Scalp Blocks

Craniotomy involves noxious stimuli such as skull pinning and dissection, causing hemodynamic instability and significant postoperative pain. Scalp nerve block (SNB) helps attenuate these responses. Dexmedetomidine, a selective α2-agonist, is effective as a perineural adjuvant in other blocks, but its role in SNB for craniotomy remains unclear. We evaluated its efficacy and safety as an SNB adjuvant in elective craniotomy. A systematic review and meta-analysis of randomized controlled trials (RCTs) comparing SNB with local anesthetic plus dexmedetomidine versus controls was conducted. Primary outcomes were hemodynamic response to perioperative noxious stimuli and postoperative pain scores; secondary outcomes were intraoperative opioid use, rescue analgesia, and adverse events. Data synthesis used RevMan 5.4; risk of bias was assessed with RoB 2.0 and certainty with GRADE. Seven RCTs (n = 528) were included. Dexmedetomidine significantly reduced heart rate (MD -8.1 bpm) and mean arterial pressure (MD -8.5 mmHg) at pin fixation, lowered pain scores at 24 h (SMD -0.31) and 48 h (SMD -0.35), prolonged time to first rescue analgesia by 215 min, and decreased intraoperative fentanyl (SMD -1.02) and rescue tramadol use (SMD -0.92). No serious adverse events were reported. Certainty of evidence was low to very low due to risk of bias, heterogeneity, and imprecision. Dexmedetomidine as an SNB adjuvant may improve perioperative hemodynamic stability and postoperative analgesia in craniotomy. However, given the overall low certainty of evidence and methodological limitations of existing RCTs, these findings should be interpreted cautiously. Larger, high-quality multicenter trials are needed to confirm efficacy and establish optimal dosing.

Dexmedetomidine, an alpha-2 adrenoceptor agonist, and dexamethasone are known to prolong analgesia when used as adjuvants in peripheral nerve blocks. However, their comparative efficacy as perineural adjuvants in scalp nerve blocks (SNB) for awake craniotomy remains uncertain. Fifty adults degree of postoperative sedation (18-65 years) undergoing awake craniotomy were randomized to receive SNB with 30 ml of 0.5 % ropivacaine plus dexmedetomidine 1 μg/kg (Group D, n = 25) or dexamethasone 8 mg (Group Z, n = 25), 20 min before skull pin fixation. The primary outcome was time to first rescue analgesia. Secondary outcomes included postoperative pain (numerical rating scale, NRS), 24-hour rescue analgesic consumption, onset of sensory block, perioperative hemodynamics during application of noxious stimulus, degree postoperative sedation, and incidence of any complications. The time to first rescue analgesia was significantly longer in Group D than in Group Z (14 [12-16] vs. 12.3 [9-13] h, P = 0.03). Rescue analgesic consumption was lower in Group D (1.64 ± 0.82 vs. 2.26 ± 0.89, P = 0.021). Pain scores were significantly reduced in Group D at 8 h (P = 0.01) and 12 h (P = 0.01). Group D also showed lower heart rate at skull pin fixation (P = 0.02), skin incision (P = 0.03), and closure (P = 0.001), and lower mean arterial pressure at dural (P = 0.001) and skin closure (P = 0.007). The onset of sensory block, sedation scores, and complications were comparable. Perineural dexmedetomidine as an adjuvant to ropivacaine in SNB prolongs postoperative analgesia, reduces rescue analgesic requirements, and provides superior attenuation of the hemodynamic response to noxious stimulus as compared to dexamethasone, in the absence of any adverse effects. Clinical Trials Registry-India (CTRI) ID: CTRI/2024/01/062046.

Postcraniotomy headache (PCH) is a common adverse event and can lead to various complications and decreased quality of life. 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.

Pain after craniotomy can be intense and its management is often suboptimal. We aimed to evaluate the available literature and develop recommendations for optimal pain management after craniotomy. A systematic review using procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials and systematic reviews published in English from 1 January 2010 to 30 June 2021 assessing pain after craniotomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. Each randomised controlled trial (RCT) and systematic review was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and NSAIDs, and current clinical relevance. Out of 126 eligible studies identified, 53 RCTs and seven systematic review or meta-analyses met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, NSAIDs, intravenous dexmedetomidine infusion, regional analgesia techniques, including incision-site infiltration, scalp nerve block and acupuncture. Limited evidence was found for flupirtine, intra-operative magnesium sulphate infusion, intra-operative lidocaine infusion, infiltration adjuvants (hyaluronidase, dexamethasone and α-adrenergic agonist added to local anaesthetic solution). No evidence was found for metamizole, postoperative subcutaneous sumatriptan, pre-operative oral vitamin D, bilateral maxillary block or superficial cervical plexus block. The analgesic regimen for craniotomy should include paracetamol, NSAIDs, intravenous dexmedetomidine infusion and a regional analgesic technique (either incision-site infiltration or scalp nerve block), with opioids as rescue analgesics. Further RCTs are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.

In this randomized controlled trial, opioid-sparing MMA provided superior postoperative pain control after elective craniotomy, with fewer adverse effects compared to conventional opioid-based regimens. These results support the incorporation of MMA into standard postoperative protocols and align with the principles of Enhanced Recovery After Surgery (ERAS) in neurosurgical care. TRIAL REGISTRATION: This trial is registered with ClinicalTrials.gov under the identifier NCT05474040, with the initial registration on 26 July 2022, and retrospective registration available at ClinicalTrials.gov.

Neurosurgeons have sought to minimize the use of opioids in neurosurgery. Preoperative medical strategies include methadone and gabapentinoids. Intraoperative strategies include local anesthetic infiltration with bupivacaine, ropivacaine, and lidocaine; scalp block; steroids such as methylprednisolone, triamcinolone, and dexamethasone; ketamine; acetaminophen; ketorolac; liposomal bupivacaine; dexmedetomidine; and performing awake surgery. Postoperative strategies include continuous infusion pumps, wound catheters, and patient-controlled analgesia. Multimodal analgesia may be most effective, with the enhanced recovery after surgery (ERAS) pathway as an example and cognitive-behavioral therapy (CBT) as an adjunct. Patient-specific demographics and clinical factors must be considered in selecting the appropriate approach for a given patient.

Neurosurgeons have sought to minimize the use of opioids in neurosurgery. Preoperative medical strategies include methadone and gabapentinoids. Intraoperative strategies include local anesthetic infiltration with bupivacaine, ropivacaine, and lidocaine; scalp block; steroids such as methylprednisolone, triamcinolone, and dexamethasone; ketamine; acetaminophen; ketorolac; liposomal bupivacaine; dexmedetomidine; and performing awake surgery. Postoperative strategies include continuous infusion pumps, wound catheters, and patient-controlled analgesia. Multimodal analgesia may be most effective, with the enhanced recovery after surgery (ERAS) pathway as an example and cognitive-behavioral therapy (CBT) as an adjunct. Patient-specific demographics and clinical factors must be considered in selecting the appropriate approach for a given patient.