|Year : 2019 | Volume
| Issue : 1 | Page : 134-139
Scalp block versus subcutaneous infiltration for stereotactic brain biopsy: a randomized controlled trial
Amr A Kassem, Azza Youssef, Nevine Ahmed, Manal Mohammed, Amira Gamal
Department of Anesthesia and Intensive Care Unit and Pain Management, Ain Shams University, Cairo, Egypt
|Date of Submission||25-Mar-2018|
|Date of Acceptance||15-Jul-2018|
|Date of Web Publication||27-Feb-2019|
Amr A Kassem
Department of Anesthesia and Intensive Care Unit and Pain Management, Ain Shams University, Cairo, 11321
Source of Support: None, Conflict of Interest: None
Objective The aim of the current study was to compare scalp block and subcutaneous infiltration anesthesia in adult patient during the placement of a stereotactic head frame and taking brain biopsy.
Patients and methods The current randomized controlled trial was conducted at the Neurosurgery Department in Ain Shams University Hospitals on patients who were scheduled for stereotactic brain biopsy. The recruited patients were randomly allocated into one of two groups: group A had 40 patients who received subcutaneous infiltration anesthesia and group B included 40 patients who received scalp nerve block. Both groups were compared regarding analgesic efficacy, hemodynamic changes, duration of local anesthetic, need of supplementary subcutaneous injections, need for postoperative analgesia, and postoperative complications.
Results A total of 80 patients were recruited in the current trial. The mean values of the 10-cm visual analogue scale for assessment of pain was significantly lower in patients of group B when compared with patients of group A.
Conclusion Scalp block with 0.5% bupivacaine reduced pain, heart rate, and mean arterial pressure response during the fixation of stereotaxy frame, the skin incision, and biopsy intake, and it also decreased the need for more local infiltration in comparison with the use of local subcutaneous infiltration. Moreover, the pain intensity was lower after scalp block in the early postoperative period with less incidence of headache in postoperative period.
Keywords: scalp block, stereotactic brain biopsy, subcutaneous infiltration
|How to cite this article:|
Kassem AA, Youssef A, Ahmed N, Mohammed M, Gamal A. Scalp block versus subcutaneous infiltration for stereotactic brain biopsy: a randomized controlled trial. Res Opin Anesth Intensive Care 2019;6:134-9
|How to cite this URL:|
Kassem AA, Youssef A, Ahmed N, Mohammed M, Gamal A. Scalp block versus subcutaneous infiltration for stereotactic brain biopsy: a randomized controlled trial. Res Opin Anesth Intensive Care [serial online] 2019 [cited 2019 Apr 25];6:134-9. Available from: http://www.roaic.eg.net/text.asp?2019/6/1/134/253118
| Introduction|| |
Evolution of neurosurgical practice is accompanied by new challenges for the anesthetist. Increasingly, we must think not only as an anesthetist but also as a neurosurgeon and neurologist . Stereotactic radio-surgery, first introduced by Lars Leksell at the Karolinska Institute in the 1960s, is widely used to treat intracranial tumors and arterio-venous malformations. This technique uses tightly focused, relatively high doses of radiation directed to the lesion. A stereotactic head frame, which is attached to the patient’s skull with pins, is utilized to ensure accuracy of treatment setup and delivery. This ambulatory treatment starts with placement of a stereotactic head frame, followed by diagnostic imaging, planning, and delivery of radiation treatment . A framed, rather than frameless, stereotactic system is used for functional procedures to accurately target areas deep within the brain and to minimize patient movement. Unfortunately, placement of the frame results in considerable discomfort in awake patients . Optimal pain treatment reduces intraoperative and postoperative surgical stress responses; therefore, it provides hemodynamic stability in craniotomies. Pain following craniotomies has been largely investigated and reported that it could be moderate or severe during postoperative period. Postoperative pain treatment might help to prevent rise in intracranial pressure as well as reduce the risk of intracerebral hemorrhage. For this purpose, pain control has become a priority in neurosurgery . The aim of multimodal pain treatment is to provide analgesia by different neurophysiological pathways. The combination of systemic analgesics and local anesthetics might reduce the amount of systemic opioids, thereby lower the incidence of opioids adverse effects, such as sedation, miosis, respiratory depression, nausea, and vomiting. For this purpose, scalp block and local anesthetic infiltration have been used with systemic opioid administration .
Scalp blocks have been used with conventional craniotomy under general anesthesia. They may be done preoperatively to reduce the hemodynamic response to head pin-holder application and postoperatively before emergence to reduce postoperative pain and improve postoperative assessment . Regional anesthesia of the scalp (skull block or infiltration) allows realizing a local anesthesia of the skin, the subcutaneous tissues and muscles, and the external periosteum of the bones of the skull. The internal periosteum and the dura, innervated by nerves satellites of the meningeal vessels, are not blocked by this infiltration . The aim of the current study was to compare scalp block and subcutaneous infiltration anesthesia in adult patient during the placement of a stereotactic head frame and taking brain biopsy regarding analgesic efficacy, hemodynamic changes, duration of local anesthetic, need of supplementary subcutaneous injections, need for postoperative analgesia, and postoperative complications.
| Patients and methods|| |
The current randomized controlled trial was conducted at the Neurosurgery Department at Ain Shams University Hospitals on patients who were scheduled for stereotactic brain biopsy. The study protocol had been approved by the Department of Anesthesia, Faculty of Medicine, Ain Shams University and Research Ethics Committee. Each participant had to sign informed written consent after thorough explanation of the purpose and procedures of the study. Eighty patients aged 20–60 years were included in this study. Just before local anesthetic injection standard monitoring devices were attached and intravenous access was established for every patient. Sedation using midazolam (2 mg) intravenous and fentanyl (1-2 ug/kg) intravenous. Oxygen was delivered for every patient either by mask or a nasal catheter.
The recruited patients were randomly allocated into one of two groups: group A included 40 patients who received subcutaneous infiltration anesthesia. Under complete aseptic conditions and after skin sterilization, local anesthesia was done by 2–3 ml bupivacaine 0.5% with 5 µg epinephrine for each 1 ml of local anesthetic solution, using a 25-G sharp-beveled needle. Subcutaneous infiltration was performed by the neurosurgeon. Surgical incision sites were infiltrated with 20 ml of bupivacaine 0.5% 10 min before the pin head holder application. With the stereotactic frame held in position by an assistant, local anesthetic solution was injected subcutaneously at each of the anticipated pin sites. After ∼2 min, the pins were applied. Supplementary subcutaneous injections were given at the time of pin placement if the level of pain was unacceptable or the patient requested more analgesia. Group B included 40 patients who received scalp nerve blocks. The scalp block was performed 10 min before the pin head holder application. Six nerves were blocked bilaterally to completely anaesthetize the scalp: the supra-trochlear, supra-orbital, zygomatico-temporal, auriculo-temporal, the lesser occipital and greater occipital nerves according to their anatomical sites .
Under complete aseptic conditions and after skin sterilization, scalp block was done by 2–3 ml of bupivacaine 0.5% with 5 µg epinephrine for each 1 ml of local anesthetic solution at each site, using a 25-G sharp-beveled needle. The depth of needle insertion is critical, and the efficacy of the blocks is maximized by depositing local anesthetic in the correct layer of the scalp. The use of epinephrine is recommended in well-vascularized areas such as the scalp to minimize acute rises in plasma concentration which may predispose to local anesthetic toxicity and to maximize the block duration. Monitoring was done using five-lead ECG, noninvasive blood pressure monitoring, and pulse oximetry to monitor oxygen saturation.
Random allocation was performed using a computer-generated randomization system. Allocation was concealed in serially numbered opaque envelops that are only opened after recruitment. Patients who had American Society of Anesthesiologists physical status III or IV, those with history of coagulation abnormality or bleeding tendency (regional techniques are contraindicated) and those who had pre-existing cardiac diseases were not included in the study. Study outcomes included analgesic efficacy using visual analogue scale (VAS) pain score. Pain was evaluated with VAS scores from 0 to 10 (0=no pain, 10=worst pain), at the following intervals during fixation: 5, 10, 15, and 30 min after pin-holder insertion, then during biopsy intake, and 1, 6, and 12 h postoperatively. Hemodynamic changes including the heart rates, mean arterial pressure (MAP), and SPO2 were recorded before induction of anesthesia (baseline), during the frame fixation, 5, and 10 min after fixation of frame, then during the biopsy as well as postoperative first, sixth, and 12th hour. Need of supplementary subcutaneous injections was recorded. Postoperative rescue analgesia as 4 intramuscularly Diclofinac was administered if needed. Postoperative complications like nausea, vomiting, and headache were recorded.
Sample size justification
Sample size calculation was guided by power of the test=80%, confidence level=95%, accepted margin of error=5%, and expected frequency of condition=20%, where 80 patients divided into two equal groups were sufficient to carry out the study.
Data were analyzed using statistical program for the social science, SPSS Inc., Acquired by IBM and became IBM SPSS, New York City, version 20. Quantitative data were expressed as mean±SD. Qualitative data were expressed as frequency and percentage. Difference between two groups was analyzed using independent Student’s t test for numeric parametric variables and χ2 test for numeric nonparametric variables. Significance level was set at 0.05.
| Results|| |
A total of 80 patients were included in this study. [Table 1] shows that there was no statistically significant difference between the groups regarding age, sex, and American Society of Anesthesiologist classification.
The comparison between group A and group B shows statistical significant difference in all periods of measured VAS ([Table 2]).
|Table 2 Comparison between both groups regarding visual pain analogue scale|
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There was a statistically significant difference between groups regarding heart rate at 30 min to postoperative 12 h. However, there was no significant difference between the two groups in the following intervals: before, during fixation, after 5 min, after 10 min, and after 15 min. There was a statistically significant difference between the two groups in the following intervals: after 30 min, during biopsy, 1 h postoperative, 6 h postoperative, and 12 postoperative hours, with more heart rate changes occurring in group A in comparison with group B ([Table 3]).
Regarding changes in MAP, there were no significant differences between the two groups in the following intervals before, during fixation, after 5 min, after 10 min, and after 15 min. However, there were statistically significant differences between the two groups in the following intervals after 30 min, during biopsy, 1 h postoperative, six postoperative hours and 12 h postoperative, as MAP was lower in group B than group A ([Table 4]). There was no statistically significant difference between both groups according to SPO2 ([Table 5]). There was statistically significant difference between both groups regarding the need for more local infiltrations, with more needed in group A than group B ([Table 6]).
|Table 6 Comparison between both groups regarding the need for more local infiltrations|
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Regarding comparison between the two groups regarding the use of postoperative analgesia, there was a highly statistically significant difference, with more need in group A than group B ([Table 7]).
|Table 7 Comparison between both groups regarding postoperative analgesia|
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There was a statistically significant difference between both groups regarding postoperative headache, which was more with group A than group B.
There was no statistically significant difference between the two groups regarding nausea and vomiting. There was no statistically significant difference between the two groups regarding other complications ([Table 8]).
| Discussion|| |
Stereotactic neurosurgery allows three-dimensional localization of specific sites within the brain using computed tomography, and more recently, MRI scanning. The initial step to stereotactic localization is the application of the base ring to the patient’s skull, using pins. This may be done under sedation and local anesthesia, nerve blocks, or general anesthesia . A framed, rather than frameless, stereotactic system is used for functional procedures to accurately target areas deep within the brain and to minimize patient movement. Unfortunately, placement of the frame results in considerable discomfort in awake patients . Optimal pain treatment reduces intraoperative and postoperative surgical stress response, therefore provides hemodynamic stability in craniotomies. Pain following craniotomies has been largely investigated, and it has been reported that it could be moderate or severe during postoperative period . Postoperative pain treatment might help to prevent rise in intracranial pressure as well as reduce the risk of intracerebral hemorrhage. For this purpose, pain control has become a priority in neurosurgery .
The current study showed statistically significantly lower VAS in group B when compared with group A. There was a statistically significant difference between the two groups regarding the need for more local infiltration, with more need in group A than group B. This is in agreement with the results of Akcil et al. , which showed that scalp block may provide better analgesia in infratentorial craniotomies than local anesthetic infiltration.
Moreover, Hwang and colleagues showed that scalp blocks with 0.75% levobupivacaine improved recovery profiles and that it effectively lowered postoperative pain and patient control analgesic (PCA) consumption without severe adverse events and also reduced the requirement for a postoperative antihypertensive agent. In this study, 52 patients scheduled for elective front-parietal craniotomy for unruptured aneurysm clipping were enrolled. After surgery, scalp blocks were performed using normal saline (group C, n=26) or 0.75% levobupivacaine (group L, n=26). Postoperative pain scores and PCA consumption were recorded for 72 h after recovery of consciousness. The time from patient recovery to the first use of PCA drug and rescue analgesics, the requirement for vasoactive agents, and adverse effects related to PCA and local anesthetics also were recorded. Postoperative pain scores and PCA consumption in group L were lower than in group C (P<0.05). The time intervals from patient recovery to the first use of PCA drug (P<0.001) and rescue analgesics (P=0.038) was longer in group L than in group C. Additionally, less antihypertensive agent was required (P=0.017), and postoperative nausea and vomiting occurred less frequently (P=0.039) in group L than in group C .
Regarding Hemodynamic parameters in our study, as previously reported
Scalp blockade drew attention in the 1990s as a means to improve hemodynamic control of the neurosurgical patient during cranial fixation. The goal was to prevent acute increases in heart rate and blood pressure, which might lead to acute changes in intracranial pressure or possible rupture of cerebral aneurysms and other vascular lesions .
Geze et al. , compared intravenous opioid analgesic controls, local anesthetic infiltration with 0.5% bupivacaine at each pin insertion site, and scalp blockade with 0.5% bupivacaine, and found that scalp blockade was superior in controlling hemodynamics during cranial fixation and for 3 min afterward. The scalp blockade group also showed lower levels of cortisol and adrenocorticotropic hormone 5 and 60 min after cranial fixation .
Investigators also have assessed the effect of scalp blockade on hemodynamics at the time of incision and until dural opening. Sixteen patients were randomized to receive blockade with either 0.25% bupivacaine or saline as a supplement to a 50% nitrous oxide and isoflurane-based anesthetic. An increase in heart rate or MAP greater than 20% over baseline triggered the use of a bolus of 2.5 mg/kg of thiopental sodium and 2 µg/kg of fentanyl. Only 25% of patients in the scalp blockade group required additional intravenous anesthetics, whereas 100% of the control group required additional treatment. At dural opening, they did not observe a difference between groups with respect to MAP or heart rate. As scalp blockade does not anesthetize the dura, it is likely that the inhalational anesthetics blunted this hemodynamic response equivalently in each group. These investigators also did not find any correlation between hemodynamic variability and plasma catecholamine levels .
Akcil et al.  found that both scalp block and local anesthetic infiltration reduced the cumulative morphine consumption in postoperative 24 h. Moreover, the pain intensity was lower after scalp block in the early postoperative period .
This in agreement with Hwang et al.  who found that scalp blocks with 0.75% levobupivacaine improved recovery profiles in that it effectively lowered postoperative pain and PCA consumption.
There was no significant difference between both groups regarding postoperative complications like nausea and vomiting, but headache was the most significant one that showed difference between the two groups.
| Conclusion|| |
Scalp block with 0.5% bupivacaine reduced pain and hemodynamics mainly (heart rate and MAP) response during the fixation of stereotaxy frame, the skin incision and biopsy intake. It also decreased the need for more local infiltration in comparison with the use of local subcutaneous infiltration. Moreover, the pain intensity was lower after scalp block in the early postoperative period with less incidence of headache in the postoperative period also.
Financial support and sponsorship
Conflicts of Interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]