scalp innervation, and give some examples of the controversial results of many previous studies. I also included my previous study of pre-incisional scalp blockade which added some inconclusive results to this arena.

Keywords: regional anesthesia, scalp blockade, craniotomy surgery

How to cite this article:
Pin-on P. Regional anesthesia to scalp for craniotomy surgery. Asia Pac J Clin Trials Nerv Syst Dis 2016;1:202-4

How to cite this URL:
Pin-on P. Regional anesthesia to scalp for craniotomy surgery. Asia Pac J Clin Trials Nerv Syst Dis [serial online] 2016 [cited 2021 May 12];1:202-4. Available from: https://www.actnjournal.com/text.asp?2016/1/4/202/193149

  Introduction Top

Insufficient treatment of postoperative pain after craniotomies can lead to major complications such as increased intracranial pressure, intracerebral hemorrhage, surgical bed hematoma, seizures, cerebral infarction, etc. It also decreased patients and their families' satisfaction. Post-craniotomy pain has been described as a somatic pain, originated from pericranial muscles and soft tissue. There were reported 55-60% of patients suffered moderate to severe headache within the first 12 hours after craniotomy (De Benedittis et al., 1996; Mordhorst et al., 2010). The incidence of pain depends on the surgical site (Thibault et al., 2007). The extended damage of temporal muscle and posterior temporal muscles provides that subtemporal and suboccipital approaches gain more pain severity compared to frontal craniotomies (Thibault et al., 2007; Flexman et al., 2010). For each neurological procedure, the level of noxious stimuli and nociception vary according to the stage of surgery. It has been illustrated by the graph of chloroform requirements during each step of craniotomy surgery (Bruder and Ravussin, 2010). Once the dura is opened, there is no pain receptor located on the brain parenchymal tissue. The anesthetic requirement is dramatically reduced (Horsley, 1906; Mordhorst et al., 2010). To this pathophysiologic knowledge, blockade of the afferent nerves innervated scalp might reduce the severity of acute postoperative pain and headache after craniotomy. Even opioid is potent analgesic, systemic opioid administration should be used cautiously in neurosurgical patients because the systemic effect obscure signs of intracranial emergencies.

  Scalp innervation and scalp blockade Top

The scalp is innervated by the branches of trigeminal and spinal nerves. The trigeminal nerve supplies anterolaterally and the spinal nerve supplies posteriorly. The ophthalmic division (V1) gives the supraorbital and supratrochlear nerves. The maxillary division (V2) gives the infraorbital, zygomaticofacial, and zygomaticotemporal nerves. The mandibular division (V3) gives the auriculotemporal cutaneous nerve. The greater and the lesser occipital nerves emerge from the second and third cervical spinal nerve root (C2, C3) (Liu, 2005; Kemp et al., 2011). A scalp blockade refers to the administration of local anesthetic (LA) of the nerves that supply sensation to the scalp. The technique is to infiltrate 2-3 mL of LA solution over the regions that these nerves emerge with a 25-27 G needle. To block the supratrochlear and supraorbital nerves, the LA is infiltrated above the eyebrow. The auriculotemporal is blocked with LA injected anterior to the ear, approximately at the level of the tragus. The zygomaticofacial, and zygomaticotemporal nerves are blocked by infiltrated LA subcutaneously between the lateral of the eye to the tragus. The greater and lesser occipital nerves are blocked with the injection of LA along the superior nuchal line between each side of mastoid process (Pinosky et al., 1996; Geze et al., 2009). The scalp blockade can be performed prior to the skull pin insertion in order to blunt the hemodynamic response and also decrease the systemic opioid requirement during the surgery (Pinosky et al., 1996; Song et al., 2015). Some authors performed blockade after the craniotomy procedure for the transitional analgesia, decreasing post-craniotomy pain and analgesic requirement (Nguyen et al., 2001; Ayoub et al., 2006; Hernández Palazón et al., 2007; Song et al., 2015). Recently, Song et al. (2015) supported that preemptive LA for scalp was significantly more efficacious in terms of pain severity and cumulative morphine consumption, compared to LA application before skin closure.

Epinephrine is usually added to the LA such as lidocaine or long-acting local anesthetics (i.e., bupivacaine, ropivacaine, levobupivacaine). The concentration ranges from 1:80,000 to 1:200,000 (10-25 µg/mL, respectively) (Nakamura et al., 2001). Many previous studies agreed that epinephrine added to local anesthetics for either local infiltration or nerve blockade showed a small but not clinically important increase in cardiovascular parameters after injection (BP, PR and HR), particularly in healthy patients (Silvestre et al., 2001; Meral et al., 2005; Faraco et al., 2007; Ketabi et al., 2012). The advantages are to decrease systemic absorption of LA, enhance the onset of LA, decrease systemic toxicity, and prolong duration of LA. However, these benefits are weakened when epinephrine is added to high-potency and long-acting LA. Accidental intravascular injection is possible in scalp blockade because of rich vascular supply. This complication is preventable by aspiration in each site of LA injection. Thus this complication quite rarely occurs in experienced hands. Nevertheless, if epinephrine is added and in the worst case, intravascular injection is unidentified, it may lead to toxic levels, presenting with tachycardia, hypertension, seizures and cardiac toxicity (Chakrabarti et al., 2014).

  Controversial issues Top

There are several studies of regional scalp block and its efficacy. However, the conclusion cannot be drawn because of relatively small sample size, difference in LA solution and its combination, the technique of scalp block, and the presence of concomitant procedures (i.e., LA infiltration on the skull pin site, opioid intermittent bolus, or opioid continuous infusion, etc.) (Guilfoyle et al., 2013). Biswas and Bithal showed that a scalp infiltration with 0.25% bupivacaine did not have any significant effect on post-craniotomy pain and analgesic requirement, but delay the requirement of the first analgesic dose (Biswas and Bithal, 2003). Our previous study showed that the patients who received 0.5% bupivacaine for scalp blockade required intraoperative fentanyl less than the patients in the control group, 5.8 ± 3.0 μg/kg vs. 6.4 ± 3.2 μg/kg, P = 0.33. The increase of mean arterial pressure during the skull pin application was greater in the control group, especially in patients with underlying hypertensive disease (14 ± 7 mmHg vs. 11 ± 9 mmHg, P = 0.38) (Pin-on et al., 2014). However, these two studies cannot be compared because the pre-emptive analgesic techniques are different, scalp infiltration vs. scalp blockade, and also the difference in LA concentration. Our study agree with Pinosky et al. (1996), who demonstrated that 0.5% bupivacaine for scalp block could maintain hemodynamic profiles (SBP, DBP, MAP, HR) within the normal range as prior to the skull pin insertion compared to the control group. However, Bloomfield et al. (1998) showed that a significant reduction in postoperative pain in patients who received a bupivacaine scalp block did not correlate to heart rate or mean arterial pressure reduction. Hwang et al. (2015) demonstrated that scalp block with 0.75% levobupivacaine improved recovery profiles in terms of postoperative pain scores, PCA consumption, rescue analgesics, hemodynamic profile, and PONV compared to normal group. Among these studies, levobupivacaine showed promising outcome because of greater anesthetic potency than bupivacaine. In my routine practice, I have found that a combination of scalp blockade and scalp infiltration with potent LA such as ropivacaine, bupivacaine, or levobupivacaine as well as the addition of lidocaine with or without epinephrine provide the most effective pre-emptive analgesia for craniotomy procedures. Chaki et al. (2016) demonstrated that the blood concentration of the LA mixture of lidocaine and ropivacaine for scalp blocks and local infiltration did not increase above half of the known toxic level.

  Conclusion Top

The efficacy of scalp blockade is needed for further studies in various perspectives, for example, the blood concentration of other potent LA (i.e., levobupivacaine, bupivacaine, with or without lidocaine, with or without epinephrine addition, etc).[26]

  References Top

Ayoub C, Girard F, Boudreault D, Chouinard P, Ruel M, Moumdjian R (2006) A comparison between scalp nerve block and morphine for transitional analgesia after remifentanil-based anesthesia in neurosurgery. Anesth Analg 103:1237-1240.   Back to cited text no. 1
Biswas BK, Bithal PK (2003) Preincision 0.25% bupivacaine scalp infiltration and postcraniotomy pain: a randomized double-blind, placebo-controlled study. J Neurosurg Anesthesiol 15:234-239.  Back to cited text no. 2
Bloomfield EL, Schubert A, Secic M, Barnett G, Shutway F, Ebrahim ZY (1998) The influence of scalp infiltration with bupivacaine on hemodynamics and postoperative pain in adult patients undergoing craniotomy. Anesth Analg 87:579-582.  Back to cited text no. 3
Bruder N, Ravussin P (2010) Supratentorial masses: Anesthetic Considerations. In: Cottrell and Young′s Neuroanesthesia, 5 th ed (Cottrell JE, ed), pp184-202. Philadelphia: Mosby Elsevier.  Back to cited text no. 4
Chaki T, Sugino S, Janicki PK, Ishioka Y, Hatakeyama Y, Hayase T, Kaneuchi-Yamashita M, Kohri N, Yamakage M (2016) Efficacy and safety of a lidocaine and ropivacaine mixture for scalp nerve block and local infiltration anesthesia in patients undergoing awake craniotomy. J Neurosurg Anesthesiol 28:1-5.  Back to cited text no. 5
Chakrabarti R, Ghazanwy M, Tewari A (2014) Anesthetic challenges for deep brain stimulation: a systematic approach. N Am J Med Sci 6:359-69.   Back to cited text no. 6
De Benedittis G, Lorenzetti A, Migliore M, Spagnoli D, Tiberio F, Villani RM (1996) Postoperative pain in neurosurgery: a pilot study in brain surgery. Neurosurgery 38:466-469.  Back to cited text no. 7
Faraco FN, Kawakami PY, Mestnik MJ, Ferrari DS, Shibli JA (2007) Effect of anesthetics containing lidocaine and epinephrine on cardiovascular changes during dental implant surgery. J Oral Implantol 33:84-88.  Back to cited text no. 8
Flexman AM, Ng JL, Gelb AW (2010) Acute and chronic pain following craniotomy. Curr Opin Anaesthesiol 23:551-557.  Back to cited text no. 9
Geze S, Yilmaz AA, Tuzuner F (2009) The effect of scalp block and local infiltration on the haemodynamic and stress response to skull-pin placement for craniotomy. Eur J Anaesthesiol 26:298-303.  Back to cited text no. 10
Guilfoyle MR, Helmy A, Duane D, Hutchinson PJ (2013) Regional scalp block for postcraniotomy analgesia: a systematic review and meta-analysis. Anesth Analg 116:1093-1102.  Back to cited text no. 11
Hernández Palazón J, Doménech Asensi P, Burguillos López S, Pérez Bautista F, Sánchez Amador A, Clavel Claver N (2007) Cranial nerve block with bupivacaine for postoperative analgesia following supratentorial craniotomy. Rev Esp Anestesiol Reanim 54:274-278.   Back to cited text no. 12
Horsley V (1906) Address in surgery on the technique of operations on the central nervous system. Lancet 2:484-490.   Back to cited text no. 13
Hwang JY, Bang JS, Oh CW, Joo JD, Park SJ, Do SH, Yoo YJ, Ryu JH (2015) Effect of scalp blocks with levobupivacaine on recovery profiles after craniotomy for aneurysm clipping: a randomized, double-blind, and controlled study. World Neurosurg 83:108-113.  Back to cited text no. 14
Kemp WJ, Tubbs RS, Cohen-Gadol AA (2011) The innervation of the scalp: A comprehensive review including anatomy, pathology, and neurosurgical correlates. Surg Neurol Int 2:178.   Back to cited text no. 15
Ketabi M, Shamami MS, Alaie M, Shamami MS (2012) Influence of local anesthetics with or without epinephrine 1/80000 on blood pressure and heart rate: A randomized double-blind experimental clinical trial. Dent Res J (Isfahan) 9:437-440.  Back to cited text no. 16
Liu GT (2005) The Trigeminal nerve and its central connections. In: Walsh and Hoyt′s Clinical Neuroophthalmology, 1 st ed (Miller NR, ed), pp1233-1241. Philadelphia, PA: Lippincott Williams & Wilkins.   Back to cited text no. 17
Meral G, Tasar F, Sayin F, Saysel M, Kir S, Karabulut E (2005) Effects of lidocaine with and without epinephrine on plasma epinephrine and lidocaine concentrations and hemodynamic values during third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100:25-30.  Back to cited text no. 18
Mordhorst C, Latz B, Kerz T, Wisser G, Schmidt A, Schneider A, Jahn-Eimermacher A, Werner C, Engelhard K (2010) Prospective assessment of postoperative pain after craniotomy. J Neurosurg Anesthesiol 22:202-206.  Back to cited text no. 19
Nakamura Y, Matsumura K, Miura K, Kurokawa H, Abe I (2001) Cardiovascular and sympathetic responses to dental surgery with LA. Hypertens Res 24:209-214.  Back to cited text no. 20
Nguyen A, Girard F, Boudreault D, Fugère F, Ruel M, Moumdjian R, Bouthilier A, Caron JL, Bojanowski MW, Girard DC (2001) Scalp nerve blocks decrease the severity of pain after craniotomy. Anesth Analg 93:1272-1276.  Back to cited text no. 21
Pin-on P, Punjasawaswong Y, Chausuwan S (2014) The effect of pre-incisional anterior scalp blockade with 0.5% bupivacaine on perioperative outcomes in patients scheduled for supratentorial craniotomy surgery. Thai J Anesth 40:193-204.   Back to cited text no. 22
Pinosky ML, Fishman RL, Reeves ST, Harvey SC, Patel S, Palesch Y, Dorman BH (1996) The effect of bupivacaine skull block on the hemodynamic response to craniotomy. Anesth Analg 83:1256-1261.  Back to cited text no. 23
Silvestre FJ, Verdú MJ, Sanchis JL, Grau D, Peñarrocha M (2001) Effects of vasoconstrictors in dentistry upon systolic and diastolic arterial pressure. Med Oral 6:57-63.  Back to cited text no. 24
Song J, Li L, Yu P, Gao T, Liu K (2015) Preemptive scalp infiltration with 0.5% ropivacaine and 1% lidocaine reduces postoperative pain after craniotomy. Acta Neurochir (Wien) 157:993-998.   Back to cited text no. 25
Thibault M, Girard F, Moumdjian R, Chouinard P, Boudreault D, Ruel M (2007) Craniotomy site influences postoperative pain following neurosurgical procedures: a retrospective study. Can J Anaesth 54:544-548.  Back to cited text no. 26


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